Situation 1- The nurse assigned in the neurology unit is taking care of a patient with medical diagnosis of increased intracranial

pressure.

1. An intracranial pressure monitor is in place and the patient is becoming lethargic. The nurse notes the intracranial pressure is high. Which of the following should be the immediate action of the nurse? A. Turn the patient to his left side with the back supported with pillows B. Elevate the legs at 15 degrees with a pillow under the head C. Elevate the head of the bed to 30 degrees D. Raise the head of the bed to 90 degrees and the head supported with pillows

ANSWER: C INTRACRANIAL PRESSURE. An increase in intracranial bulk due to blood, CSF, or brain tissue leading to an increase in pressure. can be cause by trauma, hemorrhage, tumors, abscess, hydrocephalus, edema, or inflammation. FElevate head of bed ± 30 or 40 degrees as ordered. ± This allows gravity to drain cerebral veins. (Sandra Smith ± P177)

2. The nurse is monitoring intracranial pressure of the patient. Which of the following nursing assessment would identify the earliest indication of increasing intracranial pressure? A. Widening pulse pressure B. Change in level of consciousness C. Cyanosis and hypotension D. Increased body temperature

ANSWER: B FLevel of consciousness (most sensitive indication increasing ICP) ± changes from restlessness to confusion to declining level of consciousness and coma. ( Sandra Smith ± P176 )

FAltered LOC, which is the most sensitive and earliest indication of increasing ICP. ( Saunders ± P1028)

3. The nurse completed a nursing assessment. Which of the following data concludes that the patient is showing signs of increased intracranial pressure? A. Decrease in pulse pressure, increased heart rate and irregular breathing pattern B. Dilatation of the pupil, decreased blood pressure and increase in level of consciousness C. Increase in heart rate and respiratory rate and decreased level of consciousness D. Slowing of the heart rate, increase in pulse pressure and irregular breathing pattern

ANSWER: D FRise in BP, widening pulse pressure, slowing of pulse. ( Sandra Smith ± P177 )

4. In preparing the plan of care, the nurse should prioritize which of the following nursing and medical measures? A. high backrest to prevent Valsalva¶s maneuver and promote venous drainage B. Turning every 2 hours with logrolling movement to maintain proper position C. Elevating the head of the bed and keeping the head in proper alignment D. Proper positioning and frequent change in position

ANSWER: C FElevate head of bed ± 30 to 40 degrees as prescribed. (Saunders ± P1029) 5. The nurse plan of care includes preventing environmental stimuli that may stimulate an increase in intracranial pressure. Which of the following measures should the nurse include in the nursing care plan?

1. Keeping lights on low setting 2. Keeping noise at a minimum 3. Providing a calm and restful environment 4. Having a cooling blanket available

A. 1, 2, 3 and 4 D. 2, 3 and 4

B. 1 and 2

C. 1, 2, and 3

ANSWER: C FDecrease environmental stimuli ± dim lights, speak softly, limits visitors, avoid routine procedures if client is resting. ( Sandra Smith ± P177 )

Situation 2- Mrs. Borja, 65 years old, had an acute attack of pain, soreness and swelling on both knees. She is diagnosed with rheumatoid arthritis.

6. Nurse Karen is assessing the client. Which of the following is MOST likely to be assessed? A. Early morning stiffness B. Nodules along the knees C. Joint for deformities D. Limited motions of joints

ANSWER: A ± (Black 7th e ± P2335)

FRHEUMATOID ARTHRITIS. A Chronic, systemic autoimmune disorder whose major distinctive feature is chronic, symmetrical and erosive inflammation of the synovial tissue of the joints.

FJoint pain and swelling associated with morning stiffness.

7. The client is in the acute phase of rheumatoid arthritis. In addition to the prescribed medication, the physician orders application of heat and cold to manage arthritis pain. Which of the following statements indicate that the client lacks understanding in the application of heat and cold? A. ³Cold application is applied for 20 minutes, then 20 minutes off´ B. ³Hot water bag should be covered with flannel to prevent burns.´ C. ³Heat and cold can be applied as needed.´ D. ³Heat producing liniments can be used while applying heat and cold.´

ANSWER: A ± (Lipp ± P944) FApply cold or hot to affected joints 15 ± 20 minutes, 3 ± 4x a day.

8. Nurse Karen is helping the client, who is immobilized by pain, towards self-reliance and independence. The nurse should approach the problem with which of the following: A. Set a specific goal B. Set a positive attitude toward an eventful outcome C. Need for a member of the family during the pain episode D. Recognize that little can be accomplished

ANSWER: A (Kozier 7th e. p301)

PURPOSE OF GOAL. Provide direction for planning nursing interventions, ideas for intervention come more easily. If the desired outcomes state clearly & specifically what the nurse hopes to achieve

9. The nurse should know that a client with rheumatoid arthritis will most often have pain and limited movements of the joints: A. Resulting from non-adherence to prescribed diet B. After excessive exercises C. Because of inactivity upon awakening in the morning D. During cold weather

ANSWER: C ± (Black. P2335) Restriction of movement causes the muscles to shrink from lack of use. Joint pain and swelling are associated with morning stiffness that can last several hours.

10. To prevent deformities of Mrs. Borja, the nurse includes in the nursing care plan: A. Massaging the joint with oil liniment B. Implementation of strictly prescribed diet C. Performing isometric exercises twice a day D. Alternate rest periods with active exercises

ANSWER: D ± (Black. p2344) Table 79 ± 4

FPrinciples of joint protection and associated work simplification strategies. FBalance work and rest. Rest 5 to 10 minutes periodically when doing task that takes more time. Get sufficient sleep. Take 30 minutes rest during the afternoon. FEncourage exercise consistent with degree of disease activity. Schedule adequate rest period. (Lipp±P944)

Situation 3- A team of researchers is conducting a study on the effect of high dose corticosteroids in improving the motor and sensory outcomes of patients with spinal cord injuries within 6 weeks if administered within 8 hours after injury. The study covers a three month period.

11. On the basis of the nature of the investigation, which one of the designs listed below would allow the researchers to have the most confidence that the corticosteroids is effective in improving the motor and sensory outcomes of patients with spinal cord injury: A. Quasi or semi-experimental design B. Non-experimental design study design C. Experimental design D. Retrospective-prospective

ANSWER: D - (Nsg Rea Polit 6th e. ± 179) FRETROSPECTIVE. Study begins with dependent variable and looks backward for cause of influence. PROSPECTIVE. Study begins with independent variable and looks forward for the effect.

QUASI OR SEMI-EXPERIMENTAL. Manipulation of independent variable; no randomization and/or no comparison group; but efforts to compensate for this lack. NON-EXPERIMENTAL. Non manipulation of independent variable. EXPERIMENTAL. Manipulation of independent variable; control group; randomization.

± P77) VARIABLE. 10 C. 100 B. (Nsg Rea Polit 8th e. The subjects who receive the experimental treatment or intervention. 30 ANSWER: C (Nsg Rea ± Polit 8th e. P252) 13. In the above study. 8th e± P753) F EXPERIMENTAL GROUP. Subjects C. In determining the sample size. Variables D. Is a characteristic or quality that takes on different values. the researchers should include how many participants in this study? A. Which of the following variables is sufficient for the effect to occur? A. The people who provide information to the researchers (investigators) in a study (Rea Polit 8th e. (Nsr Rea ± Polit 8th e . SUBJECTS. Experimental group Control group B. P350) 14. ± P77) CONTROL GROUP. Injection of corticosteroids within 8 hours after injury . 500 D. ANSWER: A (Nsg Rea Polit. The target participants of the intended study are homogenous in the variables being measured. Refers to a group of subjects whose performance on a dependent variable is used to evaluate the performance of the treatment group of the same dependent variables.12. Which of the following is present in conducting the above study? A. the researchers manipulate the variable under study. Clients with spinal cord injury B.

Improved recovery and lessen hospitalization period B. Questionnaire in gathering pertinent data C. (Nsg Rea Polit. The nurse in the EENT unit is preparing the 8:00 AM medication. 16% to 20% D. Studies are investigations of the ways of obtaining and organizing data and conducting rigorous research. ANSWER: D (Brunner 11th e.C. p2084) . The manipulated variable to the experimental group is the: A. the nurse should make sure that the amount of medication reaches the ocular site of action in sufficient concentration. Research methodology D. 16. She is fully aware that topical administration of ocular medication results in how many percent rate of absorption? A. 8th e± P328) 15. 21% to 25% 1% to 7% B. Improved motor and sensory outcomes D. Injection of corticosteroids within 8 hours post spinal cord injury ANSWER: D Situation 4 ± To produce a beneficial effect on eye medications. validation. and evaluation of research tools or methods. motor and sensory outcomes patients with spinal cord injuries ANSWER: D METHODOLOGIC RESEARCH. Methodologic studies address the development. 10% to 16% C.

3. 2. the nurse MUST instruct the patient which of the following measures? 1. 2. p2085) FOphthalmic ointments have extended retention time in the conjunctival sac and provide a higher concentration that eye drops. Place the fingers on the sides of the nose to prevent medication from draining 2. 4. Inform the relative of the action of the drug. Which of the following guides the nurse in the administration of the ointment? 1. What is the advantage of ointment application from instillation of eye drops? 1. 4. The nurse is to administer eye ointment to the patient. ease of absorption and decreased risk of contamination B. In the application of topical anesthetics. The nurse is preparing ocular medications for topical route of administration.FTopical administration of ocular medications results in only a 1% to 7% absorption rate by the ocular tissues. The most common ocular medications is administered through instilled eye drops and applied ointments. Extended retention time and provides a higher concentration Easy to administer with reduced adverse reaction Promotes efficiency. 18. 19. FThe major disadvantage of ointments is the blurred vision that results after application. Common ocular medication include topical anesthetic. Explain the procedure to the patient. safety and distribution of solution evenly ANSWER: B ± (Brunner 11th e. Check medical conditions that would contraindicate the use of the drug. 17. Self administration. Administer during nap time or bedtime. Place the patient in supine position with the head slightly hyperextended . ANSWER: C ± ( Lipp ± p511) FInform the patient the need of the need and reason for instilling drops or ointment. C. 3. Ocular absorption involves the entry of a medication into the aqueous humor.

The patient is sweating. P1010 Situation 5± Consumers of health care require improvement in health care. The technique used by the client in the installation of the medication is: 1. The client looks up the ceiling and instills the correct number of drops at the middle of the eyeball. Fear and anxiety B. 21. Incorrect because it may damage the cornea .3. Nurses must deliver activities and behaviors and do the right things well and continue to strive to do better to meet and satisfy the diverse needs of clients. Aimed to protect the eyeball from injury C. Allowed so that the client is less likely to blink D. Nurse Cora observes the client with glaucoma while he instills his eye drops. Refrain from rubbing the eyes to prevent corneal damage ANSWER: D (Brunner 11th e. The nurse is assessing a patient receiving mydriatic eye drop. These manifestations are indicative of: A. 20. p2085) FThe nurse must instruct the patient not to rub his or her eyes while anesthetized because this may result in corneal damage. D. Correct as this spreads the medication over the eyeball 2. complains of blurred vision and drowsiness. Allergic reactions D. Close both eyes and gently move eyes 4. Overdose of the medications effect C. Systemic anticholinergic ANSWER: C ± Saunders.

Which of the following course of action should be given priority by the nurse? A. if present. Administer the prescribed anti-emetic B. To give independent nursing measures to relieve nausea. P1951) Ffirst priority. Taylor . should be reported immediately. For this reason. Nausea & vomiting are no longer expected outcomes of the surgical procedure but.ANSWER: D ± FThe sclera is fibrous & tough. ANSWER: D (Lipp. 3. Report the complaint to the attending physician ANSWER: B ± (Black. Assure the client that this is expected following surgery D. 2. The client may resume his activity with moderation the day after the treatment The client may indulge in normal activities after the treatment The client must be restricted in bed for one week D.P803) FInstill the drops onto the outer third of the lower conjunctival sac. The client may resume gradually her usual activities within 5 to 6 weeks. application to the eye seldom is placed directly onto the eyeball. 4. P529) Within 3 weeks ± light activities may be pursued . Which of the following statements serves as guide for the client during the rehabilitation phase? 1. but the cornea is easily injured by trauma. Shortly after. The client had cataract surgery. he complains of nausea. ( Funda. The members of the nursing team were discussing about the activity of the client treated with detached retina during the nursing rounds. Fsecond priority. P1347) 22. (Kozier. 23. Give ice chips to relieve nausea C. Prolonged vomiting may result in increased IOP and wound dehiscence.

A state or process in which persons. groups. often resulting in open conflict. Feeling that the surroundings or one¶s own body is revolving FSOCIAL ISOLATION. or cultures lose as do not have communication or cooperation with one another. Plan the course of action with the husband Create an atmosphere of sense of belonging for the couple Assist the wife to accept the condition of the husband D. She is concerned about the change in the husband¶s social activities. Any medication needs to be withheld after the procedure and the physician must be notified 3.Within 6 weeks ± heavier activity and athletes are possible 24. A. 25. the team should: 1. warmth and occasional discomfort when the fluid comes in contact with the tympanic membrane 2. 26. 4. To assist the wife in adjusting to the present situation. Ear irrigation requires cooperation from the client to facilitate the introduction of the solution 4. The staff nurse performs ear irrigation on a client for removal of cerumen. A delusional patient said. ³I have no head. no stomach. Assume lying position on the unaffected side after the procedure to facilitate drainage. p891) Situation 6 ± Following are situations that are a concern for records management of nurses. Experience a feeling of fullness. What relevant information should the staff nurse share with the client at the start of the procedure? 1. nurse Jesette shares with the team the concerns of the wife of a client with Meniere¶s disease. 3. 2. During the nursing conference.´ The nurse would record this in which part of the mental status? . ANSWER: A ± (Kozier. Explain to the wife that her husband is experiencing social isolation related to attacks of vertigo ANSWER: D ± (Black. p1972) FVERTIGO.

sadness. For proper documentation and accountability of all entries to the client¶s chart. It is a tool for assessing nurse-client interactions 3. 2. All notes must have signature and title of person making entry The staff must not abbreviate SOAP The nurse implements the use of problem-oriented progress notes Client¶s problems in the medical record must bear the date of entry and numbers of client¶s problem. 3. or happiness. (Shives. Emotional State C. (Keltner. p110) FCONTENT OF THOUGHT. EMOTIONAL STATE/ AFFECT. What the client actually says. eg. Individual¶s present emotional responsiveness.1. It provides data from which nurses can assess their own behavior in interactions with clients. It is observable manifestation of one¶s emotions or feelings inferred from facial expressions. it is important for the nurse to inspect that: 1. Content of thought orientation B. Recognition of place. C. Which of the following statements about Processing Recording is NOT true? 1. P109) (Keltner. nurse determines whether verbalization makes sense. p110) 27. ANSWER: A (Shives. P109) SENSORIUM OR ORIENTATION. Sensorium or ANSWER: A ± (Shives. P120) 28. Characteristics of talk D. A. It is an important means of communication between nurses or nursing students and their clinical supervisors/instructors about their peer relationships. . It acquaints the student/nurse with rudimentary applied research skills. 4. 2. person & time. Anger. 4.

vital signs. Objective C. p332 ASSESSMENT. Are tangible and measurable data collected during a physical examination by inspection. Salient points that are summarized C. Obtained as the client. Assessment phase of the nursing process includes the collection of data about a person. P106) FConsist of information that is measured or observed by use of the senses (e. Edited and comprehensive .(Shives. P129) 30. is used to teach communication skills to student nurses in the clinical setting. examining and interviewing. Brief and simple but focused on D. Student-client role play situations are one method used to familiarized students with the process recording. P147) FPROCESS RECORDING. percussion and auscultation. Also include observable client behavior such as crying or taking out loud when no one else is in the room.ASNWER: C . In order for the process recording to be an effective learning tool for nurses. data should be: 1. 106) FOBJECTIVES. ( shives. 29. A plan of care or nursing care plan. Is a tool used in various formats to analyze nurse-client communication. Subjective D. ( shives. Data: Client is pacing. family members or significant others provide information spontaneously during direct questioning or during health history. Unedited and comprehensive essentials 2. yelling at nursing staff and other patients. Plan ANSWER: B ± (Shives.g. palpation. In the problem-oriented progress notes this data would be noted under: 1. Which focuses on verbal and nonverbal communication. family or group by the method of observing. crying. laboratory & x-ray results. waving his hands. is individualized and identifies priorities of care and proposed effective intervention. SUBJECTIVE. PLAN.)kozier 7th e. Assessment B.

Conservative management did not work and the client requires surgery. ³I empathize with the client because of her age and her fear of not surviving surgery. Professional nursing actions are both ethical and moral. ³What do you think will happen to you when you don¶t follow medical advice?´ ³Aren¶t you bothered about your condition?´ ³Are you considering other course of action?´ ³Is it difficult to follow the medical advice?´ ANSWER: A ± (Psyche. B. Using caring based reasoning which of the following justify the refusal of the nurse in the preparation of surgery? 1. D. 4. ³I feel that my responsibility with the client is protecting her rights and meeting her needs. 31. Which of the following questions should the nurse ask the client? 1.´ . Shives.´ 3. but the family and the surgeon insisted. The staff nurse assigned to her decided not to help in the preparation of surgery. A. Mrs. p141) F A therapeutic communication. ³I strongly feel that surgery will cause her more suffering and probably will not survive and the family may even feel guilty later. Belmonte.´ 2. C. 32. She does not lose weight in spite of medical advice. A 75 year old frail woman had a cervical disk disorder. a middle-aged. 2.ANSWER: A Situation 7 ± Nurses encounter situations in which they must make decision based on the determination of what is right and wrong. C. The client insisted that she does not want surgery. obese woman seeks medical help often for the recurring lower back pain. Asking direct questions is to determine if the patient is complying to the medical advice. 3.

4. Care Provider C. Provide client with the list of her rights Ask the client what her expectations are Give a list of evaluation criteria and ask the client to respond ANSWER: B ± not related 35. Gonzales. 2. However. 4. one of them is Joey who is in plaster cast of the leg and needs a great deal of teaching and the other a 60 year old female. The nurse demonstrates ethics of care when she plays the role of a: 1. she has still two clients to visit. 4. Provide client with knowledge of what constitutes good care B. Teacher Client¶s Advocate B. A community health nurse in her home visits encountered a 58 year old woman who was depressed and tearful. 2. The following actions of the nurse are appropriate in addressing the complaints EXCEPT: 1. Stay with the client to prevent further depression ANSWER: D ± for patient¶s safety 34. She was hospitalized before with glaucoma. hemiplegic needing assistance in performing activities of daily living. Weigh the facts carefully in order to divide her time justly among her clients Tell the client she will come back after attending to the other clients Ask one of the family members to attend to the client D. She has been critical of the care she received which she regarded as not of high quality. 3. .´ ANSWER: C ± Client advocate 33. She knows that she could be of help to the client by staying and talking to her longer for another hour. Mrs. 3. Which of the following is the appropriate action of the nurse? 1. ³I support the client since she has the right to decide on her medical treatment and management. a 40 year old professional was confined after suffering mild stroke. Guidance Counselor D.

The protection of human or legal rights and the securing of care for all patients based on the belief that patients have the right to make informed decisions about their own health and lives. ADVOCATE. Situation 8 ± The nurse considers factors related to safety effectiveness in the planning and delivery of nursing services. Protect client¶s head ANSWER: D 37. p14) FCARE PROVIDER. intellectual. Which of the following is the LEAST intervention? 1. The use of communication skills to asses. and spiritual needs. implement and evaluate individualized teaching plans to meet learning needs of patients and their families. Taylor. Restrain the client to prevent from falling Give adequate support when turning or moving Keep the side rails up on the bed D. The Provision of care to patients that combines both the art and the science of nursing in meeting physical. TEACHER/EDUCATOR. socio-cultural. Use of therapeutic interpersonal communication skills to provide information. emotional. 3. how should the nurse assist the client? 1. Pull on the trapeze to lift the pelvis extending both legs . 4. She is placed in an orthopedic bed and to facilitate the use of the bedpan. make appropriate referrals and facilitate the patient¶s problem-solving and decision making skills. She is aware that without protection. COUNCILOR. The nurse notices that the comatose client starts to lighten.ANSWER: B ± (Funda. the client could fall or be injured. 2. 36. Following hip replacement after 24 hours the client asks for assistance onto the bedpan.

Mild water heater temperature device C. Lifting the pelvis off the bed and turn gently toward the operative side 3. The daughter asks the nurse how to promote safety in the stairways and hallways in the home. Elevate the pelvis using the trapeze involving the unaffected upper extremity and unoperated leg ANSWER: D ± (Funda. Assist the client in lifting the pelvis 4. Red and yellow and white B. 38. 784) FTRAPEZE. Blue and green D. Her married daughter visits her from time to time. Install additional lighting for visibility prevention training B. Craven. D. Cecille. They live in a thickly populated area and is concerned for the safety of her 3 young children. is to be discharged after sustaining a sprain from fall while negotiating the last step of the stairs. 32 years old has problem with the olfactory nerve. 76 years old is living alone. What measure should the nurse recommend for home safety? A. The nurse recommends extra lighting at the stairways and suggests repainting the hallways with: 1. Andoy. Black and white C. She can do activities of daily living with limited assistance and seems to be independent . Participate in fire D. Cream ANSWER: A 39. Helps clients raise trunk from bed and allow client position hangs. Lola Carmona.2. an elderly client. Install a smoke detector ANSWER: D 40.

she is likely to obtain clinical answers that are: 1. Evidence based C. Scientific B. A staff nurse consulted a more experienced nurse and other health care providers whether aggressive ambulation expedites the patient¶s recovery or it requires too much energy. 4. A. evidence-based approach to care Good interpersonal relationship with clients and families and the health team ANSWER: A ± (Funda. Committed in the exercise of duties and responsibilities to clients and co-workers Knowledge of the most effective and reliable. 2. Taylor. Which of the following measure should be recommended to reduce sensory deprivation? 1. Routine .. 2. Encourage acquaintances to come to the house for a chat Redecorate the house and provide a separate room Provide pictures of family members Invite friends often to share meals at home ANSWER: A ± (Funda. Reduction or prevention of culturally normal interaction between an individual and the rest of society. 3. p160) 42. SENSORY DEPRIVATION. Courteous and respectful to the health team and members. she must have which of the following traits? 1. The nurse is working in a tertiary hospital for almost a year. 3. nurses are increasingly accepted as essential members of the interdisciplinary health care team. B. Situation 9 ± In today¶s health care environment. Tradition based D. p1284) FEncourage social interaction. While this approach is extremely common. 4. 41. Kozier. In order to effectively participate and lead a health care team.physically.

2. attitude. Is a general set of orderly. Involvement in the political processes that shape their profession. etc. 4. Participate in the in-service education program offered by the institution. Nurses naturally work to effect policy in the work place. disciplined procedures used to acquire information. Changing nursing¶s image in the public eye will not be easy. B. A. handmaiden to the physician. 1. Given this situation. 43. skills. 3 only C. 2. naughty nurse. 1. ANSWER: B 44. what should the nurse do to conform to the institution¶s expectations? 1. Pursue post graduate course to enhance skills and competence. Which of the following strategy/strategies is/are needed to change nursing image in the mind of image makers? 1. conference and national convention related to the nursing profession. particularly on their desired health outcomes. Image makers provide the greatest number of visual images of nurses at work such as angel of mercy. 3 and 4 ANSWER: C 45. love interest particularly to the physician. Be a member of a nursing organization . Attend seminars. and social rules. 4. 2. P15) FSCIENTIFIC. 3. 3. Emphasize the contribution of nursing to patients. 2 only B. Restriction of the term nurse to mean licensed RN. Polit. Learn new values. Increased effort to publicly praise and value nursing.ANSWER: A ± (research. 3 and 4 D. Which of the following action(s) can nurses take to increase their influence in policy setting? 1. An experienced nurse is new in the work setting.

46. 3 and 4 ANSWER: A Situation 10. Somatic therapy D. 1. 1 only B. Get to know their elected officials 1. 3 and 4 D. 2. The most important role of the nurse as a member of the team is to: A. and working .e. Participate in coalitions of organizations 4. Keeps a 24 hours watch for the patient B. i. Psychotherapy Milieu therapy B.The following questions refer to nurses¶ efforts to integrate in mental health community work. Write lobbying letters 3. 3 only C. ANSWER: D ± Milleu therapy involves clients¶ interactions with one another. Meet the needs for the physical well being of patients C. 1. Coordinate the psychosocial care and management of clients ANSWER: D ± From the issue itself which is member of the team it follows that there should be coordination. Behavioral therapy C. giving one another feedback about behavior.2. Activity therapy is a treatment that utilizes which of the following? A. practicing interpersonal relationship skills. 47. Carry out medical orders D.

D are primary level of prevention which is directed towards promoting health and preventing the development of disease process. It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. Options A. therapist¶s approach is based on a theory or combination of theories. Providing mental health consultation to health care providers C. Which of these nursing actions belong to the secondary level of preventive intervention? A. Providing mental health education to members of the community B. It is also standard practice to inquire about suicide or self-harm thoughts in any setting where people seek treatment for emotional problems. Option C ± Somatic therapy is the biologic treatment for mental disorders such as ECT. 20003). at least in principle. Call a priest D. (Videbeck p. Being politically active in relation to mental health issues ANSWER: C . impairment. or illness.Psychotherapy it is the therapeutic interaction between a qualified provider and client or group designed to benefit persons experiencing emotional distress. Tertiary prevention occurs when a defect or disability is permanent and irreversible. Refer the matter to the police B. (Potter & Perry) 49. (Videbeck) 48. feelings and attitudes thus clients learn to cope with stress to through activity.cooperatively as a group to solve day to day problems same thing with the Activity therapist focuses on remotivation of clients by directing attention outside themselves to relieve preoccupation with personal thoughts. Option B ± Behavioral therapy is a mode of treatment that focuses on modifying observable and.Secondary level of prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Providing emergency psychiatric services D. physiotherapy etc. quantifiable behavior by means of systematic manipulation of the environment and variables thought to be functionally related to the behavior (Shahrokh & Hales. When the nurse identifies a client who has attempted to commit suicide the nurse should: A. Counsel the client ANSWER: D ± Asking clients directly about thoughts of suicide is important. Refer the client to the psychiatrist C. Option A .B.328) .

Maximize the likelihood ANSWER: C ± this option is an example of an affective learning approach. The problems of out of ASNWER: B ± it is the appropriate topic because since the audience is on elementary level. Anti-depressants. Mood stabilizers. An appropriate topic would be: A. Options A.50. 52. Discipline of children at home and school school youth C. Meet diverse learning needs about medications B. Participants play with a game board and color-coded game cards which bear questions on five categories of psychotropic medications. One objective of this group experience is for the clients to describe the impact of these medications on their symptoms and day to day activities. The community health nurse was invited by the principal of an elementary school and was asked to give a talk to parents.Nurse Grazilda engaged clients in a group experience for medication education. Anti-anxiety medications and Medications for drugs of abuse. Students are paired with clients to play a game and exchange knowledge about medications and disorders. Immediate discussion and interaction about daily life situations utilizes the principle of: . The legal aspects of drug abuse B. 51. Game questions include the five categories namely: Antipsychotic medications. Share common feelings D. Marital crises D. The aim of this affective learning approach is for the clients to: A. Options C is for college students. Situation 11. An opening comment about the purpose of the group encouraged clients to gather around the table and select small toy cars to move playfully around the racetrack game board. and D are for highschool students. Satisfy client¶s level of functioning of compliance C.

Clients shared a sense of ³we-ness´ C. Efficiency ANSWER: A ± Reinforcement is a stimulus that strengthens or weakens the behavior that produced it. Flexibility is the quality of being adaptable or variable.´ ANSWER: B ± Interpersonal learning includes the gaining of insight . Appropriateness is to take one¶s self in exclusion of other¶s. One client said. Universality C. ³I don¶t want anyone to repeat this. Appropriateness C. Clients have the experience of learning to help others and in the process they begin to feel better about themselves.208) 54. One client shared her very infrequent experiences with alcohol. One client advised another client that he should get a ³pill box´ so he would remember to take medications B. and the importance of learning about oneself in relation to others. Altruism D.the development of an understanding of a transference relationship. Which of the following client behaviors demonstrate that interpersonal learning occurred? A. which she knew were contraindicated with her medications and the quietly stated. Universality can be defined as the sense of realizing that one is not completely alone in any situation. Efficiency is the quality of being efficient or producing an effect or effects. Imparting of information includes didactic instruction and direct advice and refers to the imparting of specific . (Shives p. Option C is an example of Universality.Altruism in therapy groups benefit members through the act of giving to others. Flexibility B.A. insight and reassurance while allowing themselves to gain self-knowledge and growth. Clients said they were ³all in the same boat. Group cohesiveness B. (Webster Dictionary) 53. Option D is an example of Catharsis. Reinforcement D. Both the group therapist and the members can offer invaluable support. Option A is an example of Imparting of information.´ D.´ This experience included which of these therapeutic factors? A. Imparting information ANSWER: A . ³I feel that way. the experience of correcting emotional thoughts and behaviors.

