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Republic of the Philippines

Mindanao State University

Marawi City
HS 5
Prelirm EXAM Pseudonym: ______________

Name: ______________________________ Date: _________________

Instructor: ___________________________ Total Score:____________

General Instructions:
NO ERASURES ALLOWED EXCEPT in Enumeration & Discussion! (wag kang echos, maging sigurado sa sagot bago isulat)
WRONG SPELLING, WRONG! (Please lang, wag gawing texting exam ito)
NO CHEATING! (wag maging two timer, be faithful, wag lumingon sa katabi, nakakamalas!)
FOLLOW INTRUCTION! (sumunod ha, para di nasasaktan)

Test I: IDENTIFICATION. Write the correct answer on the space provided before each number.

_______________1. It is the framework for providing professional and quality nursing care.
_______________2. Type of data that comes from the client’s point of view.
_______________3. It is a data that can be measured or tested against an accepted standard.
_______________4. It is the abnormal or extreme elevation of body temperature.
_______________5. Screening test for balance.
_______________6. It is the bluish discoloration, especially of the skin due to excessive concentration of
deoxyhemoglobin in the blood caused by deoxygenation.
_______________7. It is the yellowish discoloration of the sclera and skin caused by a build-up of bilirubin.
_______________8. Type of nursing intervention that nurses are licensed to initiate on the basis of their knowledge.
_______________9. Normal blood pressure of an adult patient.
_______________10. Normal respiratory rate of an infant.
_______________11. Normal pulse rate of an Adult.
_______________12. Normal pulse rate of an Infant.
_______________13. It indicates the number of total pregnancies of pregnant woman.
_______________14. Number of deliveries (38 weeks or more)
_______________15. Number of deliveries (from viability up to 37 weeks)
_______________16. It involves tapping of fingers or hands quickly and sharply against parts of the patient’s body.
_______________17. It involves listening for various breath, heart, and bowel sounds with a stethoscope.
_______________18. It is a tool used to test distance vision and measure visual acuity.
_______________19. Normal vision of an adult and children age 6 and older.
_______________20. It is a test using a tuning fork to evaluate bone conduction.
_______________21. A test used to compare air conduction of sound with bone conduction.
_______________22. It is an abnormal patches of a hair loss.
_______________23. A condition of the nail that may result from severe injury or illness.
_______________24. Disturbance in circulation of aqueous fluid that causes increase in intraocular pressure.
_______________25. visible, hard deposit of plaque & dead bacteria that forms at the gum lines.

Test II: TRUE/FALSE. Write T if the statement is TRUE and F if it is FALSE.

_______1. Normal nail shows convex shape with the nail plate angle of about 360 degrees.
_______2. Freckles, some birthmarks, some flat & raised nevi are normal during assessing the skin
_______3. In assessing skin turgor, if the skin returns to its original shape slowly over 30 seconds then the patient has
normal skin turgor.
_______4. Brittle hair, excessively oily and dry hair are normal during hair assessment.
_______5. Visual acuity is recorded as a fraction. The numerator is the distance from which a person with normal vision
could read the line.
_______6. Cardinal positions of gaze evaluate the oculomotor, trigeminal, and abducens cranial nerves and the
extraocular muscles.
_______7. In weber’s test, if the patient hears tone only in his impaired ear it indicates conductive hearing loss.
_______8. In rinne test, if the patient hears BC tone as long as or longer than AC tone it indicates sensorineural hearing
_______9. In assessing the patient’s neck, it should be asymmetrical and skin should be intact.
_______10. Paradoxical movement of the chest was is normal.
_______11. Adventitious breath sounds are normal no matter where you hear them in the lungs.
_______12. Whispered pectoriloquy is when the nurse asks the patient to whisper ABRACADABRA.
_______13. Bronchophony is when the nurse asks the patient to say “99”.
_______14. caries & pyorrhea are the two problems that most frequently affect teeth.
_______15. In assessing the teeth, 32 teeth are normal for an adult.
Test III: MATCHING TYPE. Match the letters in COLUMN B with the appropriate descriptions in COLUMN A.