Then she received a telephone call from the police notifying her that her husband had just been pulled from the river. Without a tear. she became focused on attending to her children and simply signed the necessary paperwork.207) . Integration is re-organizing and reintegrating the sense of self to pull life back together. second stage is Developing awareness. Development of pre-determined. 56. Use of alternative teaching strategies that fit the needs of the group C. Lily. Recovery ANSWER: B ± Engels Stages of Grieving first stage is shock and disbelief. Reality B. with death. Which of the following LEAST contribute to creating a therapeutic learning environment? A. Flexibility in accommodating the number of players ANSWER: A ± Because being in a heterogenous group will have a hard time in controlling and manipulating the participants that will hinder in creating a therapeutic environment. Shock is the initial reaction to a loss stunned numb feeling. Witnesses say her husband jumped from a bridge in the locality. Integration D. fourth stage is Resolution of loss. Recovery is the preoccupation & obsession ends and individual go on with life. Options B. Heterogenous composition of participants B. Group cohesiveness is the development of a strong sense of group membership and alliance.educational information plus the sharing of advice and guidance among members. third stage is Restitution which is participation in rituals assoc. together with her children walked a 10 block way to the funeral home to meet the medical examiner to identify the body of her husband. (Videbeck 5th edition p. fifth stage is Recovery.C. the mother of two children was cooking dinner and wondering why her husband was so late. She is in a state of: A. help to accept reality of loss. Situation 12 ± Lily. absolute group goals D. (Shives p.D will help in creating a therapeutic learning environment.208) 55. Shock C.

Reaction formation is acting the opposite of what one thinks or feels. hope and meaning to life. Destructive D. Introjection is accepting another person¶s attitudes.57. Displacement D. goals and lifestyle. Powerlessness D. beliefs and values as one¶s own. often resulting in an open conflict. Lily hurls angry and explosive outbursts toward those who are helpful to her. Spiritual distress is the state in which an individual or group experiences or is at risk of experiencing a disturbance in the belief or values system that provides strength. Hostility is distinct from anger in that the former is: A. Unable to handle her emotions. (Videbeck) ` 59. Reaction formation C. ANSWER: C ± Displacement is the ventilation of intense feelings toward persons less threatening than the one who aroused those feelings. Disturbed self-esteem C. ANSWER: C ± Hostile behavior is intended to intimidate or cause emotional harm to another and it can lead to physical aggression while Anger is a normal human emotion. groups or cultures lose or do not have communication or cooperation with one another. . (Videbeck) 58. is a strong. Disturbed self-esteem is a state in which a person is experiences or is at risk of negative evaluation about self and capabilities. Growth-promoting C. Spiritual distress Social isolation B. Lily struggled not only with finances but with confusion and rage in response to her husband¶s actions and abandonment. ANSWER: C ± Powerlessness is the state in which an individual or group perceives a lack of personal control over a certain events or situations which affects outlook. Compatible with love Ego syntonic B. This behavior is an example of: A. The nursing diagnosis is: A. Social isolation is a state or process in which persons. In the following weeks after the death of her husband. Sublimation Introjections B. Sublimation is the substituting a socially acceptable activity for an impulse that is unacceptable.

Option B and C is an example of Agreeing. emotional response to a real or perceived provocation. 61. ³Gusto mong i-kwento kung ano pa ang naiisip at nararamdaman mo?´ (³Would you like to tell me more about your thoughts and feelings?´) B. ³Huwag kang matakot. Ask Lily to describe what is the ³hardest part´ of the death for the family Assure that death of husband is not her fault An encouragement toward normalcy must be communicated The nurse should be non-reactive ANSWER: B ± Option B is an example of false reassurance. I¶ll keep watch over you. Option C is an example of reflecting. Situation 13.The nurse works in an institution that shelters street children. 60.´ (³I don¶t want to sleep alone. babantayan kita. (Videbeck) .´) ANSWER: A ± Allows verbalization about his concerns.uncomfortable. At night when the children are being prepared to go to sleep. when she actively works out her rage which of the following is NOT therapeutic? 1. She encounters varied family histories and presenting behavior patterns of these clients. During nurse-patient interactions with Lily. There¶s a ghost!´). The nurse conveys acceptance with which of these responses? A. ³Talaga? Anong itsura ng multo?´ (Really? How does the ghost look like?´) C. (Videbeck) Options A and B is inappropriate.´) D. May multo. the nurse hears from a frightened child ³Ayaw ko matulog mag-isa. 4. 3. 2.´ (³That must really be scary. Option D is Reassuring.´ (³Don¶t be afraid. Option A allows exploration through verbalization. Option D is an example of active listening. ³Nakakatakot nga ang pakiramdam na ganyan.

145 & 156) 63. other people. Family therapy for the dysfunctional families B. Support and caring to children during family crisis situations D. The nurse is MOST therapeutic in meeting their needs by being a: A. shelter. feelings and attitude. food. by providing a rest. Option B is for toddler. With adequate rest. the child: A. cleanliness. Develops a sense of competence B. Mother surrogate C. cleanliness. Option A is on school age. Child therapist ANSWER: B ± Mother surrogate is the nurturing needs of clients who are unable to carry out simple tasks. Activity therapist focuses on remotivation of clients by directing their attention outside themselves to relieve preoccupation with personal thoughts. food. Nurseteacher educates clients about specific illnesses and medication prescribed to promote stabilization of their condition. Acquires a sense of personal power others C. warmth and safety will develop the trust in oneself. Teacher B. Most street children come from broken families. Learns to trust in self and in ANSWER: D ± it is task that should be developed. Preventive interventions for children at risk are BEST achieved through: A. shelter.62. Develops a separate identity D. Play and activity therapies for children .(Shives p. warmth and safety. the environment and meaningfulness of existence. Activity therapist D. Non-government organizations and other workers paying attention to victims in conflict ridden communities C. Option C is for early adolescence. 64.

Therapist C. Her father would always come home drunk and beat up Cindy¶s mother. As an effect of this experience she had nightmares. Option A and D is inappropriate while Option B is for phobia. The Comprehensive Dangerous Drugs Act (R. tension and palpitations lasting for more than a month.9165) challenges the nurse in his/her role as a/an: A. An identifiable traumatic ANSWER: C ± this is an example of post traumatic stress disorder. In the advocate role. Option D is done after crisis. (Videbeck p. Adjustment in growing up stress B. Cindy was a frequent witness to domestic violence. Options B and c are the same. 66. 65. Counselor ANSWER: D ± it is also known as Nurse-teacher educates clients about specific illnesses and medication prescribed to promote stabilization of their condition.145). Imagined loss of parental C. speechless for weeks. the nurse informs the clients and supports him or her in whatever decision he or she makes. No. they uses therapeutic skills to help clients identify and deal with stressors or problems that have resulted in dysfunctional coping.96 and Shives p. inability to sleep. Cindy is experiencing anxiety due to: A. Situation 14 ± Increasing problems of substance abuse continue to challenge the competencies of professional nurses. Advocate D. . Health educator B. Fear of phobic proportion love D.A.ANSWER: C ± in order to divert attention of the child from crisis.

Individuals who have access to support from intact family groups D. 69.C and D are all manifesting positive behavior in dealing with drug abuse. Aware of the scope of nursing practice he/she recognizes the necessity to network with other agencies to discuss this area: A. Communication skills appropriate for different ages B. Legal implications of illegal drug use ANSWER: D ± There is needed information that should come from other agencies. The nurse is conducting Parent Education Classes. Constructive discipline C.B and C can be discussed thoroughly by a nurse. An addict who has reached bottom pit level of self-disgust and who wants help B. Which of these characteristics has the LEAST potential success of treatment of drug dependency? A. A person who began taking the drug of choice for recreational or experimental reasons ANSWER: B ± since the individual has been using drugs since his/her teenage years. Options A. 68. Option A. Mandatory basic education transformation of society C. Programs focusing on means of dealing with problems and frustration of adolescents B. Normal and deviant child and adolescent behavior and development D. An individual who became dependent on a drug before or during the teen years C.67. An integrated program requiring development of both intellectual and affective health . The BEST model of drug abuse prevention supports: A.

D. The medical treatment of drug abuse utilizing less addictive drugs ANSWER: A ± because it focuses on the concerns of the adolescents. nervous and exhausted all the time is an example of physical experience. ANSWER: D ± Denial is the failure to acknowledge an unbearable condition . I take drugs only when I am under stress. Although he has made up for this. 70. Clients says ³I am not a substance user.Eric. he cannot get this out of his mind.47) Situation 15. He reports that he failed a practical exam a year ago. ³I feel helpless and D. he reports he is ashamed and embarrassed by a mistake he made in his class oral report and feels like his classmates are going to look down on him. ³I am tense. a 19 year old. Substitution is the replacing of the desired gratification with one that is more readily available . ³I do not know what to do´ depressed´ B. Repression Denial B. Substitution C. nervous and exhausted all the time´ lot´ C. (Videbeck p. Compensation is the overachievement in one area to offset real or perceived deficiencies in another area. When the nurse asks Eric to describe his physical experience. ³I am worried and thinking a ANSWER: B ± being tense. . failure to admit the reality of the situation or how one enables the problem to continue . which of these assessment data are appropriate? A.´ What defense mechanism is this client employing? A. Compensation D. During the initial evaluation of the psychiatric nurse. second year college student is seeking assistance in coping with school related stressors and sleep disturbances. Represssion is excluding emotionally painful or anxiety provoking thoughts and feelings from conscious awareness . 71.

in . Eric admits that he has ³always been wound up´ just like his father and that he has negative thoughts of himself. 73. Option C is for middle age. ANSWER: C ± Coffee has caffeine which is an example of a stimulant. It is not conditioned by a specific trigger B. Which of these would she caution Eric to avoid? A. as opposed to GAD. Mistrust C. Classical music C. a phobia is a response to experienced anxiety and is characterized by a persistent fear of specific places or things. It results in selective attention/inattention ANSWER: A ± Similar to all anxiety disorders.72. It creates panic C. Coffee after dinner D. Role confusion B. Stagnation ANSWER: D ± Eric is an adolescent which is the task is formulating a sense of self and belonging. There is an easily recognizable stressor that provokes anxiety D. Option B is for infancy. Which of these describe the characteristic of free floating anxiety? A. 74. Other options will promote relaxation and sleep. He is having a problem of: A. Option A is for school age. Inferiority D. Warm milk A warm bath B. The nurse teaches non-pharmacologic ways to induce sleep.

Option B is on the Panic level of anxiety.Many clients in a psychiatric unit receive antipsychotic medications. Stiffening of the client¶s C.28) .which the anxiety is free-floating. Fear of losing control thus avoids going out or avoids crowds ANSWER: B ± Generalized anxiety disorder is characterized by at least 6 months of persistent and excessive worry and anxiety. Upward rolling of the eyes the hands B. (Videbeck) 75. A. Experience of anxiety after exposure to a life threatening event B. Irrational thoughts and actions D. anxiety is displaced or externalized to a source outside the body. Option D is on the Moderate level of anxiety. Pill rolling movement of ANSWER: B ± This feeling of internal restlessness and the inability to sit still or rest often leads clients to discontinue their antipsychotic medication. A common extrapyramidal symptom that is very unpleasant and intolerable to clients is called akathisia. 76. also referred to as Neuroleptics. Clients may be shifted from typical to atypical antipsychotic medications because of its minimal extrapyramidal side effects. Option A is PTSD. Presence of excessive anxiety for a period of 6 months or more C. This is: A. (Videbeck p. Options C and D are Phobia.275) Situation 16. Inability to sit or stand still neck D. Other options are also signs of EPS. A generalized anxiety disorder is distinguished by. thus. (Videbeck p.

Option B is inappropriate because the increase fluid intake is to solve constipation but not to urinate frequently.´ D. any food with cheese and processed meat. the nurse remembers that she should stop giving the medication when she observes this side effect: A. Sore throat. Option D is for MAOI¶s. Uncomfortable sun burns B.´ ANSWER: C ± Antipsychotic medications requires the use of sunscreen because photosensitivity can cause the client to sunburn easily. Low blood pressure upon getting up from bed . Facial grimacing C. Which side effect should cause the nurse to be MOST concerned? A.´ C. is given Thorazine (Chlorpromazine). decreased white blood cell count C. Fine tremors D.´ B.(Videbeck p29-30) 78. ³I will avoid pizza. ³I will drink about 2 liters of fluids daily and expect to urinate frequently. Options A.2313) 79. The client correctly understood the health techniques of the nurse when he says: A. Tremors.77. This medication has several side effects. While giving Chlorpromazine (Thorazine) to client Michelle. Carl.B and D are expected side effect and this are called EPS. Shuffling gait sclerae B. (Brunner p. ³I will immediately report any episode of diarrhea or vomiting to my doctor. Option A is for SSRI¶s. Yellow ANSWER: C ± Is an adverse effect and is a sign of hepatotoxic which is jaundice. ³I will wear long sleeve clothing and sun block when I go out. inability to stand still D. fever. Another client in the ward. Health instructions about Haldol (haloperidol) has been given to Anthony while in the hospital and before his discharge.

A therapeutic environment for Peter is: 1. Nardil (Phenelzine) D. Clients on antipsychotic medications usually receive anti-parkinson drugs to reduce Parkinson like side effects. No limitation on his activities D. Affect D. Well lit and basically colored room . He started to be bossy. grandiose.275) 80. Option B is MAOI¶s. Fluoxetine (Prozac) ANSWER: A ± it is an example of anti-parkinsonian drug. Fluphenazine (Prolixin) B. ulcerative sore throat and leukopenia. The drug must be discontinued immediately. Perception C. claiming that he is the manager on the unit. Minimal environmental stimuli 2. clients are euphoric. They have poor judgment and rapid thoughts. 81.317) 82. Congentin (Benztropine) C. (Videbeck p. Strict isolation and withholding privileges C. (Videbeck p. Conscience B. Peter¶s condition is primarily a problem of: A. Thought ANSWER: C ± During manic phases. Option C is Anti-psychotic. (Videbeck p. malaise. 29-31) Situation 17 ± Peter. manic phase.ANSWER: B ± it has the potentially fatal side effect because Agranulocytosis develops suddenly and is characterized by fever. actions and speech. a 35 year old employee was admitted to the hospital because of behavioral problems at the office. What medication would the nurse expect the client to receive? A. energetic and sleepless. On admission he was diagnosed to be having Bipolar disorder. Option D is SSRI¶s.

(Videbeckp. 4. ³Peter. 3. we don¶t favor anyone. became furious. Option B and D is not appropriate. Option D is correct since its matter of fact but the issue presents that the patient becomes FURIOUS which would further escalate due to the rsponse. change and heal. 2. 2. Options C and D are concerns of the patient. 3. 2.324) 83. Restraining would be the last intervention.ANSWER: A ± A primary nursing responsibility is to provide a safe environment for clients and for others. you don¶t sympathize but you empathize. This is BEST demonstrated by the nurse in. Option C it should be simple activities such as card games or a short walk and it is necessary to set limits when they cannot set limits on themselves. Respond with. Easily finishes projects given to him during occupational therapy Takes his medications without reminding him Demonstrates skills in activities of daily living Complies with hospital rules and regulations . 3. The nurse may recommend discharge when Peter: 1.´ ANSWER: A ± the client must establish external control. 4. Option A. 1. Restrain him and put him on isolation to protect other patients. (Videbeck) 85. Sympathizing with the miserable feelings of Peter Suppressing her own feelings towards Peter Engaging Peter in productive activity Engaging Peter in introspective thinking ANSWER: B ± Therapeutic use of self: nurses uses themselves as a therapeutic tool to establish the therapeutic relationship with clients and to help clients grow. 4. During socialization Peter was provoked. A therapeutic intervention of the nurse is: 1. started shouting and making personal demands.304) 84. Nurses must not allow their own issues & biases to color interactions. Take him away from the group until he manages to have control of himself. (Videbeck p. Therapeutic use of self is essential in relating with psychiatric patients. Everybody in the ward is in equal footing. Prevent him from becoming more furious by giving an extra PRN dose of sedative.

Following are situations that nurses presented during a monthly nursing circle. Option C. Option A is an example of giving approval. ³I thought you really liked me. I like you.´ B.110) 87. Reducing patient¶s anxiety D. He remarked. Say as a matter of fact. Option D is an example of disapproving. Jurry asked the nurse to have an ³out on pass´ privilege for the weekend but his request was not granted by the nurse.ANSWER: B ± Adherence to treatment regimen of medication and psychotherapy. (Videbeck p. The dynamics of behavior underlying manipulative behavior explain that it is a behavior of: A.328) Situation 18.´ C. Sensing fear of other people . ³You upset me with your remark. 86. Exhibiting uncooperative and hostile behavior C. ³I understand. you feel bad but of course. Ignore Jurry¶s remark D. (Videbeck p. you don¶t ignore the client. Be transparent and express disapproval openly.´ ANSWER: B ± it is an example of verbalizing the implied. ³Your behavior did not meet criteria for out on pass privilege. A sense of security and control B.The stress of hospitalization can lead to difficulties between nurses and patients. Say.´ A therapeutic response of the nurse would be: A.

³I¶m Cathy. An invitation to have a social and intimate relationship with her nurse D. This behavior can be understood by the staff as: A.469) . Avoiding taking responsibility for her own behavior and underlying feelings B.ANSWER: B ± due to lack of insight they often act-out their feelings in aggressive and hostile behavior. Immature and childish behavior ANSWER: B ± this is a normal and an understandable behavior of an elderly. ³the best´. Disturbance in emotion. Often. an elderly client idealizes some nurses as ³terrific´. Say nothing and just go on with the usual nursing interventions D. thought and perception is moderate to severe. I¶m your nurse. 88. The therapeutic response of the nurse would be to: A. Remove the patient¶s hand while saying calmly. or ³indifferent´. such as calling them by name and referring to the time of day or expected activity. ³I¶m the nurse and this is a hospital. Say her name. A patient with delirium touches the nurse inappropriately. Ask for the patient¶s name and if whether he is aware where he is. Lolita. (Videbeck p. or ³so understanding´.´ C. 89. the use of touch reassures clients and provides contact with reality. B. but refers to others as ³mean´.´ ANSWER: D ± Delirium is confusion accompanied by altered or fluctuating consciousness. The nurse provides orienting cues when talking with clients. An understandable behavior for an elderly that must not be taken seriously C.

. Brainstorming session ANSWER: B ± Since it is a nursing concern. unable to sleep` and concentrate and frequently would just be quiet and stare. Social support is emotional sustenance that comes from friends. Seminar-workshop D. Depersonalization 2. Social support ANSWER: A ± religious activities such as church attendance and praying associated social support have been shown to be very important for many people and are linked with better health and a sense of well-being. Nursing Conference C. Medical support C. 91. Some staff views it as unprofessionally punitive and uncaring. nursing conference is more appropriate. Cognitive disturbance occurs when there is clinically significant deficit in cognition from a previous level of functioning. The MOST appropriate approach to address the nursing concern is through: A. Within the next 6 months from the accident he was observed to be detaching himself from others. The staff nurses have differing emotional reactions to the use of limit setting. He tells you. A. The nurse can BEST intervene by mobilizing the client¶s relatives. ³It is my fault. Situation 19 ± Robert is a survivor of a tragic accident wherein his wife and child drowned when their boat sank due to stormy weather. friends and people to provide. What kind of husband and father am I?´ He is expressing. Spiritual support B. Inappropriate affect is displaying a facial expression that is incongruent with mood or situation. Counseling with the nursing supervisor B. Material support D. Guilt C.90. Cognitive disturbance ANSWER: B ± Guilt is the feelings of culpability especially for imagined offenses or from a sense of inadequacy. 1.491) 92. Inappropriate affect D. Depersonalization is the feelings of being disconnected from himself or herself. (Shives p.

202). Sympathy D. Verbal assaultiveness C. combat or an assault. (Videbeck) 93.family members. Personality dysfunction ANSWER: A ± Post traumatic stress disorder is a disturbing pattern of behavior demonstrated by someone who has experience a traumatic event such as natural disaster. 95. (Mosby Dictionary) 94. Psychotic breakdown C. Developmental crisis D. The patient is having a: A. Depression B. as a form of maladaptation. Option B. The nurse encourages the client to communicate and socialize because internalized hostility can lead to: A. no matter what his behavior. . (Videbeck p. Post traumatic stress disorder B. Acceptance C. Physical assaultiveness D. dependent or inactive. and even health care providers who help a person when a problem arises. Amok ANSWER: A ± Hostility turns towards self is considered depression. emotions or states of mind of another. C and D is inappropriate. A therapeutic attitude the nurse can convey to the client while he talks about his loss is: A. Optimism is an inclination to put the most favorable construction upon actions and events or to anticipate the best possible outcome. Passivity is a mental state of being submissive. Optimism B. Passivity ANSWER: Acceptance is the avoiding judgments of the person. Sympathy is an expressed interest or concern regarding the problems.

She has an IV in her left forearm. Veracity is truth-telling. (Venzon 10th edition p. Listening to old familiar . she repeatedly declares that she does not want to be restrained. 102) 97. Cortez? A. refers to the right to demand to be treated justly. and a tendency to wander. Beneficence D. Concerned that Mrs. the staff is considering the possibility of using restraint on her. Wheelchair privilege commode C. Cortez is an 85 year old woman who has been hospitalized due to a urinary tract infection and dehydration. Cortez. Fairness ANSWER: A ± Beneficence promotes doing acts of kindness and mercy that directly benefit the patient. Request for a sitter B. With a history of osteoporosis and a tendency to wander. which was difficult to establish. Justice B. 96. which of the following should be a priority? A. Playing a table board game picture album B. 98. Provision of a bedside ANSWER: C ± Safety is the priority concern. Veracity C. The staff is considering the possibility of using restraint on Mrs. She has Alzheimer¶s disease.Situation 20. Singing to or with her music C. Option C and D is the same. fairly and equally. osteoporosis. Which of the following would be LEAST likely appreciated by Mrs. however.Mrs. Going through family D. Cortez might pull out her IV and wander off the floor. Prevention of fall D. The staff is faced with an ethical dilemma of autonomy versus: A.

Mrs. Which way would you want your egg done? Scrambled? Sunny side up? With vegetable mix? Or boiled? B. How would you want to have your egg done? D.ANSWER: A ± Clients lose intellectual function. Which question is MOST effective to communicate with her? A. the client may have difficulty recalling the use of buttons and zipper. The nurse aims at highest level of self care. Which of the following will the nurse minimize? A. Labeling clothing items ANSWER: C ± Since there is a progressive cognitive impairment. 99. Do you want fried egg or boiled egg? C. SITUATIONAL Situation 1. Hand and body lotion C. Cortez has a dietary privilege of food preferences. Providing mouth swabs with buttons and zippers B. Using clothing D.The nurse assigned in the neurology unit is taking care of a patient with medical diagnosis of increased intracranial pressure. What is your favorite egg recipe? ANSWER: C ±This may asses the memory of the patient. . 100. which eventually involves the complete loss of their abilities and option A requires concentration and focus.

( Sandra Smith ± P176 ) FAltered LOC. tumors. Cyanosis and hypotension D. ( Saunders ± P1028) . edema. ± This allows gravity to drain cerebral veins. Elevate the head of the bed to 30 degrees D. FElevate head of bed ± 30 or 40 degrees as ordered. which is the most sensitive and earliest indication of increasing ICP. hemorrhage. Which of the following should be the immediate action of the nurse? A. The nurse is monitoring intracranial pressure of the patient. The nurse notes the intracranial pressure is high. Which of the following nursing assessment would identify the earliest indication of increasing intracranial pressure? A. Elevate the legs at 15 degrees with a pillow under the head C. can be cause by trauma. An intracranial pressure monitor is in place and the patient is becoming lethargic. Turn the patient to his left side with the back supported with pillows B. or inflammation.1. Change in level of consciousness C. abscess. or brain tissue leading to an increase in pressure. Raise the head of the bed to 90 degrees and the head supported with pillows ANSWER: C INTRACRANIAL PRESSURE. Widening pulse pressure B. (Sandra Smith ± P177) 2. hydrocephalus. Increased body temperature ANSWER: B FLevel of consciousness (most sensitive indication increasing ICP) ± changes from restlessness to confusion to declining level of consciousness and coma. An increase in intracranial bulk due to blood. CSF.

The nurse completed a nursing assessment. decreased blood pressure and increase in level of consciousness C. Proper positioning and frequent change in position ANSWER: C FElevate head of bed ± 30 to 40 degrees as prescribed. the nurse should prioritize which of the following nursing and medical measures? A. In preparing the plan of care. increased heart rate and irregular breathing pattern B. Decrease in pulse pressure. widening pulse pressure. high backrest to prevent Valsalva¶s maneuver and promote venous drainage B. Turning every 2 hours with logrolling movement to maintain proper position C.3. Which of the following data concludes that the patient is showing signs of increased intracranial pressure? A. slowing of pulse. increase in pulse pressure and irregular breathing pattern ANSWER: D FRise in BP. Dilatation of the pupil. Slowing of the heart rate. Providing a calm and restful environment . (Saunders ± P1029) 5. ( Sandra Smith ± P177 ) 4. Increase in heart rate and respiratory rate and decreased level of consciousness D. Elevating the head of the bed and keeping the head in proper alignment D. Keeping lights on low setting 2. Keeping noise at a minimum 3. Which of the following measures should the nurse include in the nursing care plan? 1. The nurse plan of care includes preventing environmental stimuli that may stimulate an increase in intracranial pressure.

She is diagnosed with rheumatoid arthritis. avoid routine procedures if client is resting. 3 and 4 D. symmetrical and erosive inflammation of the synovial tissue of the joints. Nurse Karen is assessing the client. 2.4. limits visitors. soreness and swelling on both knees. . FJoint pain and swelling associated with morning stiffness. 1. Nodules along the knees C. 65 years old. 1. Early morning stiffness B. A Chronic. ( Sandra Smith ± P177 ) Situation 2. Which of the following is MOST likely to be assessed? A. Joint for deformities D. had an acute attack of pain. 2. Limited motions of joints ANSWER: A ± (Black 7th e ± P2335) FRHEUMATOID ARTHRITIS. and 3 ANSWER: C FDecrease environmental stimuli ± dim lights. systemic autoimmune disorder whose major distinctive feature is chronic. Borja. 3 and 4 B. 2. Having a cooling blanket available A. 1 and 2 C. 6. speak softly.Mrs.

³Hot water bag should be covered with flannel to prevent burns. p301) PURPOSE OF GOAL. ³Heat producing liniments can be used while applying heat and cold. who is immobilized by pain. Set a positive attitude toward an eventful outcome C. towards self-reliance and independence. If the desired outcomes state clearly & specifically what the nurse hopes to achieve 9. ideas for intervention come more easily. 8. The client is in the acute phase of rheumatoid arthritis. Recognize that little can be accomplished ANSWER: A (Kozier 7th e. The nurse should approach the problem with which of the following: A. the physician orders application of heat and cold to manage arthritis pain. then 20 minutes off´ B. Set a specific goal B. Provide direction for planning nursing interventions.´ D. Need for a member of the family during the pain episode D. The nurse should know that a client with rheumatoid arthritis will most often have pain and limited movements of the joints: . ³Cold application is applied for 20 minutes.7. Which of the following statements indicate that the client lacks understanding in the application of heat and cold? A. In addition to the prescribed medication. ³Heat and cold can be applied as needed. Nurse Karen is helping the client. 3 ± 4x a day.´ ANSWER: A ± (Lipp ± P944) FApply cold or hot to affected joints 15 ± 20 minutes.´ C.

Rest 5 to 10 minutes periodically when doing task that takes more time. FEncourage exercise consistent with degree of disease activity. Schedule adequate rest period. P2335) Restriction of movement causes the muscles to shrink from lack of use. p2344) Table 79 ± 4 FPrinciples of joint protection and associated work simplification strategies.A. (Lipp±P944) . Get sufficient sleep. FBalance work and rest. Because of inactivity upon awakening in the morning D. the nurse includes in the nursing care plan: A. Implementation of strictly prescribed diet C. Borja. 10. Alternate rest periods with active exercises ANSWER: D ± (Black. After excessive exercises C. Massaging the joint with oil liniment B. Joint pain and swelling are associated with morning stiffness that can last several hours. To prevent deformities of Mrs. Performing isometric exercises twice a day D. Resulting from non-adherence to prescribed diet B. Take 30 minutes rest during the afternoon. During cold weather ANSWER: C ± (Black.

Retrospective-prospective ANSWER: D . 11. QUASI OR SEMI-EXPERIMENTAL. Experimental design D. 8th e± P753) . Manipulation of independent variable. Study begins with independent variable and looks forward for the effect. Study begins with dependent variable and looks backward for cause of influence. PROSPECTIVE.A team of researchers is conducting a study on the effect of high dose corticosteroids in improving the motor and sensory outcomes of patients with spinal cord injuries within 6 weeks if administered within 8 hours after injury.Situation 3. Non-experimental design study design C. ± 179) FRETROSPECTIVE. Quasi or semi-experimental design B. EXPERIMENTAL. NON-EXPERIMENTAL. Variables D. The study covers a three month period. no randomization and/or no comparison group. Non manipulation of independent variable. Subjects C. 12. which one of the designs listed below would allow the researchers to have the most confidence that the corticosteroids is effective in improving the motor and sensory outcomes of patients with spinal cord injury: A. Experimental group Control group B. randomization.(Nsg Rea Polit 6th e. Manipulation of independent variable. but efforts to compensate for this lack. Which of the following is present in conducting the above study? A. On the basis of the nature of the investigation. ANSWER: A (Nsg Rea Polit. control group.

In the above study. P252) 13. the researchers should include how many participants in this study? A. In determining the sample size. motor and sensory outcomes patients with spinal cord injuries ANSWER: D . P350) 14. ± P77) CONTROL GROUP. Clients with spinal cord injury B.F EXPERIMENTAL GROUP. Refers to a group of subjects whose performance on a dependent variable is used to evaluate the performance of the treatment group of the same dependent variables. The people who provide information to the researchers (investigators) in a study (Rea Polit 8th e. (Nsr Rea ± Polit 8th e . 30 ANSWER: C (Nsg Rea ± Polit 8th e. the researchers manipulate the variable under study. Research methodology D. The subjects who receive the experimental treatment or intervention. Injection of corticosteroids within 8 hours after injury C.± P77) VARIABLE. Which of the following variables is sufficient for the effect to occur? A. 10 C. Is a characteristic or quality that takes on different values. 500 D. SUBJECTS. The target participants of the intended study are homogenous in the variables being measured. 100 B. (Nsg Rea Polit 8th e.

METHODOLOGIC RESEARCH. The manipulated variable to the experimental group is the: A. 17. Studies are investigations of the ways of obtaining and organizing data and conducting rigorous research. 16% to 20% D. ANSWER: D (Brunner 11th e. Questionnaire in gathering pertinent data C. 16. Methodologic studies address the development. Injection of corticosteroids within 8 hours post spinal cord injury ANSWER: D Situation 4 ± To produce a beneficial effect on eye medications. validation. 8th e± P328) 15. Ocular absorption involves the entry of a medication into the aqueous humor. 21% to 25% 1% to 7% B. Improved recovery and lessen hospitalization period B. p2084) FTopical administration of ocular medications results in only a 1% to 7% absorption rate by the ocular tissues. She is fully aware that topical administration of ocular medication results in how many percent rate of absorption? A. the nurse should make sure that the amount of medication reaches the ocular site of action in sufficient concentration. and evaluation of research tools or methods. The nurse in the EENT unit is preparing the 8:00 AM medication. What is the advantage of ointment application from instillation of eye drops? . (Nsg Rea Polit. Improved motor and sensory outcomes D. The most common ocular medications is administered through instilled eye drops and applied ointments. 10% to 16% C. The nurse is preparing ocular medications for topical route of administration.

D. The nurse is to administer eye ointment to the patient. C. C. ease of absorption and decreased risk of contamination Extended retention time and provides a higher concentration Easy to administer with reduced adverse reaction Promotes efficiency. B. Administer during nap time or bedtime. Inform the relative of the action of the drug. Common ocular medication include topical anesthetic. C. 18. safety and distribution of solution evenly ANSWER: B ± (Brunner 11th e. Self administration. Explain the procedure to the patient. 19. FThe major disadvantage of ointments is the blurred vision that results after application. D. Check medical conditions that would contraindicate the use of the drug. In the application of topical anesthetics. B.A. the nurse MUST instruct the patient which of the following measures? A. Place the fingers on the sides of the nose to prevent medication from draining Place the patient in supine position with the head slightly hyperextended Close both eyes and gently move eyes . B. p2085) FOphthalmic ointments have extended retention time in the conjunctival sac and provide a higher concentration that eye drops. ANSWER: C ± ( Lipp ± p511) FInform the patient the need of the need and reason for instilling drops or ointment. Which of the following guides the nurse in the administration of the ointment? A.

The client looks up the ceiling and instills the correct number of drops at the middle of the eyeball. The nurse is assessing a patient receiving mydriatic eye drop. Systemic anticholinergic ANSWER: C ± Saunders. Allergic reactions D. Overdose of the medications effect C. The technique used by the client in the installation of the medication is: A. Incorrect because it may damage the cornea . Nurses must deliver activities and behaviors and do the right things well and continue to strive to do better to meet and satisfy the diverse needs of clients. p2085) FThe nurse must instruct the patient not to rub his or her eyes while anesthetized because this may result in corneal damage. Correct as this spreads the medication over the eyeball B. 20. P1010 Situation 5± Consumers of health care require improvement in health care. 21. Aimed to protect the eyeball from injury C. Allowed so that the client is less likely to blink D. Fear and anxiety B. Nurse Cora observes the client with glaucoma while he instills his eye drops. complains of blurred vision and drowsiness.D. Refrain from rubbing the eyes to prevent corneal damage ANSWER: D (Brunner 11th e. These manifestations are indicative of: A. The patient is sweating.

P1951) Ffirst priority. The client may resume his activity with moderation the day after the treatment The client may indulge in normal activities after the treatment The client must be restricted in bed for one week The client may resume gradually her usual activities within 5 to 6 weeks. Fsecond priority. . Give ice chips to relieve nausea C. ( Funda. B.P803) FInstill the drops onto the outer third of the lower conjunctival sac. Taylor . Shortly after. Administer the prescribed anti-emetic B. The client had cataract surgery. For this reason. Which of the following course of action should be given priority by the nurse? A. Nausea & vomiting are no longer expected outcomes of the surgical procedure but. he complains of nausea. Assure the client that this is expected following surgery D. application to the eye seldom is placed directly onto the eyeball. C. 23. The members of the nursing team were discussing about the activity of the client treated with detached retina during the nursing rounds. Which of the following statements serves as guide for the client during the rehabilitation phase? A. but the cornea is easily injured by trauma. To give independent nursing measures to relieve nausea. D. (Kozier. Prolonged vomiting may result in increased IOP and wound dehiscence. Report the complaint to the attending physician ANSWER: B ± (Black. P1347) 22. should be reported immediately.ANSWER: D ± FThe sclera is fibrous & tough. if present.

p1972) FVERTIGO. The staff nurse performs ear irrigation on a client for removal of cerumen. 25. groups. C. A state or process in which persons. Ear irrigation requires cooperation from the client to facilitate the introduction of the solution D. Assume lying position on the unaffected side after the procedure to facilitate drainage. What relevant information should the staff nurse share with the client at the start of the procedure? A. Explain to the wife that her husband is experiencing social isolation related to attacks of vertigo ANSWER: D ± (Black. To assist the wife in adjusting to the present situation. Experience a feeling of fullness. often resulting in open conflict. nurse Jesette shares with the team the concerns of the wife of a client with Meniere¶s disease. or cultures lose as do not have communication or cooperation with one another. She is concerned about the change in the husband¶s social activities. Any medication needs to be withheld after the procedure and the physician must be notified C. B. During the nursing conference. the team should: A. . warmth and occasional discomfort when the fluid comes in contact with the tympanic membrane B. Feeling that the surroundings or one¶s own body is revolving FSOCIAL ISOLATION. Plan the course of action with the husband Create an atmosphere of sense of belonging for the couple Assist the wife to accept the condition of the husband D. P529) Within 3 weeks ± light activities may be pursued Within 6 weeks ± heavier activity and athletes are possible 24.ANSWER: D (Lipp.

´ The nurse would record this in which part of the mental status? A. P109) SENSORIUM OR ORIENTATION. A delusional patient said. What the client actually says. ³I have no head. p110) 27. Characteristics of talk D. Sensorium or ANSWER: A ± (Shives. B. p110) FCONTENT OF THOUGHT. person & time. nurse determines whether verbalization makes sense. Emotional State C. P109) (Keltner. (Shives. . Content of thought orientation B. It is observable manifestation of one¶s emotions or feelings inferred from facial expressions. no stomach. it is important for the nurse to inspect that: A. All notes must have signature and title of person making entry The staff must not abbreviate SOAP The nurse implements the use of problem-oriented progress notes D. Anger. C.ANSWER: A ± (Kozier. sadness. (Keltner. or happiness. p891) Situation 6 ± Following are situations that are a concern for records management of nurses. Client¶s problems in the medical record must bear the date of entry and numbers of client¶s problem. Recognition of place. EMOTIONAL STATE/ AFFECT. Individual¶s present emotional responsiveness. 26. For proper documentation and accountability of all entries to the client¶s chart. eg.

Plan ANSWER: B ± (Shives. waving his hands. percussion and auscultation. P147) FPROCESS RECORDING.g.)kozier 7th e. Subjective D. Student-client role play situations are one method used to familiarized students with the process recording. D. palpation. It provides data from which nurses can assess their own behavior in interactions with clients. It acquaints the student/nurse with rudimentary applied research skills. Also include observable client behavior such as crying or taking out loud when no one else is in the room. Data: Client is pacing. Assessment B. 106) FOBJECTIVES. In the problem-oriented progress notes this data would be noted under: A. Is a tool used in various formats to analyze nurse-client communication. It is a tool for assessing nurse-client interactions C. Which of the following statements about Processing Recording is NOT true? A. Which focuses on verbal and nonverbal communication. Objective C.(Shives. vital signs. laboratory & x-ray results. P106) FConsist of information that is measured or observed by use of the senses (e. ASNWER: C . ( shives.ANSWER: A (Shives. It is an important means of communication between nurses or nursing students and their clinical supervisors/instructors about their peer relationships. p332 . P120) 28. B. is used to teach communication skills to student nurses in the clinical setting. crying. yelling at nursing staff and other patients. 29. Are tangible and measurable data collected during a physical examination by inspection.

examining and interviewing. P129) 30.ASSESSMENT. Salient points that are summarized C. a middle-aged. data should be: A. Brief and simple but focused on D. SUBJECTIVE. Which of the following questions should the nurse ask the client? A. ( shives. Obtained as the client. 31. family or group by the method of observing. Assessment phase of the nursing process includes the collection of data about a person. C. ³What do you think will happen to you when you don¶t follow medical advice?´ ³Aren¶t you bothered about your condition?´ ³Are you considering other course of action?´ ³Is it difficult to follow the medical advice?´ . Edited and comprehensive ANSWER: A Situation 7 ± Nurses encounter situations in which they must make decision based on the determination of what is right and wrong. Unedited and comprehensive essentials B. A plan of care or nursing care plan. is individualized and identifies priorities of care and proposed effective intervention. She does not lose weight in spite of medical advice. B. obese woman seeks medical help often for the recurring lower back pain. family members or significant others provide information spontaneously during direct questioning or during health history. D. Belmonte. Mrs. Professional nursing actions are both ethical and moral. In order for the process recording to be an effective learning tool for nurses. PLAN.

p141) F A therapeutic communication. Which of the following is the appropriate action of the nurse? A. ³I strongly feel that surgery will cause her more suffering and probably will not survive and the family may even feel guilty later. Using caring based reasoning which of the following justify the refusal of the nurse in the preparation of surgery? A. one of them is Joey who is in plaster cast of the leg and needs a great deal of teaching and the other a 60 year old female.´ ANSWER: C ± Client advocate 33. but the family and the surgeon insisted. ³I support the client since she has the right to decide on her medical treatment and management. Conservative management did not work and the client requires surgery. Asking direct questions is to determine if the patient is complying to the medical advice. B.´ D. Shives.´ C.ANSWER: A ± (Psyche. ³I empathize with the client because of her age and her fear of not surviving surgery.´ B. D. Weigh the facts carefully in order to divide her time justly among her clients Tell the client she will come back after attending to the other clients Ask one of the family members to attend to the client Stay with the client to prevent further depression . A 75 year old frail woman had a cervical disk disorder. C. The client insisted that she does not want surgery. hemiplegic needing assistance in performing activities of daily living. She knows that she could be of help to the client by staying and talking to her longer for another hour. A community health nurse in her home visits encountered a 58 year old woman who was depressed and tearful. she has still two clients to visit. She was hospitalized before with glaucoma. However. ³I feel that my responsibility with the client is protecting her rights and meeting her needs. The staff nurse assigned to her decided not to help in the preparation of surgery. 32.

COUNCILOR. emotional. Care Provider C. C. intellectual. Mrs. make appropriate referrals and facilitate the patient¶s problem-solving and decision making skills. Teacher Client¶s Advocate B. The following actions of the nurse are appropriate in addressing the complaints EXCEPT: A. ANSWER: B ± (Funda. She has been critical of the care she received which she regarded as not of high quality. and spiritual needs. . socio-cultural. Guidance Counselor D. Taylor. TEACHER/EDUCATOR. D. implement and evaluate individualized teaching plans to meet learning needs of patients and their families. Use of therapeutic interpersonal communication skills to provide information. Gonzales. p14) FCARE PROVIDER.ANSWER: D ± for patient¶s safety 34. The use of communication skills to asses. a 40 year old professional was confined after suffering mild stroke. The Provision of care to patients that combines both the art and the science of nursing in meeting physical. The nurse demonstrates ethics of care when she plays the role of a: A. B. Provide client with knowledge of what constitutes good care Provide client with the list of her rights Ask the client what her expectations are Give a list of evaluation criteria and ask the client to respond ANSWER: B ± not related 35.

She is placed in an orthopedic bed and to facilitate the use of the bedpan. Situation 8 ± The nurse considers factors related to safety effectiveness in the planning and delivery of nursing services. the client could fall or be injured. Following hip replacement after 24 hours the client asks for assistance onto the bedpan. D. 784) FTRAPEZE. Pull on the trapeze to lift the pelvis extending both legs Lifting the pelvis off the bed and turn gently toward the operative side Assist the client in lifting the pelvis D. how should the nurse assist the client? A. C. B. Which of the following is the LEAST intervention? A. Elevate the pelvis using the trapeze involving the unaffected upper extremity and unoperated leg ANSWER: D ± (Funda. . 36.ADVOCATE. Helps clients raise trunk from bed and allow client position hangs. Restrain the client to prevent from falling Give adequate support when turning or moving Keep the side rails up on the bed Protect client¶s head ANSWER: D 37. She is aware that without protection. The nurse notices that the comatose client starts to lighten. B. The protection of human or legal rights and the securing of care for all patients based on the belief that patients have the right to make informed decisions about their own health and lives. C. Craven.

is to be discharged after sustaining a sprain from fall while negotiating the last step of the stairs. Which of the following measure should be recommended to reduce sensory deprivation? A. Mild water heater temperature device C. Lola Carmona. Install additional lighting for visibility prevention training B. Red and yellow and white B.38. Blue and green D. 76 years old is living alone. The nurse recommends extra lighting at the stairways and suggests repainting the hallways with: A. They live in a thickly populated area and is concerned for the safety of her 3 young children. Her married daughter visits her from time to time. an elderly client. She can do activities of daily living with limited assistance and seems to be independent physically. D. The daughter asks the nurse how to promote safety in the stairways and hallways in the home. Encourage acquaintances to come to the house for a chat Redecorate the house and provide a separate room Provide pictures of family members Invite friends often to share meals at home . 32 years old has problem with the olfactory nerve. Cecille. Black and white C. Participate in fire D. C. Andoy. Install a smoke detector ANSWER: D 40. B. What measure should the nurse recommend for home safety? A. Cream ANSWER: A 39.

p160) 42. Evidence based C. Scientific B. B. Is a general set of orderly.. nurses are increasingly accepted as essential members of the interdisciplinary health care team. Tradition based D. Committed in the exercise of duties and responsibilities to clients and co-workers Knowledge of the most effective and reliable. she is likely to obtain clinical answers that are: A. Kozier. A staff nurse consulted a more experienced nurse and other health care providers whether aggressive ambulation expedites the patient¶s recovery or it requires too much energy. Polit. The nurse is working in a tertiary hospital for almost a year. Courteous and respectful to the health team and members. Reduction or prevention of culturally normal interaction between an individual and the rest of society. SENSORY DEPRIVATION. . C. Situation 9 ± In today¶s health care environment. p1284) FEncourage social interaction. P15) FSCIENTIFIC.ANSWER: A ± (Funda. Routine ANSWER: A ± (research. she must have which of the following traits? A. evidence-based approach to care Good interpersonal relationship with clients and families and the health team ANSWER: A ± (Funda. Taylor. disciplined procedures used to acquire information. D. In order to effectively participate and lead a health care team. While this approach is extremely common. 41.

attitude. Changing nursing¶s image in the public eye will not be easy. Which of the following action(s) can nurses take to increase their influence in policy setting? 1. Which of the following strategy/strategies is/are needed to change nursing image in the mind of image makers? 1. 4. Given this situation. particularly on their desired health outcomes. 1. what should the nurse do to conform to the institution¶s expectations? A. Image makers provide the greatest number of visual images of nurses at work such as angel of mercy. love interest particularly to the physician. 2. 3. ANSWER: B 44. Learn new values. Pursue post graduate course to enhance skills and competence. Emphasize the contribution of nursing to patients. Be a member of a nursing organization Write lobbying letters . Involvement in the political processes that shape their profession. 2. 2 only B. 2. naughty nurse. D. An experienced nurse is new in the work setting. Attend seminars. 1. B. etc. and social rules. 3 only C. C. Increased effort to publicly praise and value nursing. Restriction of the term nurse to mean licensed RN. Participate in the in-service education program offered by the institution.43. conference and national convention related to the nursing profession. 3 and 4 D. handmaiden to the physician. Nurses naturally work to effect policy in the work place. skills. 3 and 4 ANSWER: C 45. A.

47. Somatic therapy D. 1 only B. giving one another feedback about behavior. 1. Psychotherapy Milieu therapy B. Carry out medical orders D. Behavioral therapy C. i. Coordinate the psychosocial care and management of clients ANSWER: D ± From the issue itself which is member of the team it follows that there should be coordination. 3 and 4 D. The most important role of the nurse as a member of the team is to: A. 3 only C.3. 3 and 4 ANSWER: A Situation 10. 4. 2. Participate in coalitions of organizations Get to know their elected officials A. and working . ANSWER: D ± Milleu therapy involves clients¶ interactions with one another. Activity therapy is a treatment that utilizes which of the following? A. Meet the needs for the physical well being of patients C. practicing interpersonal relationship skills. Keeps a 24 hours watch for the patient B. 46.e. 1.The following questions refer to nurses¶ efforts to integrate in mental health community work.

Providing mental health education to members of the community B.328) . quantifiable behavior by means of systematic manipulation of the environment and variables thought to be functionally related to the behavior (Shahrokh & Hales. Option B ± Behavioral therapy is a mode of treatment that focuses on modifying observable and. When the nurse identifies a client who has attempted to commit suicide the nurse should: A. impairment. Which of these nursing actions belong to the secondary level of preventive intervention? A.cooperatively as a group to solve day to day problems same thing with the Activity therapist focuses on remotivation of clients by directing attention outside themselves to relieve preoccupation with personal thoughts. (Potter & Perry) 49. Option C ± Somatic therapy is the biologic treatment for mental disorders such as ECT. Counsel the client ANSWER: D ± Asking clients directly about thoughts of suicide is important. Being politically active in relation to mental health issues ANSWER: C . It involves minimizing the effects of long-term disease or disability by interventions directed at preventing complications and deterioration. It is also standard practice to inquire about suicide or self-harm thoughts in any setting where people seek treatment for emotional problems. Call a priest D. (Videbeck p. feelings and attitudes thus clients learn to cope with stress to through activity. Options A. (Videbeck) 48.Secondary level of prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions.Psychotherapy it is the therapeutic interaction between a qualified provider and client or group designed to benefit persons experiencing emotional distress. at least in principle. Providing emergency psychiatric services D. Providing mental health consultation to health care providers C. or illness. physiotherapy etc. Refer the client to the psychiatrist C.D are primary level of prevention which is directed towards promoting health and preventing the development of disease process. Tertiary prevention occurs when a defect or disability is permanent and irreversible. Option A . therapist¶s approach is based on a theory or combination of theories.B. Refer the matter to the police B. 20003).

The problems of out of ASNWER: B ± it is the appropriate topic because since the audience is on elementary level. Students are paired with clients to play a game and exchange knowledge about medications and disorders. The legal aspects of drug abuse B. Satisfy client¶s level of functioning of compliance C. 52. Meet diverse learning needs about medications B. Options C is for college students. Participants play with a game board and color-coded game cards which bear questions on five categories of psychotropic medications. Options A. Anti-depressants. Immediate discussion and interaction about daily life situations utilizes the principle of: . Game questions include the five categories namely: Antipsychotic medications. An appropriate topic would be: A. An opening comment about the purpose of the group encouraged clients to gather around the table and select small toy cars to move playfully around the racetrack game board. Marital crises D. Share common feelings D. Maximize the likelihood ANSWER: C ± this option is an example of an affective learning approach. The community health nurse was invited by the principal of an elementary school and was asked to give a talk to parents. One objective of this group experience is for the clients to describe the impact of these medications on their symptoms and day to day activities.50. 51. Situation 11. The aim of this affective learning approach is for the clients to: A. Anti-anxiety medications and Medications for drugs of abuse.Nurse Grazilda engaged clients in a group experience for medication education. and D are for highschool students. Mood stabilizers. Discipline of children at home and school school youth C.

Clients said they were ³all in the same boat. Universality can be defined as the sense of realizing that one is not completely alone in any situation. Altruism D. insight and reassurance while allowing themselves to gain self-knowledge and growth. (Webster Dictionary) 53. (Shives p. Option C is an example of Universality. Flexibility B.´ ANSWER: B ± Interpersonal learning includes the gaining of insight . One client said. Option D is an example of Catharsis. and the importance of learning about oneself in relation to others.Altruism in therapy groups benefit members through the act of giving to others. Imparting of information includes didactic instruction and direct advice and refers to the imparting of specific .A. Both the group therapist and the members can offer invaluable support. Option A is an example of Imparting of information. One client advised another client that he should get a ³pill box´ so he would remember to take medications B. Universality C. Appropriateness C. Reinforcement D.´ This experience included which of these therapeutic factors? A. Flexibility is the quality of being adaptable or variable. One client shared her very infrequent experiences with alcohol. Group cohesiveness B. ³I feel that way.208) 54. Which of the following client behaviors demonstrate that interpersonal learning occurred? A. Efficiency is the quality of being efficient or producing an effect or effects. Clients shared a sense of ³we-ness´ C. which she knew were contraindicated with her medications and the quietly stated.the development of an understanding of a transference relationship. Clients have the experience of learning to help others and in the process they begin to feel better about themselves.´ D. Efficiency ANSWER: A ± Reinforcement is a stimulus that strengthens or weakens the behavior that produced it. ³I don¶t want anyone to repeat this. Appropriateness is to take one¶s self in exclusion of other¶s. the experience of correcting emotional thoughts and behaviors. Imparting information ANSWER: A .

Development of pre-determined.educational information plus the sharing of advice and guidance among members. together with her children walked a 10 block way to the funeral home to meet the medical examiner to identify the body of her husband. Integration is re-organizing and reintegrating the sense of self to pull life back together. Witnesses say her husband jumped from a bridge in the locality. Without a tear. absolute group goals D. Use of alternative teaching strategies that fit the needs of the group C.D will help in creating a therapeutic learning environment. fifth stage is Recovery. Options B. Flexibility in accommodating the number of players ANSWER: A ± Because being in a heterogenous group will have a hard time in controlling and manipulating the participants that will hinder in creating a therapeutic environment. 56. Shock is the initial reaction to a loss stunned numb feeling. Shock C. Which of the following LEAST contribute to creating a therapeutic learning environment? A. with death. Recovery ANSWER: B ± Engels Stages of Grieving first stage is shock and disbelief. Lily. Group cohesiveness is the development of a strong sense of group membership and alliance. Recovery is the preoccupation & obsession ends and individual go on with life. she became focused on attending to her children and simply signed the necessary paperwork. Heterogenous composition of participants B. second stage is Developing awareness.C.207) . (Shives p. Situation 12 ± Lily. Reality B. Then she received a telephone call from the police notifying her that her husband had just been pulled from the river. the mother of two children was cooking dinner and wondering why her husband was so late. third stage is Restitution which is participation in rituals assoc.208) 55. Integration D. (Videbeck 5th edition p. help to accept reality of loss. She is in a state of: A. fourth stage is Resolution of loss.

57. In the following weeks after the death of her husband, Lily struggled not only with finances but with confusion and rage in response to her husband¶s actions and abandonment. The nursing diagnosis is: A. Spiritual distress Social isolation B. Disturbed self-esteem C. Powerlessness D.

ANSWER: C ± Powerlessness is the state in which an individual or group perceives a lack of personal control over a certain events or situations which affects outlook, goals and lifestyle; Spiritual distress is the state in which an individual or group experiences or is at risk of experiencing a disturbance in the belief or values system that provides strength, hope and meaning to life; Disturbed self-esteem is a state in which a person is experiences or is at risk of negative evaluation about self and capabilities; Social isolation is a state or process in which persons, groups or cultures lose or do not have communication or cooperation with one another, often resulting in an open conflict. (Videbeck)

58. Unable to handle her emotions, Lily hurls angry and explosive outbursts toward those who are helpful to her. This behavior is an example of: A. Sublimation Introjections B. Reaction formation C. Displacement D.

ANSWER: C ± Displacement is the ventilation of intense feelings toward persons less threatening than the one who aroused those feelings; Sublimation is the substituting a socially acceptable activity for an impulse that is unacceptable; Reaction formation is acting the opposite of what one thinks or feels; Introjection is accepting another person¶s attitudes, beliefs and values as one¶s own. (Videbeck) ` 59. Hostility is distinct from anger in that the former is: A. Compatible with love Ego syntonic B. Growth-promoting C. Destructive D.

ANSWER: C ± Hostile behavior is intended to intimidate or cause emotional harm to another and it can lead to physical aggression while Anger is a normal human emotion, is a strong,

uncomfortable, emotional response to a real or perceived provocation. (Videbeck) Options A and B is inappropriate. 60. During nurse-patient interactions with Lily, when she actively works out her rage which of the following is NOT therapeutic? A. B. C. D. Ask Lily to describe what is the ³hardest part´ of the death for the family Assure that death of husband is not her fault An encouragement toward normalcy must be communicated The nurse should be non-reactive

ANSWER: B ± Option B is an example of false reassurance; Option A allows exploration through verbalization; Option C is an example of reflecting; Option D is an example of active listening.

Situation 13- The nurse works in an institution that shelters street children. She encounters varied family histories and presenting behavior patterns of these clients.

61. At night when the children are being prepared to go to sleep, the nurse hears from a frightened child ³Ayaw ko matulog mag-isa. May multo.´ (³I don¶t want to sleep alone. There¶s a ghost!´). The nurse conveys acceptance with which of these responses? A. ³Gusto mong i-kwento kung ano pa ang naiisip at nararamdaman mo?´ (³Would you like to tell me more about your thoughts and feelings?´) B. ³Talaga? Anong itsura ng multo?´ (Really? How does the ghost look like?´) C. ³Nakakatakot nga ang pakiramdam na ganyan.´ (³That must really be scary.´) D. ³Huwag kang matakot, babantayan kita.´ (³Don¶t be afraid. I¶ll keep watch over you.´)

ANSWER: A ± Allows verbalization about his concerns. Option B and C is an example of Agreeing; Option D is Reassuring. (Videbeck)

62. Most street children come from broken families. The nurse is MOST therapeutic in meeting their needs by being a: A. Activity therapist D. Teacher B. Mother surrogate C. Child therapist

ANSWER: B ± Mother surrogate is the nurturing needs of clients who are unable to carry out simple tasks; Activity therapist focuses on remotivation of clients by directing their attention outside themselves to relieve preoccupation with personal thoughts, feelings and attitude; Nurseteacher educates clients about specific illnesses and medication prescribed to promote stabilization of their condition.(Shives p.145 & 156)

63. With adequate rest, food, cleanliness, shelter, warmth and safety, the child: A. Develops a sense of competence B. Acquires a sense of personal power others C. Develops a separate identity D. Learns to trust in self and in

ANSWER: D ± it is task that should be developed, by providing a rest, food, cleanliness, shelter, warmth and safety will develop the trust in oneself, other people, the environment and meaningfulness of existence. Option A is on school age; Option B is for toddler; Option C is for early adolescence.

64. Preventive interventions for children at risk are BEST achieved through: A. Family therapy for the dysfunctional families B. Non-government organizations and other workers paying attention to victims in conflict ridden communities C. Support and caring to children during family crisis situations D. Play and activity therapies for children

145). 65. No. they uses therapeutic skills to help clients identify and deal with stressors or problems that have resulted in dysfunctional coping. Options B and c are the same. In the advocate role.A. tension and palpitations lasting for more than a month. The Comprehensive Dangerous Drugs Act (R. (Videbeck p. As an effect of this experience she had nightmares.9165) challenges the nurse in his/her role as a/an: A. Option D is done after crisis. Situation 14 ± Increasing problems of substance abuse continue to challenge the competencies of professional nurses. Advocate D. the nurse informs the clients and supports him or her in whatever decision he or she makes. An identifiable traumatic ANSWER: C ± this is an example of post traumatic stress disorder. Health educator B. speechless for weeks. Imagined loss of parental C. 66. Cindy was a frequent witness to domestic violence. Her father would always come home drunk and beat up Cindy¶s mother. Counselor ANSWER: D ± it is also known as Nurse-teacher educates clients about specific illnesses and medication prescribed to promote stabilization of their condition. inability to sleep.96 and Shives p. Cindy is experiencing anxiety due to: A.ANSWER: C ± in order to divert attention of the child from crisis. Adjustment in growing up stress B. Therapist C. Option A and D is inappropriate while Option B is for phobia. Fear of phobic proportion love D. .

C and D are all manifesting positive behavior in dealing with drug abuse.B and C can be discussed thoroughly by a nurse. Programs focusing on means of dealing with problems and frustration of adolescents B. The nurse is conducting Parent Education Classes. Constructive discipline C. Aware of the scope of nursing practice he/she recognizes the necessity to network with other agencies to discuss this area: A. An individual who became dependent on a drug before or during the teen years C. An addict who has reached bottom pit level of self-disgust and who wants help B. A person who began taking the drug of choice for recreational or experimental reasons ANSWER: B ± since the individual has been using drugs since his/her teenage years. Mandatory basic education transformation of society . 68.67. Normal and deviant child and adolescent behavior and development D. The BEST model of drug abuse prevention supports: A. Which of these characteristics has the LEAST potential success of treatment of drug dependency? A. Option A. Communication skills appropriate for different ages B. 69. Legal implications of illegal drug use ANSWER: D ± There is needed information that should come from other agencies. Options A. Individuals who have access to support from intact family groups D.

He reports that he failed a practical exam a year ago. 70. During the initial evaluation of the psychiatric nurse. nervous and exhausted all the time´ lot´ C.47) Situation 15.´ What defense mechanism is this client employing? A. Repression Denial B. a 19 year old. Clients says ³I am not a substance user. Compensation is the overachievement in one area to offset real or perceived deficiencies in another area. Although he has made up for this. he reports he is ashamed and embarrassed by a mistake he made in his class oral report and feels like his classmates are going to look down on him. 71. ³I do not know what to do´ depressed´ B. When the nurse asks Eric to describe his physical experience.Eric. second year college student is seeking assistance in coping with school related stressors and sleep disturbances. which of these assessment data are appropriate? A.C. I take drugs only when I am under stress. (Videbeck p. ³I am tense. ³I feel helpless and D. ANSWER: D ± Denial is the failure to acknowledge an unbearable condition . failure to admit the reality of the situation or how one enables the problem to continue . Compensation D. Substitution is the replacing of the desired gratification with one that is more readily available . Represssion is excluding emotionally painful or anxiety provoking thoughts and feelings from conscious awareness . he cannot get this out of his mind. The medical treatment of drug abuse utilizing less addictive drugs ANSWER: A ± because it focuses on the concerns of the adolescents. ³I am worried and thinking a . Substitution C. An integrated program requiring development of both intellectual and affective health D.