A. Pustule
_______1. A small, discolored spot or patch on the skin.
B. Cyst
_______2. A raised lesion detectable by touch that’s usually 1 cm or more in diameter.
C. Nodule
_______3. A closed sac in or under the skin that contains fluid or semisolid material.
D. Wheal
_______4. A craterlike lesion of the skin that usually extends at least into the dermis.
_______5. A painful, cracklike lesion of the skin that extends at least into the dermis
E. Fissure
_______6. A solid, raised lesion that’s usually less than 1 cm in diameter F. Bulla
_______7. A large, fluid-filled blister that’s usually 1 cm or more in diameter. G. Macule
_______8. A small, pus-filled lesion. H. Ulcer
_______9. A raised, reddish area that’s commonly itchy and lasts 24 hours or less. I. Vesicle
_______10. A small, fluid-filled blister that usually 1 cm or less in diameter. J. Papule

Test IV: MULTIPLE CHOICE. Choose the letter of the correct answer and write it on the space provided before each

_____1. Which of the following examples are steps of nursing _____5. The Nursing Care Plan is:
assessment? (Select all that apply)
1. Collection of information from patient’s family A. A written guideline for implementation and
members evaluation
2. Recognition that further observations are B. A documentation of client care
needed to clarify information C. A projection of potential alterations in client
3. Comparison of data with another source to
D. A tool to set goals and project outcomes
determine data accuracy
4. Determining which medications to administer _____6. Once a nurse assesses a client’s condition and identifies
based on a patient’s assessment data. appropriate nursing diagnoses, a:
A. Plan is developed for nursing care.
A. 1,2,3 B. Physical assessment begins
B. 1,3,4 C. List of priorities is determined.
C. 2,3,4 D. Review of the assessment is conducted with
D. 1,2,3,4 other team members.

_____2. When a nurse conducts an assessment, data about a _____7. During the implementation step of the nursing process, a
patient often comes from which of the following sources? nurse reviews and revises a patient’s plan of care. Place
(Select all that apply.) the following steps of review and revision in the correct
1. An observation of how a patient turns and order.
1. Modify care plan is needed
moves in bed
2. Decide if the nursing intervention remain
2. The unit policy and procedure manual.
3. The care recommendations of a physical
3. Reassess the patient
therapist. 4. Compare assessment findings to validate existing
4. The results of a diagnostic x-ray film nursing diagnoses.

A. 1,2,4
B. 1,2,3 A. 1,3,2,4
C. 1,3,4 B. 2,4,1,3
D. 1,2,3,4 C. 3,4,2,1
D. 1,2,3,4
_____3. A nurse interviewed and conducted a physical
_____8. When developing a nursing care plan for a client with a
examination of a patient. Among the assessment data the
fractured right tibia, the nurse includes in the plan of care
nurse gathered were an increased respiratory rate, the
independent nursing interventions, including:
patient reports difficulty of breathing while lying flat, and
pursed-lip breathing. The data set is an example of: A. Apply a cold pack to the tibia.
B. Elevate the leg 5 inches above the heart.
A. Collaborative data set. C. Perform range of motion to right leg every 4
B. Diagnostic label hours.
C. Related factors. D. Administer aspirin 325 mg every 4 hours as
D. Data cluster. needed.

_____4. After assessing the client, the nurse formulates the _____9. Lily Cruz is 12 weeks pregnant. Her previous two
following diagnoses. Place them in order of priority, with pregnancies ended in a live birth at 41 weeks. What is the
the most important (classified as high) listed first. GTPAL of emilia?
1. Constipation
2. Anticipated grieving A. G:2, T: 1, P: 0, A: 0, L: 2
3. Ineffective airway clearance B. G:3, T: 2, P: 1, A: 0, L: 3
4. Ineffective tissue perfusion. C. G:3, T: 2, P: 0, A: 0, L: 2
D. G:2, T: 2, P: 0, A: 0, L: 2
A. 3,4,2,1
B. 4,3,2,1
C. 1,3,2,4
D. 3,4,1,2
_____10. Soong Joong Ki’s wife is experiencing her fifth pregnancy. Her first and last pregnancy ended in a spontaneous abortion at
7 & 8weeks, the second resulted in the live birth of triplet boys and girl at 38 weeks and the third resulted in the live birth
of a cute baby boy at 34 weeks. What is the GTPAL of Soong Joong Ki’s wife?

A. G:4, T: 1, P: 1, A: 1, L: 2
B. G:5, T: 3, P: 1, A: 2, L: 4
C. G:5, T: 4, P: 0, A: 2, L: 4
D. G:4, T: 4, P: 0, A: 2, L: 2

Test V: ENUMERATION. Enumerate and describe the following: (2pts each)

A. Five types of percussion sounds


B. Stages of Pressure Ulcer


C. Four qualities of Normal breath sounds


D. Four types of chest deformities


E. Seven types of abnormal breathing patterns (Depth & Rhythm)


F. Four types of abnormal breath sounds


G. Six types of lesion distribution


H. Grading for assessing the tonsils.


I. Five types of Nursing diagnosis


J. Four Physical Assessment techniques (In Order)


Test V: Discussion. (10pts)

Discuss the phases of Nursing Process.

Extra Credit: Describe your first hospital Duty in 200 WORDS (1-10pts)