The nurse teaches non-pharmacologic ways to induce sleep.ANSWER: B ± being tense. Which of these would she caution Eric to avoid? A. Other options will promote relaxation and sleep. He is having a problem of: A. Option B is for infancy. Inferiority D. 73. Eric admits that he has ³always been wound up´ just like his father and that he has negative thoughts of himself. Stagnation ANSWER: D ± Eric is an adolescent which is the task is formulating a sense of self and belonging. It is not conditioned by a specific trigger B. nervous and exhausted all the time is an example of physical experience. Option A is for school age. Mistrust C. Option C is for middle age. It results in selective attention/inattention . It creates panic C. 72. ANSWER: C ± Coffee has caffeine which is an example of a stimulant. Warm milk A warm bath B. Which of these describe the characteristic of free floating anxiety? A. Classical music C. 74. Coffee after dinner D. Role confusion B. There is an easily recognizable stressor that provokes anxiety D.

(Videbeck p. Options C and D are Phobia. A.28) . 76. Option A is PTSD. (Videbeck) 75. A generalized anxiety disorder is distinguished by. thus. also referred to as Neuroleptics.275) Situation 16. Irrational thoughts and actions D. A common extrapyramidal symptom that is very unpleasant and intolerable to clients is called akathisia. Option D is on the Moderate level of anxiety. This is: A.ANSWER: A ± Similar to all anxiety disorders. Upward rolling of the eyes the hands B. Experience of anxiety after exposure to a life threatening event B. in which the anxiety is free-floating. as opposed to GAD. Other options are also signs of EPS.Many clients in a psychiatric unit receive antipsychotic medications. anxiety is displaced or externalized to a source outside the body. Pill rolling movement of ANSWER: B ± This feeling of internal restlessness and the inability to sit still or rest often leads clients to discontinue their antipsychotic medication. Fear of losing control thus avoids going out or avoids crowds ANSWER: B ± Generalized anxiety disorder is characterized by at least 6 months of persistent and excessive worry and anxiety. Presence of excessive anxiety for a period of 6 months or more C. (Videbeck p. Inability to sit or stand still neck D. a phobia is a response to experienced anxiety and is characterized by a persistent fear of specific places or things. Option B is on the Panic level of anxiety. Stiffening of the client¶s C. Clients may be shifted from typical to atypical antipsychotic medications because of its minimal extrapyramidal side effects.

Which side effect should cause the nurse to be MOST concerned? A. decreased white blood cell count C. While giving Chlorpromazine (Thorazine) to client Michelle. ³I will avoid pizza. the nurse remembers that she should stop giving the medication when she observes this side effect: A. Tremors. Uncomfortable sun burns B. Sore throat.´ B. fever.(Videbeck p29-30) 78. Option D is for MAOI¶s.´ ANSWER: C ± Antipsychotic medications requires the use of sunscreen because photosensitivity can cause the client to sunburn easily. inability to stand still . Facial grimacing C. Carl.´ C. Options A. This medication has several side effects. Yellow ANSWER: C ± Is an adverse effect and is a sign of hepatotoxic which is jaundice. ³I will immediately report any episode of diarrhea or vomiting to my doctor.2313) 79. Option B is inappropriate because the increase fluid intake is to solve constipation but not to urinate frequently. Health instructions about Haldol (haloperidol) has been given to Anthony while in the hospital and before his discharge. is given Thorazine (Chlorpromazine).B and D are expected side effect and this are called EPS. Option A is for SSRI¶s. Fine tremors D. ³I will wear long sleeve clothing and sun block when I go out. The client correctly understood the health techniques of the nurse when he says: A. any food with cheese and processed meat. ³I will drink about 2 liters of fluids daily and expect to urinate frequently.77. (Brunner p. Shuffling gait sclerae B.´ D. Another client in the ward.

Low blood pressure upon getting up from bed ANSWER: B ± it has the potentially fatal side effect because Agranulocytosis develops suddenly and is characterized by fever. (Videbeck p. actions and speech. What medication would the nurse expect the client to receive? A. Nardil (Phenelzine) D. They have poor judgment and rapid thoughts. clients are euphoric. 29-31) Situation 17 ± Peter. Peter¶s condition is primarily a problem of: A. malaise. ulcerative sore throat and leukopenia. Conscience B. Clients on antipsychotic medications usually receive anti-parkinson drugs to reduce Parkinson like side effects. He started to be bossy. (Videbeck p. The drug must be discontinued immediately. 81. Fluphenazine (Prolixin) B. a 35 year old employee was admitted to the hospital because of behavioral problems at the office. Option B is MAOI¶s.275) 80. Minimal environmental stimuli C. Affect D. Perception C. Fluoxetine (Prozac) ANSWER: A ± it is an example of anti-parkinsonian drug. manic phase. No limitation on his activities . Congentin (Benztropine) C. A therapeutic environment for Peter is: A. (Videbeck p. Option D is SSRI¶s. energetic and sleepless. On admission he was diagnosed to be having Bipolar disorder. claiming that he is the manager on the unit. Thought ANSWER: C ± During manic phases.D. Option C is Anti-psychotic.317) 82. grandiose.

Take him away from the group until he manages to have control of himself. A therapeutic intervention of the nurse is: A. B.304) 84. (Videbeck p.B. change and heal. Option D is correct since its matter of fact but the issue presents that the patient becomes FURIOUS which would further escalate due to the rsponse. ³Peter. Strict isolation and withholding privileges D. Nurses must . Therapeutic use of self is essential in relating with psychiatric patients. became furious. D. B. C. D. Option B and D is not appropriate. Sympathizing with the miserable feelings of Peter Suppressing her own feelings towards Peter Engaging Peter in productive activity Engaging Peter in introspective thinking ANSWER: B ± Therapeutic use of self: nurses uses themselves as a therapeutic tool to establish the therapeutic relationship with clients and to help clients grow. Prevent him from becoming more furious by giving an extra PRN dose of sedative. C. A. During socialization Peter was provoked. Everybody in the ward is in equal footing. Well lit and basically colored room ANSWER: A ± A primary nursing responsibility is to provide a safe environment for clients and for others. Respond with. Option C it should be simple activities such as card games or a short walk and it is necessary to set limits when they cannot set limits on themselves.´ ANSWER: A ± the client must establish external control. This is BEST demonstrated by the nurse in. we don¶t favor anyone.324) 83. started shouting and making personal demands. Restrain him and put him on isolation to protect other patients. Restraining would be the last intervention. (Videbeckp.

Easily finishes projects given to him during occupational therapy Takes his medications without reminding him Demonstrates skills in activities of daily living Complies with hospital rules and regulations ANSWER: B ± Adherence to treatment regimen of medication and psychotherapy. 86. He remarked. Say. (Videbeck) 85. you don¶t ignore the client. I like you. Option A. you don¶t sympathize but you empathize. ³You upset me with your remark.The stress of hospitalization can lead to difficulties between nurses and patients. (Videbeck p. Option D is an example of disapproving. Be transparent and express disapproval openly. you feel bad but of course. (Videbeck p.110) . B. D. Option A is an example of giving approval. Jurry asked the nurse to have an ³out on pass´ privilege for the weekend but his request was not granted by the nurse. ³I understand. Option C. The nurse may recommend discharge when Peter: A. C.´ A therapeutic response of the nurse would be: A. Following are situations that nurses presented during a monthly nursing circle.328) Situation 18. ³I thought you really liked me. Options C and D are concerns of the patient. Say as a matter of fact. ³Your behavior did not meet criteria for out on pass privilege.´ C.not allow their own issues & biases to color interactions.´ ANSWER: B ± it is an example of verbalizing the implied. Ignore Jurry¶s remark D.´ B.

An invitation to have a social and intimate relationship with her nurse D. ³I¶m Cathy. The dynamics of behavior underlying manipulative behavior explain that it is a behavior of: A. An understandable behavior for an elderly that must not be taken seriously C. Ask for the patient¶s name and if whether he is aware where he is. A sense of security and control B. an elderly client idealizes some nurses as ³terrific´.´ C. 88. Remove the patient¶s hand while saying calmly. Immature and childish behavior ANSWER: B ± this is a normal and an understandable behavior of an elderly.´ . ³I¶m the nurse and this is a hospital. This behavior can be understood by the staff as: A. The therapeutic response of the nurse would be to: A. 89. Say her name. or ³so understanding´. or ³indifferent´. Avoiding taking responsibility for her own behavior and underlying feelings B. Reducing patient¶s anxiety D. ³the best´. A patient with delirium touches the nurse inappropriately. Exhibiting uncooperative and hostile behavior C.87. Lolita. B. Sensing fear of other people ANSWER: B ± due to lack of insight they often act-out their feelings in aggressive and hostile behavior. Say nothing and just go on with the usual nursing interventions D. I¶m your nurse. but refers to others as ³mean´.

491) . nursing conference is more appropriate. Seminar-workshop D. A. Disturbance in emotion. Counseling with the nursing supervisor B. Brainstorming session ANSWER: B ± Since it is a nursing concern. Some staff views it as unprofessionally punitive and uncaring. the use of touch reassures clients and provides contact with reality. Inappropriate affect D. The staff nurses have differing emotional reactions to the use of limit setting.ANSWER: D ± Delirium is confusion accompanied by altered or fluctuating consciousness. The MOST appropriate approach to address the nursing concern is through: A. (Shives p. The nurse provides orienting cues when talking with clients. Nursing Conference C. Depersonalization is the feelings of being disconnected from himself or herself.469) 90. such as calling them by name and referring to the time of day or expected activity. thought and perception is moderate to severe. Often. unable to sleep` and concentrate and frequently would just be quiet and stare. 91. Within the next 6 months from the accident he was observed to be detaching himself from others. (Videbeck p. What kind of husband and father am I?´ He is expressing. Situation 19 ± Robert is a survivor of a tragic accident wherein his wife and child drowned when their boat sank due to stormy weather. Cognitive disturbance occurs when there is clinically significant deficit in cognition from a previous level of functioning. B. Cognitive disturbance ANSWER: B ± Guilt is the feelings of culpability especially for imagined offenses or from a sense of inadequacy. Inappropriate affect is displaying a facial expression that is incongruent with mood or situation. He tells you. ³It is my fault. Depersonalization Guilt C.

no matter what his behavior. Depression B. The nurse can BEST intervene by mobilizing the client¶s relatives. Sympathy is an expressed interest or concern regarding the problems. Sympathy D. The nurse encourages the client to communicate and socialize because internalized hostility can lead to: A. Amok ANSWER: A ± Hostility turns towards self is considered depression. Passivity ANSWER: Acceptance is the avoiding judgments of the person. Physical assaultiveness D. (Mosby Dictionary) 94. emotions or states of mind of another. family members.92. Social support is emotional sustenance that comes from friends. Optimism is an inclination to put the most favorable construction upon actions and events or to anticipate the best possible outcome. Verbal assaultiveness C. A. Medical support C. friends and people to provide. Acceptance C. as a form of maladaptation. Passivity is a mental state of being submissive. The patient is having a: . and even health care providers who help a person when a problem arises. dependent or inactive. Spiritual support B. A therapeutic attitude the nurse can convey to the client while he talks about his loss is: A. 95. Material support D. Social support ANSWER: A ± religious activities such as church attendance and praying associated social support have been shown to be very important for many people and are linked with better health and a sense of well-being. Optimism B. (Videbeck) 93.

Provision of a bedside ANSWER: C ± Safety is the priority concern. . Request for a sitter B. Veracity C. refers to the right to demand to be treated justly. Cortez. 102) 97. Beneficence D. The staff is considering the possibility of using restraint on Mrs. She has Alzheimer¶s disease. Psychotic breakdown C.202). Option B. She has an IV in her left forearm. which was difficult to establish. Post traumatic stress disorder B. Developmental crisis D. however. With a history of osteoporosis and a tendency to wander. Personality dysfunction ANSWER: A ± Post traumatic stress disorder is a disturbing pattern of behavior demonstrated by someone who has experience a traumatic event such as natural disaster. Justice B. Prevention of fall D. she repeatedly declares that she does not want to be restrained. Option C and D is the same. Wheelchair privilege commode C. The staff is faced with an ethical dilemma of autonomy versus: A. which of the following should be a priority? A. fairly and equally. C and D is inappropriate. (Videbeck p. combat or an assault. 96. Fairness ANSWER: A ± Beneficence promotes doing acts of kindness and mercy that directly benefit the patient. Concerned that Mrs. Cortez might pull out her IV and wander off the floor. (Venzon 10th edition p. the staff is considering the possibility of using restraint on her. Cortez is an 85 year old woman who has been hospitalized due to a urinary tract infection and dehydration. Situation 20.A.Mrs. and a tendency to wander. osteoporosis. Veracity is truth-telling.

Which question is MOST effective to communicate with her? A. Going through family D. Cortez has a dietary privilege of food preferences.98. Using clothing D. 99. . What is your favorite egg recipe? ANSWER: C ±This may asses the memory of the patient. the client may have difficulty recalling the use of buttons and zipper. Singing to or with her music C. Cortez? A. 100. The nurse aims at highest level of self care. Which of the following will the nurse minimize? A. Hand and body lotion C. Which way would you want your egg done? Scrambled? Sunny side up? With vegetable mix? Or boiled? B. Do you want fried egg or boiled egg? C. Which of the following would be LEAST likely appreciated by Mrs. Providing mouth swabs with buttons and zippers B. Listening to old familiar ANSWER: A ± Clients lose intellectual function. Playing a table board game picture album B. How would you want to have your egg done? D. which eventually involves the complete loss of their abilities and option A requires concentration and focus. Mrs. Labeling clothing items ANSWER: C ± Since there is a progressive cognitive impairment.

Raise the head of the bed to 90 degrees and the head supported with pillows 2. Increased body temperature 3. Dilatation of the pupil. Decrease in pulse pressure. In preparing the plan of care. Elevate the head of the bed to 30 degrees D. Which of the following data concludes that the patient is showing signs of increased intracranial pressure? A. decreased blood pressure and increase in level of consciousness C. Elevate the legs at 15 degrees with a pillow under the head C.Situation 1. An intracranial pressure monitor is in place and the patient is becoming lethargic. Which of the following nursing assessment would identify the earliest indication of increasing intracranial pressure? A. Which of the following should be the immediate action of the nurse? A. The nurse completed a nursing assessment. Slowing of the heart rate. increased heart rate and irregular breathing pattern B. The nurse notes the intracranial pressure is high. Cyanosis and hypotension D. The nurse is monitoring intracranial pressure of the patient.The nurse assigned in the neurology unit is taking care of a patient with medical diagnosis of increased intracranial pressure. Increase in heart rate and respiratory rate and decreased level of consciousness D. Turn the patient to his left side with the back supported with pillows B. the nurse should prioritize which of the following nursing and medical measures? A. 1. increase in pulse pressure and irregular breathing pattern 4. Widening pulse pressure B. Change in level of consciousness C. high backrest to prevent Valsalva¶s maneuver and promote venous drainage .

and 3 6. 3 and 4 D.´ . Early morning stiffness B. Turning every 2 hours with logrolling movement to maintain proper position C. Proper positioning and frequent change in position 5.B. Providing a calm and restful environment 4. 2. Nodules along the knees C. Elevating the head of the bed and keeping the head in proper alignment D. Which of the following is MOST likely to be assessed? A. 1. 1. Limited motions of joints 7. Keeping lights on low setting 2. Nurse Karen is assessing the client. Keeping noise at a minimum 3. 2. Joint for deformities D. Having a cooling blanket available A. the physician orders application of heat and cold to manage arthritis pain. Which of the following statements indicate that the client lacks understanding in the application of heat and cold? A. 2. ³Cold application is applied for 20 minutes. In addition to the prescribed medication. 3 and 4 B. The client is in the acute phase of rheumatoid arthritis. then 20 minutes off´ B. ³Hot water bag should be covered with flannel to prevent burns. The nurse plan of care includes preventing environmental stimuli that may stimulate an increase in intracranial pressure. 1 and 2 C. Which of the following measures should the nurse include in the nursing care plan? 1.

towards self-reliance and independence. After excessive exercises C. Need for a member of the family during the pain episode D. Recognize that little can be accomplished 9.´ D. To prevent deformities of Mrs. Performing isometric exercises twice a day D. Set a specific goal B. the nurse includes in the nursing care plan: A. ³Heat producing liniments can be used while applying heat and cold. Because of inactivity upon awakening in the morning D. Massaging the joint with oil liniment B. The nurse should know that a client with rheumatoid arthritis will most often have pain and limited movements of the joints: A.C. The nurse should approach the problem with which of the following: A. who is immobilized by pain. Borja. ³Heat and cold can be applied as needed. Set a positive attitude toward an eventful outcome C. Resulting from non-adherence to prescribed diet B. Nurse Karen is helping the client. Alternate rest periods with active exercises . During cold weather 10.´ 8. Implementation of strictly prescribed diet C.

In the above study. Experimental design D. Experimental group D. Which of the following variables is sufficient for the effect to occur? A. Retrospective-prospective 12. 11. On the basis of the nature of the investigation. which one of the designs listed below would allow the researchers to have the most confidence that the corticosteroids is effective in improving the motor and sensory outcomes of patients with spinal cord injury: A. the researchers manipulate the variable under study. 10 C. Control group B. The target participants of the intended study are homogenous in the variables being measured. Variables 13. 500 D. The study covers a three month period. 30 14.Situation 3. motor and sensory outcomes patients with spinal cord injuries .A team of researchers is conducting a study on the effect of high dose corticosteroids in improving the motor and sensory outcomes of patients with spinal cord injuries within 6 weeks if administered within 8 hours after injury. 100 B. Non-experimental design study design C. Research methodology D. Subjects C. In determining the sample size. the researchers should include how many participants in this study? A. Clients with spinal cord injury B. Which of the following is present in conducting the above study? A. Quasi or semi-experimental design B. Injection of corticosteroids within 8 hours after injury C.

C. Improved recovery and lessen hospitalization period B. Which of the following guides the nurse in the administration of the ointment? A. Improved motor and sensory outcomes D. Administer during nap time or bedtime. The nurse is preparing ocular medications for topical route of administration. What is the advantage of ointment application from instillation of eye drops? A. . Self administration. D. B. 17. 21% to 25% 1% to 7% B. ease of absorption and decreased risk of contamination Extended retention time and provides a higher concentration Easy to administer with reduced adverse reaction Promotes efficiency. The nurse is to administer eye ointment to the patient. Questionnaire in gathering pertinent data C. The manipulated variable to the experimental group is the: A. Injection of corticosteroids within 8 hours post spinal cord injury Situation 4 ± To produce a beneficial effect on eye medications.15. 16% to 20% D. the nurse should make sure that the amount of medication reaches the ocular site of action in sufficient concentration. 10% to 16% C. The nurse in the EENT unit is preparing the 8:00 AM medication. She is fully aware that topical administration of ocular medication results in how many percent rate of absorption? A. 16. The most common ocular medications is administered through instilled eye drops and applied ointments. safety and distribution of solution evenly 18.

21. Explain the procedure to the patient. 19. Systemic anticholinergic Situation 5± Consumers of health care require improvement in health care. D. In the application of topical anesthetics. B. The technique used by the client in the installation of the medication is: A. the nurse MUST instruct the patient which of the following measures? A. Common ocular medication include topical anesthetic. Correct as this spreads the medication over the eyeball B. Fear and anxiety B. Inform the relative of the action of the drug. Check medical conditions that would contraindicate the use of the drug. Nurses must deliver activities and behaviors and do the right things well and continue to strive to do better to meet and satisfy the diverse needs of clients. C. The patient is sweating. complains of blurred vision and drowsiness. Overdose of the medications effect C. D. These manifestations are indicative of: A. Allergic reactions D. Place the fingers on the sides of the nose to prevent medication from draining Place the patient in supine position with the head slightly hyperextended Close both eyes and gently move eyes Refrain from rubbing the eyes to prevent corneal damage 20. Aimed to protect the eyeball from injury .B. The client looks up the ceiling and instills the correct number of drops at the middle of the eyeball. Nurse Cora observes the client with glaucoma while he instills his eye drops. C. The nurse is assessing a patient receiving mydriatic eye drop.

Incorrect because it may damage the cornea 22. the team should: A. Plan the course of action with the husband Create an atmosphere of sense of belonging for the couple Assist the wife to accept the condition of the husband D. Administer the prescribed anti-emetic B. The client may resume his activity with moderation the day after the treatment The client may indulge in normal activities after the treatment The client must be restricted in bed for one week The client may resume gradually her usual activities within 5 to 6 weeks. B. B. The members of the nursing team were discussing about the activity of the client treated with detached retina during the nursing rounds. Explain to the wife that her husband is experiencing social isolation related to attacks of vertigo . 24.C. C. nurse Jesette shares with the team the concerns of the wife of a client with Meniere¶s disease. he complains of nausea. The client had cataract surgery. During the nursing conference. She is concerned about the change in the husband¶s social activities. To assist the wife in adjusting to the present situation. Which of the following statements serves as guide for the client during the rehabilitation phase? A. Report the complaint to the attending physician 23. D. Shortly after. C. Give ice chips to relieve nausea C. Which of the following course of action should be given priority by the nurse? A. Allowed so that the client is less likely to blink D. Assure the client that this is expected following surgery D.

Situation 6 ± Following are situations that are a concern for records management of nurses. For proper documentation and accountability of all entries to the client¶s chart. A delusional patient said. Client¶s problems in the medical record must bear the date of entry and numbers of client¶s problem. The staff nurse performs ear irrigation on a client for removal of cerumen. B. Any medication needs to be withheld after the procedure and the physician must be notified C. Ear irrigation requires cooperation from the client to facilitate the introduction of the solution D. Content of thought orientation B.´ The nurse would record this in which part of the mental status? A. Emotional State C. . Characteristics of talk D. 26. C. ³I have no head.25. What relevant information should the staff nurse share with the client at the start of the procedure? A. warmth and occasional discomfort when the fluid comes in contact with the tympanic membrane B. no stomach. Assume lying position on the unaffected side after the procedure to facilitate drainage. Experience a feeling of fullness. it is important for the nurse to inspect that: A. Sensorium or 27. All notes must have signature and title of person making entry The staff must not abbreviate SOAP The nurse implements the use of problem-oriented progress notes D.

Belmonte. data should be: A. B. It is an important means of communication between nurses or nursing students and their clinical supervisors/instructors about their peer relationships. crying. Mrs. Brief and simple but focused on essentials D. She does not lose weight in spite of medical advice. Edited and comprehensive Situation 7 ± Nurses encounter situations in which they must make decision based on the determination of what is right and wrong. obese woman seeks medical help often for the recurring lower back pain. Which of the following questions should the nurse ask the client? . Assessment B. waving his hands. Which of the following statements about Processing Recording is NOT true? A. In order for the process recording to be an effective learning tool for nurses. 29. Unedited and comprehensive Salient points that are summarized C. 31.28. B. It acquaints the student/nurse with rudimentary applied research skills. yelling at nursing staff and other patients. It provides data from which nurses can assess their own behavior in interactions with clients. Objective C. Professional nursing actions are both ethical and moral. Plan 30. Data: Client is pacing. D. It is a tool for assessing nurse-client interactions C. a middle-aged. Subjective D. In the problem-oriented progress notes this data would be noted under: A.

³What do you think will happen to you when you don¶t follow medical advice?´ ³Aren¶t you bothered about your condition?´ ³Are you considering other course of action?´ ³Is it difficult to follow the medical advice?´ 32. D. Using caring based reasoning which of the following justify the refusal of the nurse in the preparation of surgery? A.´ B.´ 33. ³I empathize with the client because of her age and her fear of not surviving surgery. The staff nurse assigned to her decided not to help in the preparation of surgery. B. She knows that she could be of help to the client by staying and talking to her longer for another hour. She was hospitalized before with glaucoma. D. C. Weigh the facts carefully in order to divide her time justly among her clients Tell the client she will come back after attending to the other clients Ask one of the family members to attend to the client Stay with the client to prevent further depression . Conservative management did not work and the client requires surgery. A 75 year old frail woman had a cervical disk disorder. ³I support the client since she has the right to decide on her medical treatment and management. Which of the following is the appropriate action of the nurse? A. ³I feel that my responsibility with the client is protecting her rights and meeting her needs. B. ³I strongly feel that surgery will cause her more suffering and probably will not survive and the family may even feel guilty later.´ C. but the family and the surgeon insisted. C. A community health nurse in her home visits encountered a 58 year old woman who was depressed and tearful. hemiplegic needing assistance in performing activities of daily living.´ D. However. one of them is Joey who is in plaster cast of the leg and needs a great deal of teaching and the other a 60 year old female. she has still two clients to visit.A. The client insisted that she does not want surgery.

a 40 year old professional was confined after suffering mild stroke. Care Provider C. C. Provide client with knowledge of what constitutes good care Provide client with the list of her rights Ask the client what her expectations are Give a list of evaluation criteria and ask the client to respond 35. The following actions of the nurse are appropriate in addressing the complaints EXCEPT: A. Client¶s Situation 8 ± The nurse considers factors related to safety effectiveness in the planning and delivery of nursing services. the client could fall or be injured.34. Mrs. C. 36. The nurse notices that the comatose client starts to lighten. B. She is aware that without protection. Gonzales. Restrain the client to prevent from falling Give adequate support when turning or moving Keep the side rails up on the bed Protect client¶s head . Guidance Counselor D. B. D. She has been critical of the care she received which she regarded as not of high quality. Teacher Advocate B. Which of the following is the LEAST intervention? A. The nurse demonstrates ethics of care when she plays the role of a: A. D.

Participate in fire D. Elevate the pelvis using the trapeze involving the unaffected upper extremity and unoperated leg 38. Cream 39. Black and white C. an elderly client. 76 years old is living alone. She can do activities of daily living with limited assistance and seems to be independent physically.37. Install additional lighting for visibility prevention training B. B. Which of the following measure should be recommended to reduce sensory deprivation? . Andoy. Install a smoke detector 40. Red and yellow and white B. Mild water heater temperature device C. The nurse recommends extra lighting at the stairways and suggests repainting the hallways with: A. Blue and green D. C. Lola Carmona. 32 years old has problem with the olfactory nerve. Pull on the trapeze to lift the pelvis extending both legs Lifting the pelvis off the bed and turn gently toward the operative side Assist the client in lifting the pelvis D. Following hip replacement after 24 hours the client asks for assistance onto the bedpan. She is placed in an orthopedic bed and to facilitate the use of the bedpan. They live in a thickly populated area and is concerned for the safety of her 3 young children. is to be discharged after sustaining a sprain from fall while negotiating the last step of the stairs. Cecille. Her married daughter visits her from time to time. The daughter asks the nurse how to promote safety in the stairways and hallways in the home. how should the nurse assist the client? A. What measure should the nurse recommend for home safety? A.

A. B. C. D.

Encourage acquaintances to come to the house for a chat Redecorate the house and provide a separate room Provide pictures of family members Invite friends often to share meals at home

Situation 9 ± In today¶s health care environment, nurses are increasingly accepted as essential members of the interdisciplinary health care team.

41. The nurse is working in a tertiary hospital for almost a year. In order to effectively participate and lead a health care team, she must have which of the following traits? A. B. C. D. Courteous and respectful to the health team and members. Committed in the exercise of duties and responsibilities to clients and co-workers Knowledge of the most effective and reliable, evidence-based approach to care Good interpersonal relationship with clients and families and the health team

42. A staff nurse consulted a more experienced nurse and other health care providers whether aggressive ambulation expedites the patient¶s recovery or it requires too much energy. While this approach is extremely common, she is likely to obtain clinical answers that are: A. Scientific B. Evidence based C. Tradition based D. Routine

43. An experienced nurse is new in the work setting. Given this situation, what should the nurse do to conform to the institution¶s expectations? A. Pursue post graduate course to enhance skills and competence.

B. C. D.

Participate in the in-service education program offered by the institution. Attend seminars, conference and national convention related to the nursing profession. Learn new values, skills, attitude, and social rules.

44. Image makers provide the greatest number of visual images of nurses at work such as angel of mercy, love interest particularly to the physician, naughty nurse, handmaiden to the physician, etc. Changing nursing¶s image in the public eye will not be easy. Which of the following strategy/strategies is/are needed to change nursing image in the mind of image makers? 1. 2. 3. Restriction of the term nurse to mean licensed RN. Involvement in the political processes that shape their profession. Increased effort to publicly praise and value nursing.

4. Emphasize the contribution of nursing to patients, particularly on their desired health outcomes.

A. 1, 3 and 4 D. 2 only

B. 3 only

C. 1, 2, 3 and 4

45. Nurses naturally work to effect policy in the work place. Which of the following action(s) can nurses take to increase their influence in policy setting? 2. 3. 4. 5. Be a member of a nursing organization Write lobbying letters Participate in coalitions of organizations Get to know their elected officials

A. 1, 2, 3 and 4 D. 1 only

B. 3 only

C. 1, 3 and 4

Situation 10- The following questions refer to nurses¶ efforts to integrate in mental health community work.

46. The most important role of the nurse as a member of the team is to: A. Keeps a 24 hours watch for the patient B. Meet the needs for the physical well being of patients C. Carry out medical orders D. Coordinate the psychosocial care and management of clients

47. Activity therapy is a treatment that utilizes which of the following? A. Psychotherapy Milieu therapy B. Behavioral therapy C. Somatic therapy D.

48. Which of these nursing actions belong to the secondary level of preventive intervention? A. Providing mental health education to members of the community B. Providing mental health consultation to health care providers C. Providing emergency psychiatric services D. Being politically active in relation to mental health issues

49. When the nurse identifies a client who has attempted to commit suicide the nurse should: A. Refer the matter to the police B. Refer the client to the psychiatrist C. Call a priest D. Counsel the client

The legal aspects of drug abuse B. Anti-depressants. Maximize the likelihood 52. An appropriate topic would be: A. Efficiency . Mood stabilizers. Meet diverse learning needs about medications B. Participants play with a game board and color-coded game cards which bear questions on five categories of psychotropic medications. The community health nurse was invited by the principal of an elementary school and was asked to give a talk to parents. An opening comment about the purpose of the group encouraged clients to gather around the table and select small toy cars to move playfully around the racetrack game board. Reinforcement D. Appropriateness C. One objective of this group experience is for the clients to describe the impact of these medications on their symptoms and day to day activities.Nurse Grazilda engaged clients in a group experience for medication education. Marital crises D. Discipline of children at home and school school youth C. Students are paired with clients to play a game and exchange knowledge about medications and disorders. Immediate discussion and interaction about daily life situations utilizes the principle of: A.50. Flexibility B. Anti-anxiety medications and Medications for drugs of abuse. Share common feelings D. 51. The problems of out of Situation 11. Game questions include the five categories namely: Antipsychotic medications. The aim of this affective learning approach is for the clients to: A. Satisfy client¶s level of functioning of compliance C.

absolute group goals D. Development of pre-determined. She is in a state of: . Use of alternative teaching strategies that fit the needs of the group C. she became focused on attending to her children and simply signed the necessary paperwork. ³I feel that way.´ This experience included which of these therapeutic factors? A.53. which she knew were contraindicated with her medications and the quietly stated. ³I don¶t want anyone to repeat this. Universality C. One client advised another client that he should get a ³pill box´ so he would remember to take medications B. One client shared her very infrequent experiences with alcohol. Lily. Which of the following client behaviors demonstrate that interpersonal learning occurred? A. Heterogenous composition of participants B. together with her children walked a 10 block way to the funeral home to meet the medical examiner to identify the body of her husband. 56. Group cohesiveness B. Altruism D.´ D. Clients said they were ³all in the same boat. One client said. Flexibility in accommodating the number of players Situation 12 ± Lily. the mother of two children was cooking dinner and wondering why her husband was so late. Witnesses say her husband jumped from a bridge in the locality.´ 54. Which of the following LEAST contribute to creating a therapeutic learning environment? A. Without a tear. Then she received a telephone call from the police notifying her that her husband had just been pulled from the river. Clients shared a sense of ³we-ness´ C. Imparting information 55.

58. Reality B. Hostility is distinct from anger in that the former is: A. Integration D. Destructive D. Compatible with love Ego syntonic B. Lily hurls angry and explosive outbursts toward those who are helpful to her. Sublimation Introjections B. C. Powerlessness D.The nurse works in an institution that shelters street children. Recovery 57. 60. 59. The nursing diagnosis is: A. Ask Lily to describe what is the ³hardest part´ of the death for the family Assure that death of husband is not her fault An encouragement toward normalcy must be communicated The nurse should be non-reactive Situation 13. . Reaction formation C. Disturbed self-esteem C. This behavior is an example of: A. Unable to handle her emotions. She encounters varied family histories and presenting behavior patterns of these clients. In the following weeks after the death of her husband. Lily struggled not only with finances but with confusion and rage in response to her husband¶s actions and abandonment. During nurse-patient interactions with Lily. Shock C. Spiritual distress Social isolation B. D. Growth-promoting C. B. Displacement D.A. when she actively works out her rage which of the following is NOT therapeutic? A.

Acquires a sense of personal power others 64. the child: A. The nurse is MOST therapeutic in meeting their needs by being a: A. Support and caring to children during family crisis situations D. babantayan kita. Family therapy for the dysfunctional families B.´ (³Don¶t be afraid. Teacher B. Develops a separate identity D. ³Gusto mong i-kwento kung ano pa ang naiisip at nararamdaman mo?´ (³Would you like to tell me more about your thoughts and feelings?´) B. ³Talaga? Anong itsura ng multo?´ (Really? How does the ghost look like?´) C. the nurse hears from a frightened child ³Ayaw ko matulog mag-isa. Most street children come from broken families. Play and activity therapies for children C.´ (³I don¶t want to sleep alone. food. The nurse conveys acceptance with which of these responses? A. Child therapist 63. May multo. At night when the children are being prepared to go to sleep. Develops a sense of competence B.´ (³That must really be scary.´) 62. Activity therapist D. Learns to trust in self and in .´) D. Preventive interventions for children at risk are BEST achieved through: A. Non-government organizations and other workers paying attention to victims in conflict ridden communities C. cleanliness. Mother surrogate C. ³Nakakatakot nga ang pakiramdam na ganyan. There¶s a ghost!´).61. ³Huwag kang matakot. I¶ll keep watch over you. With adequate rest. shelter. warmth and safety.

Fear of phobic proportion love D. Constructive discipline C. Counselor 67. Health educator B. Cindy was a frequent witness to domestic violence. No. The nurse is conducting Parent Education Classes. An identifiable traumatic Situation 14 ± Increasing problems of substance abuse continue to challenge the competencies of professional nurses. The Comprehensive Dangerous Drugs Act (R. Therapist C. speechless for weeks. Her father would always come home drunk and beat up Cindy¶s mother. Aware of the scope of nursing practice he/she recognizes the necessity to network with other agencies to discuss this area: A.A. Cindy is experiencing anxiety due to: A. Legal implications of illegal drug use . Adjustment in growing up stress B. Normal and deviant child and adolescent behavior and development D. tension and palpitations lasting for more than a month. Imagined loss of parental C.65. inability to sleep. As an effect of this experience she had nightmares.9165) challenges the nurse in his/her role as a/an: A. 66. Advocate D. Communication skills appropriate for different ages B.

Repression Denial B. Although he has made up for this. Which of these characteristics has the LEAST potential success of treatment of drug dependency? A. Individuals who have access to support from intact family groups D. Situation 15. which of these assessment data are appropriate? . When the nurse asks Eric to describe his physical experience. The medical treatment of drug abuse utilizing less addictive drugs 70. a 19 year old. During the initial evaluation of the psychiatric nurse. He reports that he failed a practical exam a year ago. second year college student is seeking assistance in coping with school related stressors and sleep disturbances.Eric. he cannot get this out of his mind. An addict who has reached bottom pit level of self-disgust and who wants help B. Clients says ³I am not a substance user. The BEST model of drug abuse prevention supports: A.´ What defense mechanism is this client employing? A. I take drugs only when I am under stress. 71. Substitution C. he reports he is ashamed and embarrassed by a mistake he made in his class oral report and feels like his classmates are going to look down on him. Programs focusing on means of dealing with problems and frustration of adolescents B. A person who began taking the drug of choice for recreational or experimental reasons 69. An individual who became dependent on a drug before or during the teen years C.68. Mandatory basic education transformation of society C. Compensation D. An integrated program requiring development of both intellectual and affective health D.

Warm milk A warm bath B. He is having a problem of: A. Coffee after dinner D. Classical music C. A generalized anxiety disorder is distinguished by. There is an easily recognizable stressor that provokes anxiety D. Inferiority D. ³I am tense. It creates panic C. ³I do not know what to do´ depressed´ B. . Which of these describe the characteristic of free floating anxiety? A. ³I am worried and thinking a 72. The nurse teaches non-pharmacologic ways to induce sleep. nervous and exhausted all the time´ lot´ C. Mistrust C. 74. Stagnation 73. ³I feel helpless and D. Role confusion B. Which of these would she caution Eric to avoid? A. It is not conditioned by a specific trigger B. It results in selective attention/inattention 75.A. Eric admits that he has ³always been wound up´ just like his father and that he has negative thoughts of himself.

While giving Chlorpromazine (Thorazine) to client Michelle. Upward rolling of the eyes the hands B. ³I will wear long sleeve clothing and sun block when I go out. Irrational thoughts and actions D.´ C. Experience of anxiety after exposure to a life threatening event B. Shuffling gait sclerae B.´ B.´ D. Pill rolling movement of 77. This is: A. ³I will immediately report any episode of diarrhea or vomiting to my doctor. Fear of losing control thus avoids going out or avoids crowds Situation 16. Presence of excessive anxiety for a period of 6 months or more C. Yellow .A. Facial grimacing C.´ 78. also referred to as Neuroleptics. Clients may be shifted from typical to atypical antipsychotic medications because of its minimal extrapyramidal side effects. any food with cheese and processed meat. The client correctly understood the health techniques of the nurse when he says: A. Inability to sit or stand still neck D. the nurse remembers that she should stop giving the medication when she observes this side effect: A. Fine tremors D. Stiffening of the client¶s C. A common extrapyramidal symptom that is very unpleasant and intolerable to clients is called akathisia. Health instructions about Haldol (haloperidol) has been given to Anthony while in the hospital and before his discharge. ³I will drink about 2 liters of fluids daily and expect to urinate frequently.Many clients in a psychiatric unit receive antipsychotic medications. ³I will avoid pizza. 76.

Affect D. He started to be bossy. decreased white blood cell count C. Minimal environmental stimuli C. No limitation on his activities . Which side effect should cause the nurse to be MOST concerned? A. This medication has several side effects. manic phase. On admission he was diagnosed to be having Bipolar disorder. Perception C. Tremors. inability to stand still D. A therapeutic environment for Peter is: A. Clients on antipsychotic medications usually receive anti-parkinson drugs to reduce Parkinson like side effects. Low blood pressure upon getting up from bed 80. Conscience B. Fluphenazine (Prolixin) B. fever. Thought 82. Uncomfortable sun burns B. 81. Sore throat. Another client in the ward.79. Carl. a 35 year old employee was admitted to the hospital because of behavioral problems at the office. Fluoxetine (Prozac) Situation 17 ± Peter. is given Thorazine (Chlorpromazine). Peter¶s condition is primarily a problem of: A. Congentin (Benztropine) C. What medication would the nurse expect the client to receive? A. claiming that he is the manager on the unit. Nardil (Phenelzine) D.

The stress of hospitalization can lead to difficulties between nurses and patients. Sympathizing with the miserable feelings of Peter Suppressing her own feelings towards Peter Engaging Peter in productive activity Engaging Peter in introspective thinking 85. ³Peter. During socialization Peter was provoked.´ 84. C. Therapeutic use of self is essential in relating with psychiatric patients. Respond with. . Easily finishes projects given to him during occupational therapy Takes his medications without reminding him Demonstrates skills in activities of daily living Complies with hospital rules and regulations Situation 18. Everybody in the ward is in equal footing.B. C. we don¶t favor anyone. Take him away from the group until he manages to have control of himself. Strict isolation and withholding privileges D. B. Well lit and basically colored room 83. Following are situations that nurses presented during a monthly nursing circle. became furious. Restrain him and put him on isolation to protect other patients. The nurse may recommend discharge when Peter: A. B. B. D. D. started shouting and making personal demands. Prevent him from becoming more furious by giving an extra PRN dose of sedative. A. A therapeutic intervention of the nurse is: A. D. C. This is BEST demonstrated by the nurse in.

An invitation to have a social and intimate relationship with her nurse D. Exhibiting uncooperative and hostile behavior C. He remarked. or ³so understanding´. ³You upset me with your remark. an elderly client idealizes some nurses as ³terrific´.´ 87. ³the best´. Say as a matter of fact. but refers to others as ³mean´. Reducing patient¶s anxiety D. Immature and childish behavior . Be transparent and express disapproval openly. This behavior can be understood by the staff as: A. or ³indifferent´.´ B.´ A therapeutic response of the nurse would be: A. Lolita. ³I thought you really liked me. ³I understand. I like you. The dynamics of behavior underlying manipulative behavior explain that it is a behavior of: A. Jurry asked the nurse to have an ³out on pass´ privilege for the weekend but his request was not granted by the nurse. Ignore Jurry¶s remark D. An understandable behavior for an elderly that must not be taken seriously C. Say.´ C. you feel bad but of course. Sensing fear of other people 88.86. A sense of security and control B. Avoiding taking responsibility for her own behavior and underlying feelings B. ³Your behavior did not meet criteria for out on pass privilege.

Medical support C. Say nothing and just go on with the usual nursing interventions D. Brainstorming session Situation 19 ± Robert is a survivor of a tragic accident wherein his wife and child drowned when their boat sank due to stormy weather. Social support . Inappropriate affect D. B. B. Nursing Conference C. The nurse can BEST intervene by mobilizing the client¶s relatives.´ C. ³I¶m Cathy. Seminar-workshop D. The staff nurses have differing emotional reactions to the use of limit setting. unable to sleep` and concentrate and frequently would just be quiet and stare. Remove the patient¶s hand while saying calmly. ³I¶m the nurse and this is a hospital. Some staff views it as unprofessionally punitive and uncaring. Material support D. I¶m your nurse.89. Say her name. Depersonalization Guilt C. A. Spiritual support B. The MOST appropriate approach to address the nursing concern is through: A. What kind of husband and father am I?´ He is expressing. He tells you. 91. Counseling with the nursing supervisor B. Ask for the patient¶s name and if whether he is aware where he is. A. Cognitive disturbance 92.´ 90. friends and people to provide. The therapeutic response of the nurse would be to: A. Within the next 6 months from the accident he was observed to be detaching himself from others. A patient with delirium touches the nurse inappropriately. ³It is my fault.

which was difficult to establish. however. The staff is considering the possibility of using restraint on Mrs. Amok 95. The nurse encourages the client to communicate and socialize because internalized hostility can lead to: A. Psychotic breakdown C. Passivity 94. Sympathy D. Cortez is an 85 year old woman who has been hospitalized due to a urinary tract infection and dehydration. Cortez might pull out her IV and wander off the floor. Depression B. She has an IV in her left forearm. Developmental crisis D. Fairness . Justice B. 96.Mrs.93. Concerned that Mrs. she repeatedly declares that she does not want to be restrained. Post traumatic stress disorder B. The staff is faced with an ethical dilemma of autonomy versus: A. the staff is considering the possibility of using restraint on her. Acceptance C. Personality dysfunction Situation 20. Veracity C. Verbal assaultiveness C. and a tendency to wander. The patient is having a: A. Optimism B. She has Alzheimer¶s disease. Physical assaultiveness D. A therapeutic attitude the nurse can convey to the client while he talks about his loss is: A. Cortez. osteoporosis. Beneficence D.

97. How would you want to have your egg done? D. Singing to or with her music C. The nurse aims at highest level of self care. Request for a sitter B. Provision of a bedside 98. Hand and body lotion C. Which way would you want your egg done? Scrambled? Sunny side up? With vegetable mix? Or boiled? B. Cortez? A. Wheelchair privilege commode C. Which of the following will the nurse minimize? A. Labeling clothing items 100. which of the following should be a priority? A. Using clothing D. Playing a table board game picture album B. Cortez has a dietary privilege of food preferences. Which question is MOST effective to communicate with her? A. Mrs. Providing mouth swabs with buttons and zippers B. With a history of osteoporosis and a tendency to wander. Do you want fried egg or boiled egg? C. Going through family D. Which of the following would be LEAST likely appreciated by Mrs. Listening to old familiar 99. What is your favorite egg recipe? . Prevention of fall D.

When a nurse establishes a therapeutic relationship with a client. Mrs..SITUATION 1: Technique of therapeutic communication should be utilized and incorporated into nursing practice. 70 years old. so that the client can more effectively cope with problems.The nurse establishes the therapeutic relationship. Both medical and nursing diagnosis would be important in understanding the client. The nurse functions as a positive role model to encourage health oriented patient behavior c. The medical diagnosis c. is admitted to the hospital for cervical cancer d. Improving social interaction. However. The client s needs and problems d.The purpose of the therapeutic communication is to foster a helping relationship. R. Which of the following communication technique is MOST effective in dealing with covert communication? a. To elicit cooperation c. The other tasks described are part of the helping relationship but are not the over-all purpose 3. is admitted to the hospital after a stroke. but it is not the purpose of the relationship 2. Mrs. Needs to understand that patients may test her before he can accept and trust her . 50 years old.. the nurse provides care for person. Evaluation d. 30 years old is admitted to the hospital for the first time for acute appendicitis b. is admitted for fractured tibia. To facilitate a helping relationship d. to assist the client in working in his needs and problems. Evaluation doesn t have to do with covert communication 5. In which of the following situations would communications be LEAST likely hindered? a. T. He speaks Spanish only Answer: C. The client s social interaction Answer: B. Mr. 1. Mrs. The nursing diagnosis b. which of the following is the primary focus of the client s care? a. Which of the following is the overall purpose of therapeutic communication? a. The nurse recognizes that some patient regress when confronted with illness b. To analyze client s problems b. the rest can hinder communication except C. unless if the patient with cervical cancer is in severe pain (but not present in situation) 4. diabetic.L. Validation Answer: A. She has right hemiplegia c. Listening c. 45 years old. D. Clarification b. Which of the following is MOST important in fostering a positive relationship? a. not the diagnosis. To provide emotional support Answer: C.Clarification and validation is just the result of listening. which is a helping relationship.

The nurse should accept the role of the patient SITUATION 2: Stress can bring about various human reactions that may result to illness or enhance one s coping mechanism. Moderate c.General adaptation syndrome refers to the physiologic response to stress 7. Which of the following levels of anxiety is BEST for client s learning? a. Transaction based model Answer: D. Stimulus based model c. No anxiety Answer: B. Regression c. Physiologic response to stress d. Repression b. Mobilize energy needed for adaptation d.d. Alert the individual to danger Answer: C. Present the individual from having an unpleasant experience c. 16 year old was committed to a mental health facility with diagnosis of personality disorder. Which of the following BEST describes the general adaptation syndrome. Mild d. The nurse must fully share the patient s feelings before she can develop her goal for her nursing care Answer: D. Psychological response to stress c. The purpose of the first stage of the General Adaptation Syndrome is which of the following? a. Moderate anxiety increases client s arousal state to a point where the person expresses feelings of tension.Suppression refers to consciously forgetting of painful events while repression refers to unconsciously forgetting of painful events 9. effect of social environment and the resources used to deal with stress as determinants to stress and stress reactions? a. it produces a slight arousal state that enhances perception. Severe b. perception is further decreased 8.Transaction based model was created by Lazarus which is a Stimulus Theory and Response theory in which do not consider individual differences 10. Projection Answer: B. nervousness and concerns but perceptual ability is narrowed. practice and norms of the peer group. It is a: a. Suppression d. Determine the causes of the danger b.this is the purpose of the first stage of GAS in order to prevent crisis SITUATION 3: Paul.In mild level of anxiety. Response based model b. learning and productive abilities. Adaptation based model d. He has a history of promiscuity and running away. Which of the following defense mechanism is consciously used in coping mechanism with stress? a. Sociocultural response to stress Answer: B. I . 6. He tells the staff I can t stand this place. Stress also triggers local and general adaptation syndrome. Which of the following models identifies ability to cope with stress. Behavioral response to stress b. Sever anxiety consumes most of person s energies and requires intervention.

Failure to identify positively with father c. Ignore the threat Answer: C. Isolate Paul d. 16. 11. Consistency Answer: D. Lack of parental love and discipline d. Severe parental rejection c. I ll get sick if I use heroine on this medication. visual hallucinations Answer: B. talkativeness. impaired concentration b. the staff will help him control herself d. Severe temper tantrums b. Lack of the capacity to trust others Answer: B. Active friendliness c. Love and understanding b.Firmness. Ignore him demands c. How would you describe parental rejection? a. Failure to identify positively with father Answer: A 13. the nurse should convey an attitude of: a. Lock him in her room c.Safety precautions must be posed to protect others. Tell him firmly that if he does not control herself. Which of the following behaviors would indicate stimulant intoxication? a. provide endorsement to other nurses 15.Clients with antisocial disorder lacks trust for others 14. matter of fact and consistency is used to approach clients with antisocial personality SITUATION 4: Mark was brought to the National Center for Mental Health for substance abuse. Relaxed inhibitions. Protect others from being manipulated Answer: D. Slurred speech. In dealing with manipulative behavior. talkativeness.Choice a are manifestations of depressants. . Hyperactivity. What should the nurse do to prevent Paul from manipulating and dominating others? a.want to go away. Which of the following statements would indicate the teaching about Naltrexone (Revia) had been effective? a. global 12. distorted perceptions d. Tell him to stay in her room b. dilated pupils. How would the nurse deal effectively with Paul s threat to run away? a. increased appetite. euphoria are signs of stimulant intoxication 17. The early experiences of Paul may indicate a history of: a. unsteady gait. euphoria c. Failure in interpersonal relationship d. Depersonalization. choice b and c are manifestations of hallucinogen while hyperactivity. Permissiveness d. Observe him closely b. Lack of recognition as a person b.

Assessing the client s blood pressure b. Monitoring the client for tremors d. This medication will block the effects of any opioid substance I take. If I use opioid while taking naltrexone.It is due to availability of drugs 20. Most nurses are exposed to various substances and believe they are not risk to develop the disease d.Clonidine (Catapres) is an antihypertensive which is given to patients with opioid withdrawal because these patients are hyperactive which results to increase in their vital signs.Other than her stepfather let the child stay with the relatives 22. She knows that teaching has been effective when staff identify the following as the greatest risk for substance abuse among professionals: a. 19. Psychological addiction Answer: C. Completing a thorough physical assessment Answer: A. The client tells the nurse that she takes a drink every morning to calm her nerves and stops her tremors. Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Worries .b. Beth is experiencing: a. Ask the child to get away from her stepfather d. A neurological disorder d. d. 21. Which of the following nursing assessments is essential before giving a dose of this medication? a. I ll become extremely ill.Naltrexone (Revia) is a narcotic antagonist 18. The nurse realizes the client is at risk for: a. Using naltrexone may make me dizzy. As a nurse. Most nurses are codependent in their personal and professional relationships b. Tell the mother to keep watching her daughter b. Marinel. Most nurses come from dysfunctional families and are risk for developing addiction c. Let the child stay with the relatives Answer: D. Tell the child get to her regular activities c. Most nurses have preconceived ideas about what kind of people become addicted Answer: C. Determining when the client last use an opiate c. c. Answer: B. The nurse has provided an in-service program on impaired professionals. Marinel s high school friend made a visit and talked to her father. a 16 years old young lady was left with her stepfather and with a mother who is working in the office the whole day. what would be your advice? a. An anxiety disorder c.Physical dependence is a physical effect of drug SITUATION 5: A nurse must be aware of the latest issues on Child Abuse and Family Violence. Physical dependence b. Marinel feels fidgety and continuously smoked while her friend is talking to her mother.

as evidenced by crying Answer: C. dancing. The fact that they don t stand up straight c. Teaching the client about abuse and the cycle of violence c. and swimming d. Risk for violence related to abusive husband. This is due to: a. Parish d. which of the following measures would be most important to include? a. Inaccurate measurement Answer: C . not even to visit my friends. Helping the client develop a safety plan Answer: D.So that the client can escape the abuse for safety reason 25. Physical activity. When planning the care for a client who is abused. Powerlessness related to abusive husband. Which of the following nursing diagnoses would the nurse formulate in respect to this information? a. Loss of bone mass in the vertebral discs b. Police station b. The best way a nurse can advise an abused child is to call the: a. During the session with the nurse. and losing weight b. I don t know what to do anymore.b. Bantay Bata 163 Answer: D.Powerlessness related to abusive husband. and lack of exercise c. The rest of the population has grown taller d.Nervousness is a physiological symptom to relieve anxiety 23. School c. and weight lifting Answer: A 27. a client who is being abused states. deep breathing. they lose height (become shorter). Stress Answer: C. as evidenced by inability to make decisions d. Knee bends. Low Self-Esteem related to victimization. as evidenced by inability to make decisions refers to marital status SITUATION 6: The following questions pertains to Musculoskeletal System of aging persons 26. as evidenced by victim s statement of being battered b. Anger c. Drinking tea. Explaining to the client his or her personal and legal rights d. Which of the following behaviors contribute to osteoporosis: a. As people gets older. Nervousness d.Bantay Bata 163 is a non-government organization 24. Smoking. shopping. Being compassionate and empathetic b. as evidenced by not being able to leave the house c. Ineffective Coping related to victimization. He doesn t want me to go anywhere while he s at work.

They show poor social judgment Ans. 31. Minimal use of direct touch b. workers assigned in mining industries or a family member assigned in far places.. Becomes like a dancer c. Which of the following are observed in sensorially deprived adult and elderly people because of deafness? a. Is more steady b. Which nursing intervention would be appropriate for client with hyperthesia? a. the gait of older people: a. Stays about the same b. Restriction of the environment in patients who are on absolute bed rest c.. Allergy b. They prefer interaction with hearing adults b. becoz the rest can aggravate sensitivity to stimuli of any senses . Elimination of order or meaning from input in the case of ICU patients or was in reverse isolation Ans. Increased sensory input brought about by unlimited visitors from families and friends b. Contagion d. As one ages. They become more flexible in daily routine d. C. Vigorous hair brushing d. Which of the following will LEAST likely result to sensory deprivation? a. Infection c. they show poor social judgment becoz of the deprived hearing loss 33. Reduced sensory input in the case of patients who have just been operated on glaucoma d. They show greater interdependence than hearing adult c. Increases d. Fractures Answer: D SITUATION 7: Sensory deprivation is experienced by most people in any setting whether they are patients confined in hospitals.. the rest can lead to sensory deprivation.A. A is the least 32.28. Decreases c. Frequent back rubs Ans. Hardly changes at all Answer: B 30.A. Is less stable and balanced when walking d. muscle mass (that is muscle size): a. Can go either way Answer: A 29. Changes in the bone of older people make which of the following a major danger? a.. Firm pressure when touching body parts c. As a result of changes in long bones and the spinal column.

Protection against constipation b. 36. The nurse should stand slightly infront so you can better guide the patient with visual impairment 35. Stand on the client s dominant side and grasp the client s arm c. D. Hormonal decline in women causes: a. The nurse however must be able to identify and address the sexual changes to provide nursing care. Stand on the client s dominant aside slightly in front of the client. grasping the client s arm b. Menopause is considered complete when: a. Stand on the client s nondominant side. Speak loud enough or shout if you may so that client will be able to hear you Ans. A post-operative blind patient needs to be assisted for ambulation.. No changes in risk for atherosclerotic plaques b. allowing the client to grasp the nurse s arm d. Which of the following should the nurse do in ambulating a client with visual impairment? a. Benefits of hormone replacement therapy (HRT) include: a. approximately one step behind the client. Which of the following is an appropriate communication method for client s with hearing impairment? a. Stand slightly in front of the client s nondominant side allowing the client to grasp the nurse s arm Ans.34. Protection against osteoporosis and elimination of the unpleasant symptoms of menopause c. Emotional stability ends d. Irritability goes away Answer: C 37. Use visual aide and gestures to enhance the spoken word c. Decreased risk for atherosclerotic plaques d. Talk side by side with the client b. Gesture and visual aids can enhance better understanding for people with hearing impairment SITUATION 8: Sexuality is one problem area that is often neglected by nurses in the care of elderly clients. A woman has been without periods for a year b. Increased risk for atherosclerotic plaques c. Protection against fever . None of the above Answer: A 38. Protection against the flu d. B. Hot flashes cease c. Restrict use of the client s hands d.

Flat with small pillow under the nape of the neck c. Marking the area of drainage on the dressing . Re-explain why she is having difficulty of speaking d. Which nursing intervention protects the client without increasing her ICP? a. A client undergoes a craniotomy for removal of her brain tumor.This lessens the possibility of hemorrhage. Tuck her arms and hands under the draw sheet d. the position that would be most appropriate for this client would be: a. Post operatively.It is best for the client to wear mitts. A client is regaining consciousness after a craniotomy becomes restless and attempts to pull out her intravenous line. Speak to her in simple words and short sentences Answer: B. Wrap her hands in soft mitten restraints c. Place her in a jacket restraint b. Breast and endometrial cancers d. To promote the client s use of speech the nurse should: a. Apply a wrist restraint to each arm Answer: B. He was scheduled for craniotomy. and promotes venous return 41. Which of the following interventions is most appropriate? a. The nurse notes that her dressing is saturated with blood.Recognition of effort is motivating 43. because restraining her movements will cause agitation and lead to an increase of the ICP 42. Lung cancer Answer: D SITUATION 9: The nurse is caring for an adult admitted with a diagnosis of brain tumor. Head of the bed elevated 20 degrees with the head turned to the operative side d. Respond to her crude efforts of speaking c. Head of the bed elevated 45 degrees with a large pillow under the head and shoulders Answer: D. 40. a female client is still having some motor speech difficulty. Replacing the dressing b. A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Correct her mistakes immediately b. Formation of blood clots and hypertension b. High fowler s with knee gatch raised b. provides for better circulation of CSF. Following 3 months of rehabilitation after craniotomy. Which of the following is NOT a known risk of hormone replacement therapy: a. Development of noncancerous fibroid tumors in the uterus c.Answer: B 39.

When assessing a client with dementia. Doing nothing because this is normal occurrence Answer: C.Loss of judgment decreases the ability to control impulses and behaviors in social situations.If the dressing becomes saturated with blood. the client typically exhibits inappropriate language and sexual behaviors. After craniotomy. which of the following behaviors would the nurse interpret as a manifestation of disinhibition? a. ACUTE dementia is due to causes which can be reversed. not disinhibition 48. Prevent secondary surgery d. what is your primary goal? a. When there is a small amount of drainage on the dressing. Decreased interest in bathing and hygiene d. Prevent infection c. As one gets older. Auditory and/or visual hallucinations c. The remaining cells are more than enough for learning and remembering d. especially hyponatremia (loss of sodium) Answer: D 47. Multiple Infarcts d. Wandering and getting lost b. A frequent cause of this type of dementia is: a. Electrolyte imbalance.c. A cell transplant is indicated b. The significance of this is: a. Alzheimer s disease c. The brains of persons with Alzheimer s disease are characterized by the presence of: a. Therefore. The lost cells will regenerate on their own c. The significance is not known Answer: C 46. Fatty deposits c. Inappropriate language and sexual behaviors Answer: D. it should be reinforced and the doctor notified immediately. there is a loss of brain cells. Calcium deposits . Wandering and getting lost involve cognitive changes. The dressing shouldn t be removed because removing it might disturb clot formation. Prevent hemorrhage SITUATION 10: Dementing illness and changes in the brain 45. Cerebrovascular accident b. Reinforcing the dressing and notifying the doctor immediately d. The patient may need to return to the operating room to stop the bleeding. the drainage area can be marked to easily identify an increase in drainage 44. Prevent increased ICP b.

he says.b. Express doubt and do not argue d. The President of the Philippines told me to take you to dinner. He needs clear.A delusional client is wrapped up in his false beliefs that he tends to disregard activities of daily living. Encourage ventilation of anger Answer: C. concise. Delusion c. Lack of gray matter Answer: B SITUATION 11: A 23 year-old man was voluntarily admitted to the inpatient unit with a diagnosis of paranoid schizophrenia.A delusion is a fixed false belief 50. 49.Paranoid clients develop a delusional system to defend against anxiety. I ll die. Mood disturbance c. Provide an anxiety-free environment c. Disturbance of thought d. A schizophrenic patient who began taking haloperidol (Haloperidol) 1 week ago now exhibits jerking movements of the neck and mouth. The client tells his primary nurse that he s scheduled to meet the President of the Philippines a special time. Which of the following responses by the nurse is most appropriate? a. Your physician expects you to follow the unit s schedule. such as nutrition and hydration. the main principle is to: a. Disturbance of perception 51. possibly evoking mistrust on the part of the client. The second option belittles and tricks the client. It s meal time. b. c. The last option is demeaning and doesn t address the delusion 53. The third option evades the issue of meeting his basic needs. Let s go so you can eat. Use logic and be persistent b. making it impossible for the client to leave his room for dinner. Hallucination b. This is an example of: a. Psychomotor disturbance b. Idea of reference Answer: B. Answer: A. Arguing with the client would increase his anxiety 52. d. People who don t eat on this unit aren t being cooperative. These are signs of: . Delusion is: a. As the nurse approaches the client. Senile plaques and neurofibrillary tangles d. Illusion d. firm directions from a caring nurse to meet his needs. When communicating with a paranoid client. If you come any closer.

a. Dystonia b. Psychosis c. Akathisia d. Parkinsonism Answer: A- Haloperidol and other high-potency conventional antipsychotics cause a high incidence of dystonia and other extrapyramidal adverse effects. Dystonia is marked by prolonged, repetitive muscle contractions that cause twisting or jerking movements especially of the neck, mouth, and tongue SITUATION 12: Nico, 27 yrs. old, is admitted for treatment of a major depression. 54. He is withdrawn, appears disheveled, and states, No one could ever love me. The nurse can expect the client to be placed on a. Antiparkinsonism medication b. Suicide precautions c. A low-salt diet d. Phototherapy Answer: B- Maintaining safety for the client is a priority because she may have suicidal ideation and/or plan 55. Which of the following behaviors indicates to the nurse that a client s major depression is improving? The client: a. Displays a blunted effect b. Has lost an additional 2 pounds c. States one good thing about himself d. Sleeps about 16 hours per day Answer: C- This behavior may indicate an increase in self-esteem that accompanies an improvement in depression. A depressed person often cannot problem solve or acknowledge any positive aspects of their lives 56. Nico is scheduled for electroconvulsive therapy (ECT) tomorrow. The nurse would plan for which of the following activities? a. Force fluids 6 to 8 hours before treatment b. Administer succinylcholine (Inestine, Anectine) during pretreatment care c. Encourage the client s spouse to accompany him d. Reorient the client frequently during posttreatment care Answer: D- Common side effects of bilateral treatment include confusion, disorientation, and short-term memory loss. The nurse should provide frequent orientation statements that are brief, distinct, and simple 57. Nico is recovering from a severe depression. Which of the following behaviors alerts the nurse to a risk for suicide? a. The client sleeps most of the day

b. The client has a plan to kill himself c. The client loses 5 pounds d. The client does not attend unit activities Answer: B- Having a suicide plan is a risk factor. The lethality needs to be assessed. When a depression is lifting, the client may have the energy and resources to carry out a plan. Behavioral, somatic, and emotional cues may be overt or covert 58. Nico has been depressed severely depressed for 2 weeks. He had mentioned ending it all prior to admission. Which of the following questions should the nurse ask during the prescreen assessment? a. How long have you thought about harming yourself? b. What is it that makes you think about harming yourself? c. How has your concentration been? d. What specifically have you thought about doing to harm yourself? Answer: D- This question assists in determining suicidal intent and lethality SITUATION 13: A client is admitted with a diagnosis of Alzheimer s Disease. 59. When developing the plan of care for a client with Alzheimer s disease who is experiencing moderate impairment, which of the following types of care would the nurse expect to include? a. Considerable assistance with activities of daily living b. Managing complex medication schedule c. Constant supervision and total care d. Supervision of risky activities, such as shaving Answer: D- Considerable assistance is associated with moderate impairment when the client is unable to make decisions but can follow directions. Supervision of shaving is appropriate with mild impairment that is, when the client still has motor function but lacks judgment about safety issues. Managing medications is needed even in mild impairment. Constant care is unable to follow directions 60. Which of the following would be priority to include in the plan of care for a client with Alzheimer s disease who is experiencing difficulty processing and completing complex tasks? a. Repeating the directions until the client follows them b. Asking the client to do one step of the task at a time c. Demonstrating for the client how to do the task d. Maintaining routine and structure for the client Answer: B- Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple step, ones that the client is able to process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. However, demonstrating one step would be helpful. Although maintaining structure and routine is important, it is unrelated to task completion 61. Clients with Alzheimer s disease may have delusions about being harmed by staff and others. When

the client expresses fear of being killed by staff, which of the following responses would be most appropriate? a. What makes you think we want to kill you? b. We like you too much to want to kill you. c. You are in the hospital. We are nurses trying to help you. d. Oh, don t be so silly. No one wants to kill you here. Answer: C- The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn t recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn t know that they are false beliefs. It also restates the word, kill, which may reinforce the client s delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate 62. When helping the families of clients with Alzheimer s disease to cope with vulgar or sexual behaviors, which of the following suggestions would be most helpful? a. Ignore the behaviors, but try to identify the purposes b. Give feedback on the inappropriateness of the behaviors c. Employ anger management strategies d. Administer the prescribed risperidone (Risperdal) Answer: A- The vulgar or sexual behaviors are often expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors 63. The nurse determines that the son of the client with Alzheimer s disease needs further education about the disease when he makes which of the following statements? a. I didn t realize the deterioration would be so incapacitating. b. The Alzheimer s support group has so much good information. c. I get tired of the same old stories, but I know it s important for Dad. d. I woke up this morning hoping that my old Dad would be back. Answer: D- The statement about hoping that the Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about Alzheimer s group is based in reality and demonstrates the son s involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son s part SITUATION 14: A 34-year old is hospitalized with bipolar disorder. 64. The nurse knows that the major factor that distinguishes a bipolar from a unipolar disorder is the

Higher incidence in women b.a. The intervention in answer choice (D) is inappropriate because the client is told only what is unacceptable and is not given any alternatives 68. the nurse the nurse finds him phoning friends all across the country to discuss his new plan for eradicating world hunger. Problem-solving therapy Answer: A.A drug frequently used to treat manic clients is lithium carbonate (Eskalith) 66. not appropriate in treatment of bipolar disorders 67. Supportive therapy for a client who is exhibiting manic behavior may include all of the following EXCEPT: a. It is not the responsibility of the peer group to monitor the client s behavior. Recommend the client to be hospitalized for treatment d. A tricyclic depressant b. Which of the following nursing intervention is most appropriate? a. Leading a group activity b. Tell client that his behavior is not appropriate Answer: B. An antianxiety drug Answer: C.The nurse s response is an alternative behavior for unacceptable ones in order to assist the client in self-control. An MAOI-inhibitor antidepressant c. Describe acceptable behavior and set realistic limits with the client c. At 2 a.m. The nurse caring for him knows the drug most likely to be prescribed for this client is: a. Reading the newspaper d. insight-oriented psychotherapy. The client is creating considerable chaos in a day treatment program with dominating and manipulative behavior. The client is skipping up and down the hallway practically running into other clients. Allow the peer group to intervene b. The client s behavior does not warrant hospitalization. The diagnosis of bipolar disorder is given to persons who also experience manic episodes 65. Severity of the depression c. Genetic etiology d. Psychoanalysis b. but he won t quiet down. Which of the following activities would the nurse expect to include in the client s plan of care? a. Cleaning the dayroom tables . Watching television c.Psychoanalysis is an in-depth. Interpersonal therapy d. Presence of mania Answer: D. Cognitive therapy c. His excited explanations are keeping the entire unit awake.Both unipolar and bipolar disorders include episodes of depression. Lithium carbonate (Eskalith) d.

the successful completion of a helpful task would give the nurse the opportunity to thank the client for the help. Dilatation of the pupil and blood vessels b. Produces aqueous humor b. The retina contains the rods and cones. Regulates the amount of light entering the eye Answer: C.Answer: D. This preparation acts in the eye produce a. Participating in this type of activity also would be probably causes the client to be disruptive. blurring. causing the pupil to dilate. Opacity of the lens blocks light rays from reaching the retina. Eye pain and irritation are not associated with glaucoma. thereby enhancing the client s self-esteem. Typically. light scattering occurs and is related to the degree of opacity of the lens.Instilled in the eye. What does the lens of my eye do? The nurse should explain that the lens of the eye: a. Leading a group activity is too stimulating for the client. Halos and rainbows around lights b.A client with a cataract usually complains of dimness. Dilatation of the pupil and constriction of blood vessels c. The iris regulates the amount of light entering the eye 70. The client asks. Constriction of the pupil and constriction of blood vessels d. Eye pain and irritation that worsens at night c. Focuses light rays onto the retina d. The ligaments influence the tension on the lens and thereby focus light rays onto the retina. SITUATION 15: A client is admitted to outpatient surgery for cataract extraction on the right eye. 69. Blurred and hazy vision d. Because the client is distracted easily and can concentrate only for short periods. Constriction of the pupil and dilatation of blood Answer: B. Holds the rods and cones c.The lens of the eye is suspended on the suspensory ligaments. and/or hazy vision. A short time after cataract surgery. The ciliary bodies secrete aqueous humor. Accommodation is the ability of the lens to adjust to near and far objects. Which of the following represents the nurse s best course of action? . Eye strain and headache when doing close work Answer: C. The client would most likely to complain of which symptoms? a. the client complains of nausea. phenylephrine hydrochloride asks as a mydriatic. Watching television or reading the newspaper would be inappropriate for the client who is unable to sit for a period of time. It also constricts small blood vessels in the eye 72.The client with mania is very active and needs to have this energy channeled in a constructive task such as cleaning or tidying the dayroom. Eye strain and headache when doing close work is associated with refractive errors 71. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into a client s right eye before cataract removal surgery.

Rigidity b. Discharge planning would include: a. 74. Maintaining a safe environment d. Bending with the knees and keep the head straight d. Which of the following topics that the nurse plans to discuss is the most important? a. Medicate the client with an antiemetic. Deep breathing is unlikely to relieve nausea. Tell the client to call the nurse promptly if vomiting occurs d. when the client s energy level is high b. This type of gait often causes the client to fall or to have trouble stopping 76. it doesn t necessarily pass quickly and can lead to vomiting. Lifting light objects is acceptable c. Maintaining a balanced nutritional diet b. Bradykinesia d. Akinesia Answer: B. Which of the following is an initial sign of Parkinson s disease? a. Vomiting can increase intraocular pressure. Early in the morning.The primary focus is on maintaining a safe environment. Explain that this is a common feeling that will pass quickly c. characterized by a tendency to take increasingly quicker steps while walking. which should be avoided after eye surgery because it can cause complications. Postoperative nausea may be common. because the client with Parkinson s disease often has a propulsive gait.The first sign of Parkinson s disease is usually tremors.a. Enhancing the immune system c. Instruct the client to take a few deep breaths until the nausea subsides b. To coincide with the peak action of drug therapy . and bradykinesia is the third sign. The client often is the first to notice this sign. Telling the client to call only if vomiting occurs ignores the client s need for comfort and intervention to prevent complications 73. Wearing eye patches for the first 72 hours b. The nurse develops a teaching plan for a client newly diagnosed with Parkinson s disease. Akinesia is a later stage of bradykinesia 75. as ordered Answer: D. Engaging in diversional activity Answer: C. Rigidity is the second sign. however. Bending with the waist is acceptable if slowly done SITUATION 16: A client is admitted with a diagnosis of Parkinson s disease.A prescribed antiemetic should be administered as soon as the client who has undergone cataract extraction complains of nausea. When does the nurse encourage a client with Parkinson s disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? a. Tremor c. because the tremors may be minimal at first.

When family members will be available Answer: B. however. To stop the progression of the disease c. Artificial tears will remove the purulent drainage from your eye. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible 77. but she becomes annoyed when the nurse offers assistance and refuses all help. To cure the disease b. The client needs a long time to complete her morning hygiene. This will only decrease the client s self-esteem and her desire to try to continue self-care. Tell the client that she is being unrealistic about her abilities and accept that she needs help d. Suggest to the client that if she insists on self care. which speeds healing. Suggesting that the client modify her routine seems to put the hospital or the nurse s time schedule before the patient s needs. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson s disease? a.The most appropriate and realistic goal is to help the client function at his best. Tell the client firmly that she needs assistance and help her with her care b.Demanding physical activity should be performed during the peak action of drug therapy. The eye may not close completely.Bell s palsy may cause paralysis of the eyelid and loss of the blink reflex on the affected side. There is no known cure for Parkinson s disease. a. When your affected eye fails to make tears. The client should be given additional time as needed and praised for her efforts to remain independent. she should at least modify her routine Answer: B. A client with Bell s Palsy asks the nurse why artificial tears were ordered by the physician. and there is no known way to stop its progression. and it would not be appropriate to start planning terminal care at this time 78. Because you cannot blink the affected eye. Telling the client that her perception is unrealistic does not foster hope in her ability to care for herself. b. To maintain optimal body function Answer: D. These problems render the eye susceptible to drying and irritation from dust or other debris . c. Which statement is the nurse s best initial response in this situation? a.c. Praise the client for her desire to be independent and give her extra time and encouragement c. d. it can become dry and irritated. Parkinson s disease progresses in severity. which is obviously important to her SITUATION 17: A client is admitted to the hospital with Bell s Palsy. the eye can become irritated and ulcerated.Ongoing self-care is a major goal for clients with Parkinson s disease. 79. Answer: D. Many clients live for years with the disease. Because your eye remains closed. To begin preparations for terminal care d. Firmly telling the client that she needs assistance will undermine her self-esteem and defeat her efforts to be independent. foreign matter can be trapped beneath the lid. Select the best reply by the nurse. Immediately after a rest period d.

Provide ample time for her to complete her rituals Answer: B. Placing an eye patch over her eye c. therefore. Remind the client several times of her appointment b.80. The client has a feeling of stiffness and a drawing sensation of the face. Placing a patch over the eye is the most appropriate intervention to prevent eye injury. The main nursing goal is to: a. Instilling artificial tears once every shift d. Risk for impaired physical mobility Answer: B. Her family reports she washes her hands at least 30 times each day. All of the above SITUATION 18: A 46-year old is admitted to the hospital because her family is unable to manage her constant hand washing rituals. Eye is susceptible to injury when eyelid does not close b. The nurse observes that the client s right eye does not close completely. An unstructured schedule of activities . and cracked. he ll be at risk for injury to the cornea 81. Making sure the client wears her eyeglasses at all times will not help protect the eye from injury. which of the following nursing interventions would be most appropriate? a. the cornea may be dry and irritated. The nurse noticed the client s hands are reddened. Based on this. Which nursing diagnosis takes priority for the patient with Bell s palsy? a. Risk for injury related to corneal laceration c. Limit the number of hand washings c. Which of the following is an appropriate treatment for this client? a. Cleaning the eye will prevent ulceration d. A once-per-shift intervention will not adequately relieve the potential for injury from a dry and irritating ocular environment.The patient with Bell s palsy will be unable to close his eyelid on the affected side. What would be an important teaching to the patient? a. Making sure the client wears her eyeglasses at all times b.Obsessive-compulsive behavior represents displacement of anxiety. Drooling from an increased saliva on the affected area may occur c. not tap water 82. 83. Risk for dysfunctional grieving b. A concrete measurable goal is to decrease the number of hand washings 84. Cleansing the eye with a clean washcloth every shift Answer: B. Tell her it is her responsibility to be there on time d. A normal saline solution should be used to moisten the eye.When the blink reflex is absent or the eyes do not close completely. scaly. Risk for chronic low self-esteem d.

Tell her to stop each time she is observed doing it Answer: A. Lock the door to her room and restrict access to the bathroom d. Drinking Ensure between meals b. The nurse and the client will know That discharge planning is appropriate when the client: a. 88. Negative reinforcement every time she performs her rituals Answer: B. Limits her hand and face washing to a few times a day Answer: D. Give the client a detailed explanation of his panic reaction Answer: B.The major issue is control of behavior and thoughts. Interrupt the activity briefly and frequently c. Which nursing intervention would the client be most likely to comply with? a. Explain to the client that there s no need to worry because he s safe d. Is able to start talking about her guilt and anxiety d. Drinking 8 oz water every hour between meals d.b. Expresses a desire to leave the hospital c.Allowing the client a certain amount of time to engage in the activity alleviates some of the client s anxiety 86. Intense counseling d. The client is also constipated and dehydrated.Planning a structured schedule of activities provides the client with ways other than hand washing to reduce anxiety 85. limit her hand and face washing to a few times a day. Options . Which intervention would be most appropriate? a. simple sentences are the most effective means of communication.Building the intake of a specified amount of liquid into a daily schedule of activities is very consistent with the obsessive-compulsive client s need to control as many aspects of her life as possible 87. Regains her normal body weight b. Tell the client he s all right. Allow her a certain amount of time each shift to engage in this behavior b.. she will then be able to resume normal activities of daily living SITUATION 19: The nurse is caring for a client who is experiencing panic attack. ie.The client experiencing a panic attack is unable to focus and his ability to relate to others is diminished. short. therefore. Speak to the client in short. A structured schedule of activities c. The most effective way for the nurse to intervene with her hand and face washing is to: a. Upon admission she was also dehydrated and underweight. simple sentences c. When the client is able to control her compulsive behavior. and there is no need to panic b. Drinking extra fluids with meals c. Drinking adequate amounts of fluid during the day Answer: C.

dizziness and fearfulness. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months Answer: D. Tachypnea . and the client response is vague and not focused on nurse s question.Pharmacologic management would consist of either tricyclic antidepressants or benzodiazepines. Clients having regular obsessions are probably suffering from obsessivecompulsive disorder. Panic Answer: C. Hyperventilation d. Frequently. The nurse assesses the client s level of anxiety as: a. the client described is unable to do this. The client has regular obsessions b. Which of the following is a behavior manifestation of anxiety. a racing heart. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder d. used for hypertensive emergencies. Severe d. Moderate anxiety is characterized by the ability to focus on central concerns. Panic b. B and C minimize the patient s anxiety 89. the level of anxiety is severe. Moderate c. Lithium carbonate Answer: A. what would the nurse anticipate administering? a. Suspecting a psychological component to these symptoms. The nurse asks the client if something upsetting happens. All of these symptoms have occurred almost daily for the past 3 months. The client reports that she often feels a choking sensation in her throat. Lithium carbonate is an antimanic agent 90. Mild b. The client has a generalized anxiety disorder. Mild anxiety is characterized by increased alertness and problem-solving ability. Panic level of anxiety is characterized by complete inability to focus and reduced perceptions. Nitropusside d. Benzodiazepines b. pharmaceutical therapy with benzodiazepines can help. except: a.When the client has difficulty focusing and exhibits excessive motor activity. The client is pacing and complains of racing thoughts. but the inability to solve problem without assistance.Constant patterns of anxiety that affect the client for more than 6 months and interfere with normal activities are characteristic of generalized anxiety disorder. Nightmares and flashbacks are typical symptoms of posttraumatic stress disorder 91. Proton pump inhibitors c. Relaxation techniques and psychotherapy are necessary for care c. Nitroprusside is a potent vasodilator. Tachycardia c. Proton pump inhibitors are used for GI disorders. the client described is unable to do this. Which statement is true about this client? a. the client described is not at this point 92.A.

Denial Answer: D. Displacement c. Which of the following defense mechanism is Sam using? a. In patients with dissociative disorders. and elevated enzymes. Sublimation Answer: D. Passive-aggression b. It can serve as a normal protection in the early stages of crisis. Nina is admitted to the ICU with chest pain. an abnormal ECG. When the significance of this is explained to her. released from prison for selling narcotics has been rehabilitated and now works for a youth drug prevention agency. The nurse suspects the client is using which defense mechanism? a. Sublimation b.Repression is the defense mechanism used most often to block traumatic experiences. Regression c. Reaction formation c. Projection d. Repression Answer: D. Denial b. The other choices do not apply to this situation 94. You must be mistaken. Denial d. the defense mechanism most often used to block traumatic experiences is: a.The failure to acknowledge the reality of the diagnosis is an example of defense mechanism of denial. she says. Sam is diagnosed with cancer does not talk about or acknowledge the diagnosis. Denial b. I can t be having a heart attack. Identification c. Identification d. Nathaniel. Neither reaction formation nor denial is relevant in these disorders . The other answer choice options are not applicable to this situation 95.Denial helps the person escape unpleasant or intolerable reality by refusing to perceive the facts. but if the denial persists it will prevent the client from coping 96. Dissociation d. Darwin is reflecting which of the following defense mechanism? a.SITUATION 20: Defense Mechanisms 93. socially acceptable behavior for strong impulses that are unacceptable.Sublimation is the defense mechanism whereby an individual substitutes constructive. Rationalization Answer: A. No way.

He has been seen by many medical specialists in the past without discovery of organic pathology.Hypochondriasis is excessive preoccupation with one s physical health. Denial c. Conversion disorder b. The nurse assesses that the client is probably experiencing which of the following problems? a. but physical examination and diagnostic tests find no physiological cause PART II CARE FOR CLIENTS WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS SITUATION 1: Technique of therapeutic communication should be utilized and incorporated into nursing practice. Hypochondriasis Answer: D.This is an appropriate long term goal related to the client s ineffective coping (use of conversion symptom. Conversion disorder d. She seems unconcerned about her paralysis. without organic pathology 99. An appropriate long term goal for the nurse to formulate is that client will: a. Somatic illness c.97. Compensation d. paralysis) related to unresolved conflicts and anxiety 100. Develop an increased sense of relatedness to others Answer: A. Reaction formation SITUATION 21: Psychosomatic disorders 98. A patient who reports paralysis with no specific cause but has a history of a recent stressful event has a probable diagnosis of: a. symptoms suggest a physical disorder. Amie is hospitalized for treatment of conversion disorder. Express feelings about conflict d. A man s family brought him onto the hospital because of his many somatic complaints. . Pain disorder Answer: C. Body dysmorphic disorder c. Identify stressors c.In conversion disorder. She complained of paralysis of her right side after her husband threatened to leave her and their children. Displacement b. The defense mechanism utilized by manic patients to cover up depression is: a. Cope effectively with stress without using conversion b. Hypochondriasis b. Malingering d.

The nurse functions as a positive role model to encourage health oriented patient behavior c. is admitted to the hospital for cervical cancer d. Which of the following BEST describes the general adaptation syndrome. It is a: a.L. which of the following is the primary focus of the client s care? a. D. diabetic. The client s needs and problems d. Evaluation d. Behavioral response to stress b. She has right hemiplegia c. Psychological response to stress c. The nurse must fully share the patient s feelings before she can develop her goal for her nursing care SITUATION 2: Stress can bring about various human reactions that may result to illness or enhance one s coping mechanism. To elicit cooperation c. Stress also triggers local and general adaptation syndrome. 6. To analyze client s problems b. Mrs. is admitted to the hospital after a stroke. The client s social interaction 2. Sociocultural response to stress . 50 years old.1. Clarification b. The nursing diagnosis b. is admitted for fractured tibia. He speaks Spanish only 4. Mrs. The nurse recognizes that some patient regress when confronted with illness b. To facilitate a helping relationship d. R. Mrs. The medical diagnosis c. Mr. Listening c. When a nurse establishes a therapeutic relationship with a client. T. Needs to understand that patients may test her before he can accept and trust her d. 70 years old. Physiologic response to stress d. In which of the following situations would communications be LEAST likely hindered? a. Which of the following is the overall purpose of therapeutic communication? a. 30 years old is admitted to the hospital for the first time for acute appendicitis b. Validation 5. Which of the following is MOST important in fostering a positive relationship? a. Which of the following communication technique is MOST effective in dealing with covert communication? a. To provide emotional support 3. 45 years old.

Adaptation based model d. He tells the staff I can t stand this place. Mild d. How would the nurse deal effectively with Paul s threat to run away? a. Stimulus based model c. Suppression d. The early experiences of Paul may indicate a history of: a. Projection 9. Tell him to stay in her room b. 11. Lock him in her room c. Failure in interpersonal relationship d. Severe temper tantrums b. Which of the following models identifies ability to cope with stress. Which of the following levels of anxiety is BEST for client s learning? a. Ignore the threat 12. Transaction based model 10. Moderate c. effect of social environment and the resources used to deal with stress as determinants to stress and stress reactions? a. practice and norms of the peer group.7. Response based model b. Severe parental rejection c. Mobilize energy needed for adaptation d. Failure to identify positively with father 13. No anxiety 8. Which of the following defense mechanism is consciously used in coping mechanism with stress? a. Regression c. Alert the individual to danger SITUATION 3: Paul. the staff will help him control herself d. 16 year old was committed to a mental health facility with diagnosis of personality disorder. Present the individual from having an unpleasant experience c. The purpose of the first stage of the General Adaptation Syndrome is which of the following? a. Severe b. I want to go away. Repression b. How would you describe parental rejection? . Tell him firmly that if he does not control herself. He has a history of promiscuity and running away. Determine the causes of the danger b.

Using naltrexone may make me dizzy.Firmness. 16. I ll get sick if I use heroine on this medication. Lack of parental love and discipline d. c. Depersonalization. Active friendliness c. dilated pupils. Love and understanding b. Permissiveness d.a. Consistency Answer: D. provide endorsement to other nurses 15. d. In dealing with manipulative behavior. Assessing the client s blood pressure b. talkativeness. distorted perceptions d. Protect others from being manipulated Answer: D. She knows that teaching has been effective when staff identify the following as the greatest risk for substance abuse among professionals: . 18. Slurred speech. matter of fact and consistency is used to approach clients with antisocial personality SITUATION 4: Mark was brought to the National Center for Mental Health for substance abuse. I ll become extremely ill. Isolate Paul d. Determining when the client last use an opiate c. euphoria c. Observe him closely b. Which of the following statements would indicate the teaching about Naltrexone (Revia) had been effective? a. Failure to identify positively with father c. Relaxed inhibitions. Which of the following nursing assessments is essential before giving a dose of this medication? a. Lack of the capacity to trust others 14. b. Which of the following behaviors would indicate stimulant intoxication? a. Completing a thorough physical assessment 19. Lack of recognition as a person b. increased appetite. This medication will block the effects of any opioid substance I take. Hyperactivity. unsteady gait. Ignore him demands c. impaired concentration b. Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal.Safety precautions must be posed to protect others. The nurse has provided an in-service program on impaired professionals. visual hallucinations 17. Monitoring the client for tremors d. What should the nurse do to prevent Paul from manipulating and dominating others? a. If I use opioid while taking naltrexone. the nurse should convey an attitude of: a.

Bantay Bata 163 24. 21. what would be your advice? a. Parish d. Stress 23. Physical dependence b. Most nurses have preconceived ideas about what kind of people become addicted 20. Let the child stay with the relatives 22. which of the following measures would be most important to include? a. An anxiety disorder c. A neurological disorder d. Anger c. Marinel feels fidgety and continuously smoked while her friend is talking to her mother. The nurse realizes the client is at risk for: a. Explaining to the client his or her personal and legal rights . When planning the care for a client who is abused. Beth is experiencing: a. As a nurse. School c. Nervousness d. a 16 years old young lady was left with her stepfather and with a mother who is working in the office the whole day. The best way a nurse can advise an abused child is to call the: a. Most nurses come from dysfunctional families and are risk for developing addiction c. Police station b. Worries b. Tell the child get to her regular activities c. Tell the mother to keep watching her daughter b. Most nurses are exposed to various substances and believe they are not risk to develop the disease d. Being compassionate and empathetic b. Marinel s high school friend made a visit and talked to her father. Marinel. The client tells the nurse that she takes a drink every morning to calm her nerves and stops her tremors. Most nurses are codependent in their personal and professional relationships b. Ask the child to get away from her stepfather d.a. Psychological addiction SITUATION 5: A nurse must be aware of the latest issues on Child Abuse and Family Violence. Teaching the client about abuse and the cycle of violence c.

as evidenced by victim s statement of being battered b. as evidenced by not being able to leave the house c. As people gets older. Ineffective Coping related to victimization. they lose height (become shorter). deep breathing. and swimming d. Increases d. Physical activity. Infection c. Changes in the bone of older people make which of the following a major danger? a. Knee bends. as evidenced by crying SITUATION 6: The following questions pertains to Musculoskeletal System of aging persons 26. Inaccurate measurement 28. Becomes like a dancer c. . Drinking tea. Risk for violence related to abusive husband. workers assigned in mining industries or a family member assigned in far places. Decreases c. Helping the client develop a safety plan 25. As one ages. Allergy b. and weight lifting 27. shopping. Which of the following behaviors contribute to osteoporosis: a. Can go either way 29. as evidenced by inability to make decisions d. dancing. and lack of exercise c. During the session with the nurse. a client who is being abused states. He doesn t want me to go anywhere while he s at work. muscle mass (that is muscle size): a. Is more steady b. Low Self-Esteem related to victimization. not even to visit my friends. Is less stable and balanced when walking d. This is due to: a. and losing weight b. Loss of bone mass in the vertebral discs b.d. Stays about the same b. The rest of the population has grown taller d. Smoking. Powerlessness related to abusive husband. I don t know what to do anymore. Fractures SITUATION 7: Sensory deprivation is experienced by most people in any setting whether they are patients confined in hospitals. The fact that they don t stand up straight c. the gait of older people: a. Hardly changes at all 30. Which of the following nursing diagnoses would the nurse formulate in respect to this information? a. As a result of changes in long bones and the spinal column. Contagion d.

Speak loud enough or shout if you may so that client will be able to hear you SITUATION 8: Sexuality is one problem area that is often neglected by nurses in the care of elderly clients. They show greater interdependence than hearing adult c. Elimination of order or meaning from input in the case of ICU patients or was in reverse isolation 32. Which of the following should the nurse do in ambulating a client with visual impairment? a.31. Which nursing intervention would be appropriate for client with hyperthesia? a. Use visual aide and gestures to enhance the spoken word c. Frequent back rubs 34. Stand on the client s nondominant side. Increased sensory input brought about by unlimited visitors from families and friends b. Which of the following are observed in sensorially deprived adult and elderly people because of deafness? a. Which of the following will LEAST likely result to sensory deprivation? a. Restriction of the environment in patients who are on absolute bed rest c. Firm pressure when touching body parts c. A post-operative blind patient needs to be assisted for ambulation. Stand on the client s dominant side and grasp the client s arm c. They become more flexible in daily routine d. They prefer interaction with hearing adults b. approximately one step behind the client. Which of the following is an appropriate communication method for client s with hearing impairment? a. Restrict use of the client s hands d. The nurse however must be able to identify and address the sexual changes to provide nursing . Stand slightly in front of the client s nondominant side allowing the client to grasp the nurse s arm 35. Reduced sensory input in the case of patients who have just been operated on glaucoma d. Vigorous hair brushing d. Talk side by side with the client b. Minimal use of direct touch b. grasping the client s arm b. allowing the client to grasp the nurse s arm d. They show poor social judgment 33. Stand on the client s dominant aside slightly in front of the client.

care. Benefits of hormone replacement therapy (HRT) include: a. None of the above 38. Lung cancer SITUATION 9: The nurse is caring for an adult admitted with a diagnosis of brain tumor. A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex. Breast and endometrial cancers d. He was scheduled for craniotomy. A woman has been without periods for a year b. Irritability goes away 37. High fowler s with knee gatch raised b. Place her in a jacket restraint b. Emotional stability ends d. Wrap her hands in soft mitten restraints . 36. Post operatively. Protection against fever 39. Protection against the flu d. Decreased risk for atherosclerotic plaques d. Menopause is considered complete when: a. Development of noncancerous fibroid tumors in the uterus c. No changes in risk for atherosclerotic plaques b. Hormonal decline in women causes: a. Which nursing intervention protects the client without increasing her ICP? a. Flat with small pillow under the nape of the neck c. Increased risk for atherosclerotic plaques c. Protection against osteoporosis and elimination of the unpleasant symptoms of menopause c. Protection against constipation b. Hot flashes cease c. Head of the bed elevated 45 degrees with a large pillow under the head and shoulders 41. the position that would be most appropriate for this client would be: a. 40. Which of the following is NOT a known risk of hormone replacement therapy: a. Formation of blood clots and hypertension b. Head of the bed elevated 20 degrees with the head turned to the operative side d. A client is regaining consciousness after a craniotomy becomes restless and attempts to pull out her intravenous line.

The lost cells will regenerate on their own c. what is your primary goal? a. a female client is still having some motor speech difficulty. Prevent hemorrhage SITUATION 10: Dementing illness and changes in the brain 45. Reinforcing the dressing and notifying the doctor immediately d. Speak to her in simple words and short sentences 43. Doing nothing because this is normal occurrence 44. Cerebrovascular accident b. A client undergoes a craniotomy for removal of her brain tumor. Prevent secondary surgery d. As one gets older.c. Which of the following interventions is most appropriate? a. The significance of this is: a. Respond to her crude efforts of speaking c. After craniotomy. Electrolyte imbalance. especially hyponatremia (loss of sodium) . A frequent cause of this type of dementia is: a. there is a loss of brain cells. Tuck her arms and hands under the draw sheet d. The remaining cells are more than enough for learning and remembering d. Alzheimer s disease c. A cell transplant is indicated b. Prevent increased ICP b. Following 3 months of rehabilitation after craniotomy. Re-explain why she is having difficulty of speaking d. Replacing the dressing b. Prevent infection c. Correct her mistakes immediately b. The nurse notes that her dressing is saturated with blood. The significance is not known 46. To promote the client s use of speech the nurse should: a. Marking the area of drainage on the dressing c. Apply a wrist restraint to each arm 42. Multiple Infarcts d. ACUTE dementia is due to causes which can be reversed.

It s meal time. the main principle is to: a. Mood disturbance c.47. Delusion c. Hallucination b. Which of the following responses by the nurse is most appropriate? a. Delusion is: a. When communicating with a paranoid client. . Calcium deposits b. Idea of reference 50. Let s go so you can eat. Disturbance of perception 51. 49. I ll die. As the nurse approaches the client. Auditory and/or visual hallucinations c. Provide an anxiety-free environment c. The brains of persons with Alzheimer s disease are characterized by the presence of: a. Senile plaques and neurofibrillary tangles d. he says. This is an example of: a. Disturbance of thought d. Lack of gray matter SITUATION 11: A 23 year-old man was voluntarily admitted to the inpatient unit with a diagnosis of paranoid schizophrenia. Wandering and getting lost b. Express doubt and do not argue d. The client tells his primary nurse that he s scheduled to meet the President of the Philippines a special time. When assessing a client with dementia. Psychomotor disturbance b. making it impossible for the client to leave his room for dinner. Decreased interest in bathing and hygiene d. Illusion d. Inappropriate language and sexual behaviors 48. Use logic and be persistent b. Fatty deposits c. If you come any closer. which of the following behaviors would the nurse interpret as a manifestation of disinhibition? a. Encourage ventilation of anger 52.

Antiparkinsonism medication b. Your physician expects you to follow the unit s schedule. The nurse can expect the client to be placed on a. Nico is scheduled for electroconvulsive therapy (ECT) tomorrow. States one good thing about himself d. Parkinsonism SITUATION 12: Nico. old. The client sleeps most of the day . He is withdrawn. Displays a blunted effect b. Which of the following behaviors indicates to the nurse that a client s major depression is improving? The client: a. Reorient the client frequently during posttreatment care 57. The President of the Philippines told me to take you to dinner. Anectine) during pretreatment care c. is admitted for treatment of a major depression. and states. A low-salt diet d. 27 yrs. 53. People who don t eat on this unit aren t being cooperative. d. Has lost an additional 2 pounds c. The nurse would plan for which of the following activities? a.b. Nico is recovering from a severe depression. Dystonia b. No one could ever love me. Sleeps about 16 hours per day 56. Force fluids 6 to 8 hours before treatment b. appears disheveled. Suicide precautions c. These are signs of: a. Akathisia d. c. Phototherapy 55. Encourage the client s spouse to accompany him d. Which of the following behaviors alerts the nurse to a risk for suicide? a. Administer succinylcholine (Inestine. 54. Psychosis c. A schizophrenic patient who began taking haloperidol (Haloperidol) 1 week ago now exhibits jerking movements of the neck and mouth.

What is it that makes you think about harming yourself? c. Which of the following questions should the nurse ask during the prescreen assessment? a. How has your concentration been? d. Asking the client to do one step of the task at a time c. When the client expresses fear of being killed by staff. Managing complex medication schedule c. What specifically have you thought about doing to harm yourself? SITUATION 13: A client is admitted with a diagnosis of Alzheimer s Disease. No one wants to kill you here. Supervision of risky activities. Considerable assistance with activities of daily living b. Constant supervision and total care d. You are in the hospital. which of the following suggestions would be most helpful? . Oh. What makes you think we want to kill you? b. How long have you thought about harming yourself? b. When developing the plan of care for a client with Alzheimer s disease who is experiencing moderate impairment. The client has a plan to kill himself c.b. 59. such as shaving 60. Maintaining routine and structure for the client 61. which of the following types of care would the nurse expect to include? a. He had mentioned ending it all prior to admission. The client loses 5 pounds d. don t be so silly. d. Demonstrating for the client how to do the task d. c. The client does not attend unit activities 58. We like you too much to want to kill you. When helping the families of clients with Alzheimer s disease to cope with vulgar or sexual behaviors. We are nurses trying to help you. Clients with Alzheimer s disease may have delusions about being harmed by staff and others. 62. which of the following responses would be most appropriate? a. Repeating the directions until the client follows them b. Nico has been depressed severely depressed for 2 weeks. Which of the following would be priority to include in the plan of care for a client with Alzheimer s disease who is experiencing difficulty processing and completing complex tasks? a.

Genetic etiology d. Employ anger management strategies d. The client is creating considerable chaos in a day treatment program with dominating and . but I know it s important for Dad. but he won t quiet down. Supportive therapy for a client who is exhibiting manic behavior may include all of the following EXCEPT: a. Problem-solving therapy 67. 64. Interpersonal therapy d. but try to identify the purposes b. Presence of mania 65. I get tired of the same old stories. A tricyclic depressant b. Higher incidence in women b. The nurse caring for him knows the drug most likely to be prescribed for this client is: a. At 2 a. His excited explanations are keeping the entire unit awake. I didn t realize the deterioration would be so incapacitating. An MAOI-inhibitor antidepressant c. Lithium carbonate (Eskalith) d. Administer the prescribed risperidone (Risperdal) 63. Psychoanalysis b. The nurse knows that the major factor that distinguishes a bipolar from a unipolar disorder is the a. The nurse determines that the son of the client with Alzheimer s disease needs further education about the disease when he makes which of the following statements? a. Give feedback on the inappropriateness of the behaviors c. Severity of the depression c. I woke up this morning hoping that my old Dad would be back. the nurse the nurse finds him phoning friends all across the country to discuss his new plan for eradicating world hunger. An antianxiety drug 66.a. SITUATION 14: A 34-year old is hospitalized with bipolar disorder.m. d. Ignore the behaviors. The Alzheimer s support group has so much good information. c. Cognitive therapy c. b.

Eye strain and headache when doing close work 71. Eye pain and irritation that worsens at night c. Dilatation of the pupil and constriction of blood vessels c. Holds the rods and cones c. This preparation acts in the eye produce a. Watching television c. Which of the following represents the nurse s best course of action? . 69. Focuses light rays onto the retina d. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into a client s right eye before cataract removal surgery. Reading the newspaper d. The client asks. Allow the peer group to intervene b. Dilatation of the pupil and blood vessels b. A short time after cataract surgery. The client would most likely to complain of which symptoms? a. Which of the following activities would the nurse expect to include in the client s plan of care? a. Blurred and hazy vision d. The client is skipping up and down the hallway practically running into other clients. the client complains of nausea. Regulates the amount of light entering the eye 70. Cleaning the dayroom tables SITUATION 15: A client is admitted to outpatient surgery for cataract extraction on the right eye. Tell client that his behavior is not appropriate 68. Constriction of the pupil and dilatation of blood 72. Produces aqueous humor b.manipulative behavior. Which of the following nursing intervention is most appropriate? a. Halos and rainbows around lights b. What does the lens of my eye do? The nurse should explain that the lens of the eye: a. Constriction of the pupil and constriction of blood vessels d. Describe acceptable behavior and set realistic limits with the client c. Recommend the client to be hospitalized for treatment d. Leading a group activity b.

Discharge planning would include: a. Rigidity b. Wearing eye patches for the first 72 hours b. Explain that this is a common feeling that will pass quickly c. Tell the client to call the nurse promptly if vomiting occurs d. Lifting light objects is acceptable c. Early in the morning. To begin preparations for terminal care d. To coincide with the peak action of drug therapy c.a. When family members will be available 77. Akinesia 75. To cure the disease b. Bending with the waist is acceptable if slowly done SITUATION 16: A client is admitted with a diagnosis of Parkinson s disease. Which of the following topics that the nurse plans to discuss is the most important? a. Immediately after a rest period d. Enhancing the immune system c. Which of the following is an initial sign of Parkinson s disease? a. To stop the progression of the disease c. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson s disease? a. Medicate the client with an antiemetic. To maintain optimal body function . Instruct the client to take a few deep breaths until the nausea subsides b. Bradykinesia d. Maintaining a balanced nutritional diet b. The nurse develops a teaching plan for a client newly diagnosed with Parkinson s disease. as ordered 73. Maintaining a safe environment d. Tremor c. Engaging in diversional activity 76. Bending with the knees and keep the head straight d. When does the nurse encourage a client with Parkinson s disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? a. when the client s energy level is high b. 74.

Because you cannot blink the affected eye. The client needs a long time to complete her morning hygiene. The nurse observes that the client s right eye does not close completely. Instilling artificial tears once every shift d. Based on this. 80. c. Placing an eye patch over her eye c. a. foreign matter can be trapped beneath the lid. d. Artificial tears will remove the purulent drainage from your eye. What would be an important teaching to the patient? a. When your affected eye fails to make tears. The client has a feeling of stiffness and a drawing sensation of the face. Risk for dysfunctional grieving b. but she becomes annoyed when the nurse offers assistance and refuses all help. the eye can become irritated and ulcerated. A client with Bell s Palsy asks the nurse why artificial tears were ordered by the physician.78. 79. Cleansing the eye with a clean washcloth every shift 82. Cleaning the eye will prevent ulceration d. Risk for injury related to corneal laceration c. Eye is susceptible to injury when eyelid does not close b. which of the following nursing interventions would be most appropriate? a. Praise the client for her desire to be independent and give her extra time and encouragement c. Drooling from an increased saliva on the affected area may occur c. Select the best reply by the nurse. Tell the client that she is being unrealistic about her abilities and accept that she needs help d. it can become dry and irritated. which speeds healing. All of the above . Which statement is the nurse s best initial response in this situation? a. Risk for impaired physical mobility 81. b. Because your eye remains closed. she should at least modify her routine SITUATION 17: A client is admitted to the hospital with Bell s Palsy. Suggest to the client that if she insists on self care. Making sure the client wears her eyeglasses at all times b. Risk for chronic low self-esteem d. Tell the client firmly that she needs assistance and help her with her care b. Which nursing diagnosis takes priority for the patient with Bell s palsy? a.

Drinking 8 oz water every hour between meals d. A structured schedule of activities c. Which nursing intervention would the client be most likely to comply with? a. Drinking Ensure between meals b. and cracked. The most effective way for the nurse to intervene with her hand and face washing is to: a. Regains her normal body weight b. Allow her a certain amount of time each shift to engage in this behavior b. Interrupt the activity briefly and frequently c. Provide ample time for her to complete her rituals 84. Limit the number of hand washings c. scaly. Which of the following is an appropriate treatment for this client? a. The nurse noticed the client s hands are reddened. The main nursing goal is to: a. Expresses a desire to leave the hospital c. The client is also constipated and dehydrated. The nurse and the client will know That discharge planning is appropriate when the client: a. Intense counseling d. Negative reinforcement every time she performs her rituals 85. 83. Is able to start talking about her guilt and anxiety d. Drinking adequate amounts of fluid during the day 87. Her family reports she washes her hands at least 30 times each day.SITUATION 18: A 46-year old is admitted to the hospital because her family is unable to manage her constant hand washing rituals. Lock the door to her room and restrict access to the bathroom d. An unstructured schedule of activities b. Drinking extra fluids with meals c. Remind the client several times of her appointment b. Upon admission she was also dehydrated and underweight. Tell her it is her responsibility to be there on time d. Limits her hand and face washing to a few times a day . Tell her to stop each time she is observed doing it 86.

Nitropusside d. Panic 92. The client is pacing and complains of racing thoughts. Severe d. Moderate c. Hyperventilation d. The client has regular obsessions b. The nurse assesses the client s level of anxiety as: a. Lithium carbonate 90. Mild b. The client has a generalized anxiety disorder. Explain to the client that there s no need to worry because he s safe d. The nurse asks the client if something upsetting happens. Proton pump inhibitors c. a racing heart. All of these symptoms have occurred almost daily for the past 3 months. Which statement is true about this client? a.SITUATION 19: The nurse is caring for a client who is experiencing panic attack. Give the client a detailed explanation of his panic reaction 89. Suspecting a psychological component to these symptoms. and there is no need to panic b. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months 91. Tachypnea SITUATION 20: Defense Mechanisms . simple sentences c. Tell the client he s all right. dizziness and fearfulness. except: a. Which intervention would be most appropriate? a. The client reports that she often feels a choking sensation in her throat. what would the nurse anticipate administering? a. Relaxation techniques and psychotherapy are necessary for care c. Benzodiazepines b. Tachycardia c. and the client response is vague and not focused on nurse s question. 88. Panic b. Which of the following is a behavior manifestation of anxiety. Speak to the client in short. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder d.

The defense mechanism utilized by manic patients to cover up depression is: a. Identification c. Rationalization 94. In patients with dissociative disorders. released from prison for selling narcotics has been rehabilitated and now works for a youth drug prevention agency. Displacement c. she says.93. No way. Darwin is reflecting which of the following defense mechanism? a. Denial b. Passive-aggression b. Regression c. Projection d. Sublimation b. He has been seen by many medical specialists in the past without discovery of organic pathology. Sam is diagnosed with cancer does not talk about or acknowledge the diagnosis. Denial d. Reaction formation SITUATION 21: Psychosomatic disorders 98. I can t be having a heart attack. Sublimation 95. Displacement b. Compensation d. Nina is admitted to the ICU with chest pain. The nurse suspects the client is using which defense mechanism? a. When the significance of this is explained to her. and elevated enzymes. A man s family brought him onto the hospital because of his many somatic complaints. an abnormal ECG. Which of the following defense mechanism is Sam using? a. Denial b. Repression 97. The nurse assesses that the client is probably experiencing which of the following problems? . Dissociation d. the defense mechanism most often used to block traumatic experiences is: a. Identification d. Denial c. Denial 96. Reaction formation c. You must be mistaken. Nathaniel.

(venzon p140) 3. Pain disorder The JAY BALICHA Predictor test 1. Also the year where first board exam in the Philippines was given by the board of examiners for nurses (d) April of 1944. First True Philippine Nursing Law a. Conversion disorder d. You will soon be a registered nurse. Technically focused . Hypochondriasis b. In 1919 RA 2808 was passed. 1920 b. Conversion disorder b. She seems unconcerned about her paralysis. A patient who reports paralysis with no specific cause but has a history of a recent stressful event has a probable diagnosis of: a. Hypochondriasis 99. Amie is hospitalized for treatment of conversion disorder. graduate nurses took the first board examination at the Iloilo Mission Hospital.a. Knowledge-based d. 1953 which pertains to the need for registration as nurse before anyone may practice nursing in the Philippines. (Venzon p140) 2. RA 887 d. She complained of paralysis of her right side after her husband threatened to leave her and their children. Develop an increased sense of relatedness to others 100. Cope effectively with stress without using conversion b. 1944 (Answer) A. RA 877 c. RA 2493 was passed during this year. Malingering d. RA 2880 (Answer) A. Body dysmorphic disorder c. Express feelings about conflict d. Somatic illness c. An appropriate long term goal for the nurse to formulate is that client will: a. People-oriented c. First board exam a. Identify stressors c. Which of the following best describe contemporary nursing practice? Humanistic caring b. It created the first board of examiners for nurses. 1915 c. RA 2808 b. 1953 d. (B) Philippine Nursing law enacted on June 19. Also known as the first true nursing law.

Contemporary nursing has become an evidence-based practice. The nurse should recognize that a pulse volume of 1 indicates the client s pulse is difficult to feel. The first action is to check the client s condition and circulatory status. A client who is unconscious needs frequent mouth care. As a science and a helping profession. It can easily be obliterated. Unfixed electrical circuits . A nursing change of shift report has indicated that a client s pulse volume is described as 1 (one). Unstable and slippery stairway c. thready. While performing mouth care. which is not an appropriate nursing practice. In this position. Document that the pulse volume is normal b. Supine position d. the saliva and other liquid automatically runs out of the mouth by gravity or pool in the side of the mouth where it could be suctioned rather than being aspirated into the lungs (kozier p730) 6. refers to the force of blood with each beat. 2 Weak pulse. Notify the physician c. Which can be felt with moderate pressure 4 full or bounding. (Kozier p146) 0 Absent pulse: no pulsation is felt despite extreme pressure 1 Thready pulse. A number of conceptual frameworks contribute to the knowledge base of nursing and give direction to nursing practice. (book #18) Pulse volume is the pulse strength or amplitude. The other options are not applicable to the situation. nursing is a welldefined body of knowledge and expertise. Usually the pulse volume is the same with beat. light pressure causes it to disappear 3 a normal pulse. education. Which of the following is not a physical hazard? a. Side-lying position c. in what position should the client be placed? a. (Kozier p7) 4. Trendelenburg position (Answer) B. Inadequate lighting on inside and outside home b. The nurse s first action after report is to do which of the following? a.(Answer) C. Therefore knowledge is the foundation. Assess the client right away d. and ongoing research. and the client s circulatory status is altered. In the advent of nursing research. Stronger than a thready pulse. If the nurse notified the physician first. Fowler s position b. the nurse will be reporting another nurse s assessment. It can range from bounding to absent. Change the clients position (Answer) B. It can be obliterated only with great pressure (Taylor p413) 5. Large windows for good ventilation d.

(Answer) B. (Edge p44) Nonmalecicence The principle that imposes the duty to avoid or refrain from harming the patient (edge p46) Respect for others having empathy for others and not using people as a means to an end Autonomy Independent. Doing a nursing procedure without the patient s informed consent may bring nurse Andrei to the court of law for this violation: . a student nurse believes that all patients should be treated as individuals. self-governing. Nonmaleficence c. Nutrition noted by dietitian c. Apply cold around wound area after dressing c. Adequacy of lighting. Unanchored of frayed electrical cords and outlets those are overloaded or near water. Beneficence b. A sample of his daily diet d. Foods he ate yesterday b. His height and weight (Answer)D . Dan Paolo. Nutrition can be initially assessed by measuring the height and the weight and if it is proportional to each other and the age and built of the client. Isolation is not necessary in this case 9. Beneficence The principle that imposes on the practitioner a duty to seek the good for the patient under all circumstances. you must keep in mind the following. When dressing contaminated wounds. Jordan Luis appears quite thin and dehydrated. Autonomy (Answer) C. Respect for others d. What data would you initially need to determine his level of nutrition: a. Last would be hazardous placement of furniture with sharp corners. except a. Isolate patient from those with clean wounds (Answer) D. physical hazards includes uneven and highly polished or slippery floors and any unanchored rugs or mats. (kozier p144-145) 7. Use a non-irritating disinfectant solution b. self-determination (kozier p 73) 10. In home care assessment. It s anthropometric measurements 8. in particular the availability of night-light and availability of light switches. Disinfect all instruments d. The ethical principle that this reflect: a.

overdelegation occurs when too much authority or accountability is transferred to the delegate. Positivism a direct relationship between two variables. Natural inquiry c. Laissez faire also known as nondirective leadership. What leadership style works well with professional groups but does not in health care settings? a. Assault c. Battery d. Laissez faire b. as one increases. Descriptive d. understanding human expertise) a. Positivism (Answer) B.a. Expert power is power vested in the skills and talents on the individuals. tort is a legal wrong doing. pursuant to a duty. Situational manage as the need arises Autocratic under one command Democratic rule of the majority 12. It is an intentional. Expert power A. Reverse delegation occurs when authority is transferred to an individual of higher rank. committed against a person or property independent of a contract which renders the person who has been liable for damages in a civil action. It has four elements: Randomization. Assult is the imminent treat of harmful or offensive bodily contact Negligence refers to the commission or omission of an act. The researcher consciously manipulates and control situations related to the study. (Answer) (book 54 mosby s dictionary) 11. Quasi-experimental c.g. What is the research design used? a. Situational c. Autocratic d. unconsented touching of another person. that a reasonably prudent person in the same or similar circumstance would or would not do. Reverse delegation b.use of statistical methods to analyze data (mosbys dicationary) 14. Quantitative research d. Logical positioning deals with the rules and test of sound thinking and proof of reasoning Natural inquiry study of the phenomenon as it unravels or qualitative research (book 169) Quantitative research . Also known as permissive or ultraliberalism. Logical position b. the other can be expected to increase. Substitution delegation d. Over delegation c. Experimental an inquiry on cause and effect relationships. Exploratory (Answer) A. Experimental b. Negligence b. validity and . Democratic (Answer) A. Tort (Answer) D. This would be an example of which of the following? a. Which type of research inquiring and investigating the issues of human complexities (e. Substitution delegation is not a recognized term. Battery is an example of tort. Nurse Reggie assigns the new nurse to be charge nurse for the evening shift because the regular nurse has called in sick. control. 13. The leader participates minimally and often only on request of the members.

Nobody can take care of him at home c. the pink row needs: a. Carry out physician s order as giving medication or injection . the patient can be classified under dysentery. Urgent referral is the priority in patients classified under the pink row. Advise the mother on feeding a child who has PERSISTENT DIARRHEA c. practices. 17. EXCEPT: a. Persistent diarrhea is considered when the patient has diarrhea for 14 days and more. (Answer) Exploratory also known as investigative research 15. No specific treatment such as antibiotics b. 18. Urgent referral b. all of these (Answer) D.manipulation Quasi-experimental an experiment that lacks one or more of the elements of the true experiment. During the patient s clinic visit. Urgent referral The pink row is classified as severe dehydration. What is the recommended treatment for patients classified under the yellow row having blood in the stool? a. Persons considered dangerous to self and others because of mental disorder can be involuntarily treated. Descriptive an applied research that described the nature of the phenomenon under investigation of after a survey of current trends. Giving fluid and food to treat diarrhea at home is a plan A treatment for patients classified under the green row or No Dehydration . (keltner p48) 16. Bert can be advised that his brother can be treated involuntarily if: a. Give fluid and food to treat diarrhea at home Ans. and conditions that relate to that phenomenon. No urgent measures d. involuntary means an individual who has the legal capacity to consent to mental treatment refuses to do so. The third condition is being gravely disabled. It is based on human judgment. He is dangerous to others b. C If the patient has diarrhea and blood has been seen in the stool. With this classification you should treat the child with an oral antibiotic specific for shigella for 5 days. Specific antibiotics c. Urgent referral to a hospital is necessary. He has suicidal tendencies d. with the mother giving the child frequent sips of ORS on the way to prevent further dehydration. it is the PHN s duty to carry out one of the following. Oral antibiotics for 5 days d. Using IMCI model.

The nurse s initial action should be to: a. d As a PHN it s a part of the duty to carry out physician s orders such as giving medication or injection. Slightly below the ischial spines b. Which of the following specific preventive method is the role of the nurse to the family? a. 19. During the nursing history. Margot visits her gynecologist to confirm a suspected pregnancy. The nurse calculates that her due date is: a. January 18 d. Place her hands in warm water to encourage micturation d. A 23. giving medications to the client is an order of the physician which is the nurses responsibility to carry out and cannot be delegated to midwives. B 21. Slightly above the ischial spine Ans. High in the false pelvis D. Another is explanation and reinforcement of the physician s orders and advises.b. February 15 Ans. Reyes still has not voided. C 22. and assessing health status of the whole family. On the perineum C. During labor. Four hours after a vaginal delivery Mrs. Inform the physician of her inability to void and await orders Ans. Palpate her suprapubic area for distention b. Cathy states that some spotting occurred in May 8. Advise the family to consult the physician as soon as symptoms occur b. she states that her last menstrual period began on April 11. Interpret nature of disease and discuss proper preventive practices d. Encourage the patient to increase fluid intake Ans: C 20. February 12 b. Explain the mechanism of actions of the drugs c. Instruct midwife to give the medication to the client ans. Encourage voiding by placing her on a bedpan frequently c. However. The community health survey aims to analyze: . station +1 indicates that the presenting part is: a. Seek information regarding health status of other family members d. January 10 c. Explain and reinforce physician s orders and advises c. If this task will be delegated to the midwives the PHN will be over delegating.

Monitoring blood pressure Observing for Jaundice d. The cause of acute glomerulonephritis is unknown. health education program c. Assessing for dysuria c. To allay the fears of the mother. Fever and weight gain c. 28. Acute glomerulonephritis is caused by an antigen-antibody response secondary to group A betahemolytic streptococcus ANSWER: ( D ) The beta-hemolytic streptococcal immune complex becomes trapped in the glomerular capillary loop. Which of the following pre-operative assessment is important for a client who will undergo kidney transplant: a. Acute glomerulonephritis is inherited by an autosomal recessive trait but usually occurs only in males c. The action that has priority is: a. D SITUATION 4 A child is admitted to the pediatric unit with a diagnosis of acute glomerulonephritis. A mother whose child has glomerulonephritis is fearful that her other child may get the disease. causing glomerulonephritis. The client is at the physician s office for a follow-up visit. Testing vomits for occult blood 25. 26. Urine output b. SITUATION 5 A young man is admitted in chronic renal failure and scheduled for kidney transplant. 24.a. Signs and symptoms of infection Client s support system and understanding of life style changes 27. Muscle atrophy ANSWER: ( A ) Signs of rejection increase WBC and fever because the body is recognizing the graft as foreign and attempting to fight. the status of health education b. the nurse should tell her that: a. I am not . date of introducing charges d. Signs of graft rejection c. Which of the following symptoms indicate acute rejection of a transplanted kidney? a. Oliguria b. The client tells the office nurse. Hematuria and seizure d. Acute glomerulonephritis is caused by clot formation in the small renal tubules secondary to systemic function d. so it is difficult to know how to prevent b. the population and environment that influence the health of community Ans.

When taking Mrs. palpitations. SITUATION 6 Jane Santos has an acute episode of right-sided heart failure and is receiving furosemide (Lasix). Which of the following conditions is a major complications of this drug therapy: a. 31. 30. Regression ANSWER: ( C ) Denial disowning intolerable thoughts. To limit edema of the feet the nurse should prepare to: a. vertigo. Fatigue. Hemorrhage is complication related with anticoagulant therapy. fatigue c. Do range-of-motion exercises ANSWER ( B ) Elevation of an extremity promotes venous and lymphatic drainage by gravity. Denial b. A feeling of distress when breathing ANSWER ( A ) Congestive Heart Failure is the failure of the heart to pump adequately to meet the needs of the body. ascites. . resulting in a backward build up of pressure in the venous system. Dyspnea. Peptic ulcer disease ANSWER: ( C ) Infection major complications because its an immuno suppressive drug. the nurse would expect her to complain of: a. Depression may occur post transplantation but not because of drug.worried about rejection. The nurse can best assess the degree of edema in an extremity by: a. Client denying feelings of anxiety and seriousness of potential rejection of the organ. I am not going to be here weekly. Infection b. headache d. Santos has edematous ankles. The nurse interprets his reaction to constant follow-up care as an example of: a. Santos admission history. nausea b. tachycardia. Restrict fluids c. Adaptations by the body include edema. hepatomegaly. Weighing Mrs. Peptic ulcer is a complication of steroid therapy. Projection c. edema. The client with renal transplant has started cyclosporine therapy to prevent graft rejection. Intellectualization d. Santos d. Observing intake and output ANSWER ( C ) Measuring an area is an objective assessment and is not subject to individual interpretations. dyspnea. Apply elastic bandages Elevate the legs d. Depression c. 29. 32. Weakness. Mrs. Hemorrhage d. and fatigue. Checking for pitting c. Measuring the affected area b.

What is the most common symptoms in a client with abdominal aortic aneurysm? a. 35. When hands will be exposed to cold. Oxidizing fatty acids to produce energy d. Which of the following should the nurse include in the teaching plan for her? a. 1200 calories . Simon would be: a. Ask him to lie on his stomach c. Producing phospholipids b. The nurse is having difficulty assessing peripheral pulses. soft c. 36. low carbohydrate. 37. Converting fat to lipoproteins for rapid transport out into the body ANSWER ( D ) In the liver a simple protein combines with a lipid to form a lipoprotein. Raise the hands above the head to relieve spasms d. warm gloves or mittens should be worn.33. Headache Diaphoresis d. high fat. Abdominal pain c. low carbohydrate. Asks him to flex and extend his foot b. The nurse recognizes that the main role of the liver in relation to fat metabolism is: a. Storing fat for energy reserves c. Headache and diaphoreses not associated. low saturated fat. Flexing and extending the foot may obliterate the pulse. Low protein. Upper back pain ANSWER: ( A ) Abdominal pain results from the disruption of normal circulation in abdominal region. Lower back pain not upper signifying expansion and impending rupture of aneurysm. Reduce intake of high fat or high cholesterol foods c. Drink a hot beverage such as tea or coffee to relieve spasms b. low fat b. Simon is admitted with cirrhosis of the liver. malnutrition. The most appropriate action for the nurse to take is to: a. Lipoproteins circulates freely in the blood and can be utilized easily and quickly in various metabolic processes. High carbohydrate. SITUATION 8 Mr. An adult female experiences painful arterial spasm in her hands due to Raynaud s phenomenon. High protein. Ask him to elevate his leg ANSWER: ( A ) Asking to lie in prone position will provide greater exposure to the popliteal space and thereby make assessment easier. The most therapeutic diet for Mr. Wear gloves when handling refrigerated foods ANSWER: ( D ) Cold induces arterial spasm. ascites. 34. and elevated BP. Have him do 20 jumping jacks d.

the client tells the nurse My wife wants to make love. Mr. moderate fat and high calories and vitamins help repair a long-standing nutritional deficit. Which of the following responses from the nurse would be appropriate? . high calorie. Serum albumin level of 3.20 mg increase kidney disease. frothy appearance. high vitamin. Intestinal edema c. 40 mg hypoglycemia impair brain and neurological system s ability to function. ruddy complexion ANSWER ( C ) This is a characteristic of a child in nephrotic syndrome. moderate fat and high calories and vitamins help repair a long-standing nutritional deficit. the nurse should assess for: a.4 1. Blood glucose level of 40 mg b. When admitting a 4-year-old child with nephrotic syndrome to the hospital.6 mg ANSWER ( C ) This is caused by the trauma of intestinal manipulation and the depressive effects of anesthetics and analgesics. Dark. Crea ( N ) . Proper functioning of nasogastric suctions SITUATION 11 A client was admitted to the hospital diagnosed with myocardial infarction. Which laboratory result should the nurse report to the physician? a. low protein controls ammonia formation in proportion to the liver s ability to detoxify ammonia in forming urea. I m worried that it might kill me. Aminocaproic acid (Amicar) ANSWER ( D ) Low sodium controls fluid retention. 39. 38.5 mg 42. BUN ( N ) 10 . protein to tolerance. Serum creatinine level of 0. and consequently edema. and consequently edema. 40. Gastric suctioning d. Severe lethargy c. 41. Flushed.d. soft ANSWER ( D ) Low sodium controls fluid retention. A presurgical decrease in fluid intake d. ANSWER: ( C ) Glucose level 60 120 mg. Low sodium. but I don t think I can. The nurse should realize this is a result of: a. Balloon tamponade b. The absence of gastrointestinal motility a. blood pressure. 5 g d. Chronic hypertension d. Gastric lavage c. low protein controls ammonia formation in proportion to the liver s ability to detoxify ammonia in forming urea. blood pressure. moderate fat. large amounts of protein in the urine cause it to have a dark. Eight weeks after MI. During the first 24 hours the colostomy does not drain. Blood urea nitrogen of 15 mg/ dl c. Simon s emergency medical treatment for bleeding esophageal varices that is unrelated to the control of hemorrhage is: a. frothy urine output b.

This is best done by assessing her baseline . the nurse should: a. Encouraging the patient to talk to her family c. Place Sheila in a croup tent d. The nurse recognizing the need to decrease the size and vascularity of the thyroid gland prior to thyroidectomy. 44. Palpate the surrounding area for crepitus c. Change the dressing daily using aseptic technique d. SITUATION 18 Sheila is a 3 year old who has asthma. Lugol s iodine solution d. Which of the following actions should the nurse implement with administration of the drug? a. Potassium permanganate b. exerting negative feedback on thyroid tissue and decrease its metabolism and vascularity. When caring for this client. Assess Sheila s vital signs c. Encouraging the patient to become involve in her exercises ANSWER ( C ) Mastectomy support groups provide an opportunity for patient to talk with other women who have had similar surgery. Let s increase your rehabilitation schedule c. This is referred as crepitus. Ask to verbalize permit to gain insight into problem. Let me call the doctor for you d. Empty the drainage chambers at the end of the shift ANSWER: ( B ) Leakage of air into subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated. 45. A client has chest tubes attached to a chest tube drainage system. 43. Sheila s initial treatment is to be aminophylline IV. although hemostat should be available. It would be essential for the nurse to monitor her cardiovascular response to the drug. Tell me about your feelings b. Check Sheila s temperature b. Tell your wife when you re able to make love ANSWER: ( A ) Nurse must address patient s concern. A & D anti thyroid. 46. Liothyronine sodium (Cytomel) ANSWER: (B) Adds iodine to body fluids. Clamp the chest tubes when suctioning b. Allowing the patient time alone so that she can reflect on her surgery b. Propythiuracil c. Administer oxygen to Sheila ANSWER: ( A ) Xanthenes can cause either hypotension or tachycardia. Offering the patient the name of a support group d. She appears withdrawn after a mastectomy although her recovery is uneventful the nurse can be helpful during this period by: a. would expect the physician to order? a.a. for 20 minutes every 8 hours.

D symptoms of hyper parathyroidism. Mixing the 2 gives insulin over a 24 hours period requiring fewer injections for the client. 49. Repeated in 5 minutes. Give IV fluids boluses ANSWER: ( A ) Liquids are best tolerated if they re warm. Give cold juice or ice pops d. 48. dyspnea on exertion and angina b. Onset of the regular insulin within 2 hours c. A total duration of action of 24 hours ANSWER: ( D ) NPH is an intermediate acting insulin. Immediate onset of the regular insulin b. Dehydration should be corrected slowly overhydration may increase interstitial pulmonary fluid and exacerbate small airway obstruction. 10 grams of rapidly absorbed CHO in prescribed. vomiting. When the nurse enters the room to administer the morning dose of regular and NPH insulin. Give the usual dose of regular insulin and get the client s breakfast tray b. nausea. Retinopathy. 47. The nurse does a blood glucose which is 30.vital signs prior to and with administration. Fatigue. A peak action of the NPH insulin at 2 hours d. hold all insulin and call the doctor ANSWER: ( D ) Symptom indicate hypoglycemia. neuropathy and coronary artery disease c. The client was taking regular and NPH insulin. Leg ulcers. Regular is rapid acting insulin. C complication of sickle cell anemia CARE FOR CLIENTS WITH PHYSIOLOGICAL AND PSYCHOSOCIAL ALTERATIONS SITUATION 1: Technique of therapeutic communication should be utilized and incorporated into nursing . diaphoresis and nausea. Hold insulin but should administer concentrated CHO. What is the next nursing action? a. Small frequent meals should be provided to avoid abdominal distension that may interfere with diaphragm excursion. the client complains of dizziness. She asks the nurse why she must mix the 2 insulin. Which of the following nursing interventions is appropriate to correct dehydration for a 2 year old client with asthma? a. Give warm liquids c. Provide three meals and three snacks b. cerebral ischemia events. Which of the following chronic complications is associated with diabetes mellitus? a. The nurse explains that regular and NPH are mixed to ensure: a. muscle weakness and cardiac arrhythmias ANSWER: ( B ) All chronic complications A. and pulmonary infarcts d. Hold the regular and NPH insulin and call the physician d. Hold the NPH insulin but give the regular insulin c. Dizziness. 50. if client does not feel better. Give the client a glass of orange juice. Cold liquids may cause bronchospasm and should be avoided.symptoms of aortic valve stenosis.

Mr. Which of the following is the overall purpose of therapeutic communication? a. 50 years old. Which of the following BEST describes the general adaptation syndrome. Which of the following is MOST important in fostering a positive relationship? a. Mrs. Listening c. Sociocultural response to stress . Mrs. The client s needs and problems d. 70 years old. The nurse must fully share the patient s feelings before she can develop her goal for her nursing care SITUATION 2: Stress can bring about various human reactions that may result to illness or enhance one s coping mechanism. Validation 5.practice. 45 years old. Behavioral response to stress b. which of the following is the primary focus of the client s care? a. R. 6. D. 1. Evaluation d. To elicit cooperation c. It is a: a. 30 years old is admitted to the hospital for the first time for acute appendicitis b. When a nurse establishes a therapeutic relationship with a client. The nursing diagnosis b.L. He speaks Spanish only 4. T. In which of the following situations would communications be LEAST likely hindered? a. is admitted to the hospital after a stroke. is admitted to the hospital for cervical cancer d. To provide emotional support 3. The nurse recognizes that some patient regress when confronted with illness b. Physiologic response to stress d. Psychological response to stress c. Needs to understand that patients may test her before he can accept and trust her d. diabetic. To facilitate a helping relationship d. Which of the following communication technique is MOST effective in dealing with covert communication? a. The medical diagnosis c. The nurse functions as a positive role model to encourage health oriented patient behavior c. To analyze client s problems b. Stress also triggers local and general adaptation syndrome. She has right hemiplegia c. The client s social interaction 2. is admitted for fractured tibia. Mrs. Clarification b.

Severe temper tantrums b. He tells the staff I can t stand this place. Response based model b. Alert the individual to danger SITUATION 3: Paul. How would the nurse deal effectively with Paul s threat to run away? a. effect of social environment and the resources used to deal with stress as determinants to stress and stress reactions? a. Severe parental rejection c. Suppression d. Which of the following defense mechanism is consciously used in coping mechanism with stress? a. The purpose of the first stage of the General Adaptation Syndrome is which of the following? a. Determine the causes of the danger b.7. Which of the following levels of anxiety is BEST for client s learning? a. Tell him to stay in her room b. Stimulus based model c. the staff will help him control herself d. No anxiety 8. The early experiences of Paul may indicate a history of: a. Which of the following models identifies ability to cope with stress. Failure to identify positively with father . He has a history of promiscuity and running away. practice and norms of the peer group. Present the individual from having an unpleasant experience c. Mobilize energy needed for adaptation d. Moderate c. Ignore the threat 12. I want to go away. Transaction based model 10. Projection 9. Regression c. Severe b. Tell him firmly that if he does not control herself. Failure in interpersonal relationship d. Mild d. Lock him in her room c. Repression b. Adaptation based model d. 16 year old was committed to a mental health facility with diagnosis of personality disorder. 11.

Isolate Paul d. provide endorsement to other nurses 15. Lack of recognition as a person b. Slurred speech. Clonidine (Catapres) is prescribed for symptoms of opioid withdrawal. Protect others from being manipulated Answer: D. Which of the following nursing assessments is essential before giving a dose of this medication? a. Hyperactivity. Depersonalization.Firmness. c. Ignore him demands c.13.Safety precautions must be posed to protect others. 16. Consistency Answer: D. Assessing the client s blood pressure b. How would you describe parental rejection? a. unsteady gait. 18. Using naltrexone may make me dizzy. b. Determining when the client last use an opiate c. She knows that teaching has been effective when staff identify the following as the greatest risk for substance abuse among . The nurse has provided an in-service program on impaired professionals. Which of the following statements would indicate the teaching about Naltrexone (Revia) had been effective? a. I ll become extremely ill. talkativeness. Failure to identify positively with father c. Relaxed inhibitions. increased appetite. the nurse should convey an attitude of: a. Observe him closely b. Completing a thorough physical assessment 19. d. In dealing with manipulative behavior. euphoria c. This medication will block the effects of any opioid substance I take. I ll get sick if I use heroine on this medication. dilated pupils. Lack of the capacity to trust others 14. Lack of parental love and discipline d. Monitoring the client for tremors d. impaired concentration b. visual hallucinations 17. distorted perceptions d. Love and understanding b. Which of the following behaviors would indicate stimulant intoxication? a. What should the nurse do to prevent Paul from manipulating and dominating others? a. matter of fact and consistency is used to approach clients with antisocial personality SITUATION 4: Mark was brought to the National Center for Mental Health for substance abuse. Active friendliness c. Permissiveness d. If I use opioid while taking naltrexone.

Marinel s high school friend made a visit and talked to her father. Beth is experiencing: a. Most nurses have preconceived ideas about what kind of people become addicted 20. Nervousness d.professionals: a. When planning the care for a client who is abused. Marinel feels fidgety and continuously smoked while her friend is talking to her mother. Psychological addiction SITUATION 5: A nurse must be aware of the latest issues on Child Abuse and Family Violence. Being compassionate and empathetic b. Parish d. Tell the child get to her regular activities c. a 16 years old young lady was left with her stepfather and with a mother who is working in the office the whole day. The client tells the nurse that she takes a drink every morning to calm her nerves and stops her tremors. Police station b. Ask the child to get away from her stepfather d. which of the following measures would be most important to include? a. Most nurses are exposed to various substances and believe they are not risk to develop the disease d. The nurse realizes the client is at risk for: a. what would be your advice? a. 21. A neurological disorder d. Teaching the client about abuse and the cycle of violence . Tell the mother to keep watching her daughter b. Marinel. As a nurse. School c. The best way a nurse can advise an abused child is to call the: a. Anger c. Most nurses come from dysfunctional families and are risk for developing addiction c. Bantay Bata 163 24. Most nurses are codependent in their personal and professional relationships b. Worries b. An anxiety disorder c. Let the child stay with the relatives 22. Physical dependence b. Stress 23.

I don t know what to do anymore. Increases d. . Loss of bone mass in the vertebral discs b. As a result of changes in long bones and the spinal column. Drinking tea. Allergy b. Risk for violence related to abusive husband. Becomes like a dancer c. they lose height (become shorter). Smoking. Which of the following nursing diagnoses would the nurse formulate in respect to this information? a. Stays about the same b. as evidenced by victim s statement of being battered b. Powerlessness related to abusive husband. Infection c. This is due to: a. and lack of exercise c. the gait of older people: a. as evidenced by crying SITUATION 6: The following questions pertains to Musculoskeletal System of aging persons 26. Changes in the bone of older people make which of the following a major danger? a. as evidenced by not being able to leave the house c. shopping. The rest of the population has grown taller d. Can go either way 29. Low Self-Esteem related to victimization. a client who is being abused states. He doesn t want me to go anywhere while he s at work. As one ages. dancing. not even to visit my friends. The fact that they don t stand up straight c. Hardly changes at all 30. Inaccurate measurement 28. Is less stable and balanced when walking d. Explaining to the client his or her personal and legal rights d. Contagion d. deep breathing. muscle mass (that is muscle size): a. Fractures SITUATION 7: Sensory deprivation is experienced by most people in any setting whether they are patients confined in hospitals. Helping the client develop a safety plan 25. as evidenced by inability to make decisions d. Knee bends.c. and swimming d. Decreases c. Physical activity. and weight lifting 27. Is more steady b. Which of the following behaviors contribute to osteoporosis: a. As people gets older. Ineffective Coping related to victimization. During the session with the nurse. and losing weight b. workers assigned in mining industries or a family member assigned in far places.

Stand on the client s nondominant side. Firm pressure when touching body parts c.31. They prefer interaction with hearing adults b. They become more flexible in daily routine d. Reduced sensory input in the case of patients who have just been operated on glaucoma d. They show greater interdependence than hearing adult c. approximately one step behind the client. A post-operative blind patient needs to be assisted for ambulation. Stand slightly in front of the client s nondominant side allowing the client to grasp the nurse s arm 35. Elimination of order or meaning from input in the case of ICU patients or was in reverse isolation 32. Restrict use of the client s hands d. Use visual aide and gestures to enhance the spoken word c. Vigorous hair brushing d. Talk side by side with the client b. Speak loud enough or shout if you may so that client will be able to hear you SITUATION 8: Sexuality is one problem area that is often neglected by nurses in the care of elderly . Which of the following should the nurse do in ambulating a client with visual impairment? a. allowing the client to grasp the nurse s arm d. Which nursing intervention would be appropriate for client with hyperthesia? a. grasping the client s arm b. Which of the following will LEAST likely result to sensory deprivation? a. Minimal use of direct touch b. They show poor social judgment 33. Frequent back rubs 34. Which of the following is an appropriate communication method for client s with hearing impairment? a. Stand on the client s dominant aside slightly in front of the client. Which of the following are observed in sensorially deprived adult and elderly people because of deafness? a. Increased sensory input brought about by unlimited visitors from families and friends b. Stand on the client s dominant side and grasp the client s arm c. Restriction of the environment in patients who are on absolute bed rest c.

A client is regaining consciousness after a craniotomy becomes restless and attempts to pull out her intravenous line. A client has a supratentorial craniotomy for a tumor in the right frontal lobe of the cerebral cortex.clients. Lung cancer SITUATION 9: The nurse is caring for an adult admitted with a diagnosis of brain tumor. A woman has been without periods for a year b. The nurse however must be able to identify and address the sexual changes to provide nursing care. None of the above 38. Which of the following is NOT a known risk of hormone replacement therapy: a. Development of noncancerous fibroid tumors in the uterus c. Protection against constipation b. Hormonal decline in women causes: a. Decreased risk for atherosclerotic plaques d. Head of the bed elevated 45 degrees with a large pillow under the head and shoulders 41. Formation of blood clots and hypertension b. Emotional stability ends d. Which nursing intervention protects the client without increasing her ICP? a. Irritability goes away 37. Post operatively. Flat with small pillow under the nape of the neck c. No changes in risk for atherosclerotic plaques b. Benefits of hormone replacement therapy (HRT) include: a. Menopause is considered complete when: a. the position that would be most appropriate for this client would be: a. Hot flashes cease c. Head of the bed elevated 20 degrees with the head turned to the operative side d. Place her in a jacket restraint . Protection against fever 39. Breast and endometrial cancers d. High fowler s with knee gatch raised b. 36. He was scheduled for craniotomy. Protection against osteoporosis and elimination of the unpleasant symptoms of menopause c. 40. Increased risk for atherosclerotic plaques c. Protection against the flu d.

ACUTE dementia is due to causes which can be reversed. Electrolyte imbalance. Which of the following interventions is most appropriate? a. A frequent cause of this type of dementia is: a. especially hyponatremia (loss of sodium) . Cerebrovascular accident b. Prevent increased ICP b. Re-explain why she is having difficulty of speaking d. Speak to her in simple words and short sentences 43. Doing nothing because this is normal occurrence 44. Reinforcing the dressing and notifying the doctor immediately d. Wrap her hands in soft mitten restraints c. Alzheimer s disease c.b. The lost cells will regenerate on their own c. The significance of this is: a. The remaining cells are more than enough for learning and remembering d. Prevent secondary surgery d. there is a loss of brain cells. Prevent infection c. Multiple Infarcts d. To promote the client s use of speech the nurse should: a. A cell transplant is indicated b. Marking the area of drainage on the dressing c. The nurse notes that her dressing is saturated with blood. Respond to her crude efforts of speaking c. As one gets older. Correct her mistakes immediately b. Replacing the dressing b. The significance is not known 46. Following 3 months of rehabilitation after craniotomy. Apply a wrist restraint to each arm 42. Tuck her arms and hands under the draw sheet d. a female client is still having some motor speech difficulty. After craniotomy. what is your primary goal? a. A client undergoes a craniotomy for removal of her brain tumor. Prevent hemorrhage SITUATION 10: Dementing illness and changes in the brain 45.

Provide an anxiety-free environment c. Delusion c. Hallucination b. Mood disturbance c.47. Illusion d. Express doubt and do not argue d. Disturbance of perception 51. the main principle is to: a. Use logic and be persistent b. The client tells his primary nurse that he s scheduled to meet the President of the Philippines a special time. Wandering and getting lost b. making it impossible for the client to leave his room for dinner. Encourage ventilation of anger 52. Lack of gray matter SITUATION 11: A 23 year-old man was voluntarily admitted to the inpatient unit with a diagnosis of paranoid schizophrenia. Calcium deposits b. Decreased interest in bathing and hygiene d. Auditory and/or visual hallucinations c. This is an example of: a. he says. Idea of reference 50. 49. Inappropriate language and sexual behaviors 48. which of the following behaviors would the nurse interpret as a manifestation of disinhibition? a. When communicating with a paranoid client. The brains of persons with Alzheimer s disease are characterized by the presence of: a. When assessing a client with dementia. Fatty deposits c. Which of the following responses by the nurse is most appropriate? . If you come any closer. As the nurse approaches the client. Delusion is: a. Disturbance of thought d. I ll die. Senile plaques and neurofibrillary tangles d. Psychomotor disturbance b.

A low-salt diet d. and states. 27 yrs. Let s go so you can eat. It s meal time. Your physician expects you to follow the unit s schedule. Akathisia d. No one could ever love me. The nurse can expect the client to be placed on a. 54. is admitted for treatment of a major depression. Suicide precautions c. These are signs of: a. Sleeps about 16 hours per day 56. Force fluids 6 to 8 hours before treatment b. 53. Phototherapy 55.a. Has lost an additional 2 pounds c. c. Nico is scheduled for electroconvulsive therapy (ECT) tomorrow. Parkinsonism SITUATION 12: Nico. Anectine) during pretreatment care c. Nico is recovering from a severe depression. Which of the following behaviors indicates to the nurse that a client s major depression is improving? The client: a. The President of the Philippines told me to take you to dinner. Dystonia b. States one good thing about himself d. Encourage the client s spouse to accompany him d. Antiparkinsonism medication b. appears disheveled. The nurse would plan for which of the following activities? a. Reorient the client frequently during posttreatment care 57. Displays a blunted effect b. Which of the following behaviors alerts the nurse to a risk for suicide? . d. Administer succinylcholine (Inestine. He is withdrawn. Psychosis c. People who don t eat on this unit aren t being cooperative. b. A schizophrenic patient who began taking haloperidol (Haloperidol) 1 week ago now exhibits jerking movements of the neck and mouth. old.

We like you too much to want to kill you. Nico has been depressed severely depressed for 2 weeks. Demonstrating for the client how to do the task d. d. What is it that makes you think about harming yourself? c. The client sleeps most of the day b. The client has a plan to kill himself c. How long have you thought about harming yourself? b. No one wants to kill you here. don t be so silly. Managing complex medication schedule c. You are in the hospital. How has your concentration been? d. When helping the families of clients with Alzheimer s disease to cope with vulgar or sexual . Maintaining routine and structure for the client 61. What makes you think we want to kill you? b. Which of the following would be priority to include in the plan of care for a client with Alzheimer s disease who is experiencing difficulty processing and completing complex tasks? a. Considerable assistance with activities of daily living b. 62. The client loses 5 pounds d. What specifically have you thought about doing to harm yourself? SITUATION 13: A client is admitted with a diagnosis of Alzheimer s Disease. which of the following types of care would the nurse expect to include? a. 59. Repeating the directions until the client follows them b. such as shaving 60. Asking the client to do one step of the task at a time c. The client does not attend unit activities 58. We are nurses trying to help you.a. He had mentioned ending it all prior to admission. Oh. which of the following responses would be most appropriate? a. When developing the plan of care for a client with Alzheimer s disease who is experiencing moderate impairment. Constant supervision and total care d. When the client expresses fear of being killed by staff. Which of the following questions should the nurse ask during the prescreen assessment? a. Supervision of risky activities. c. Clients with Alzheimer s disease may have delusions about being harmed by staff and others.

but try to identify the purposes b. but he won t quiet down. An antianxiety drug 66. Give feedback on the inappropriateness of the behaviors c. Ignore the behaviors. Problem-solving therapy . 64. The Alzheimer s support group has so much good information. His excited explanations are keeping the entire unit awake.behaviors. Higher incidence in women b. I get tired of the same old stories. which of the following suggestions would be most helpful? a. b. SITUATION 14: A 34-year old is hospitalized with bipolar disorder. but I know it s important for Dad. Cognitive therapy c. Employ anger management strategies d. A tricyclic depressant b. c. Lithium carbonate (Eskalith) d. Presence of mania 65. The nurse knows that the major factor that distinguishes a bipolar from a unipolar disorder is the a. I didn t realize the deterioration would be so incapacitating. d. Supportive therapy for a client who is exhibiting manic behavior may include all of the following EXCEPT: a. At 2 a. Genetic etiology d. An MAOI-inhibitor antidepressant c. Severity of the depression c. The nurse caring for him knows the drug most likely to be prescribed for this client is: a. the nurse the nurse finds him phoning friends all across the country to discuss his new plan for eradicating world hunger. Administer the prescribed risperidone (Risperdal) 63. Interpersonal therapy d. The nurse determines that the son of the client with Alzheimer s disease needs further education about the disease when he makes which of the following statements? a. Psychoanalysis b.m. I woke up this morning hoping that my old Dad would be back.

67. Describe acceptable behavior and set realistic limits with the client c. Which of the following nursing intervention is most appropriate? a. Which of the following . What does the lens of my eye do? The nurse should explain that the lens of the eye: a. The client is skipping up and down the hallway practically running into other clients. Watching television c. Cleaning the dayroom tables SITUATION 15: A client is admitted to outpatient surgery for cataract extraction on the right eye. Constriction of the pupil and dilatation of blood 72. Tell client that his behavior is not appropriate 68. Eye strain and headache when doing close work 71. Dilatation of the pupil and blood vessels b. Halos and rainbows around lights b. Regulates the amount of light entering the eye 70. Holds the rods and cones c. Reading the newspaper d. This preparation acts in the eye produce a. Dilatation of the pupil and constriction of blood vessels c. A short time after cataract surgery. Leading a group activity b. The client would most likely to complain of which symptoms? a. Blurred and hazy vision d. The nurse is to instill drops of phenylephrine hydrochloride (Neo-Synephrine) into a client s right eye before cataract removal surgery. 69. Eye pain and irritation that worsens at night c. Allow the peer group to intervene b. Recommend the client to be hospitalized for treatment d. Focuses light rays onto the retina d. Produces aqueous humor b. the client complains of nausea. The client is creating considerable chaos in a day treatment program with dominating and manipulative behavior. Constriction of the pupil and constriction of blood vessels d. The client asks. Which of the following activities would the nurse expect to include in the client s plan of care? a.

To cure the disease b. Lifting light objects is acceptable c. Maintaining a safe environment d. Tremor c. 74. The nurse develops a teaching plan for a client newly diagnosed with Parkinson s disease. Instruct the client to take a few deep breaths until the nausea subsides b. Tell the client to call the nurse promptly if vomiting occurs d. Medicate the client with an antiemetic. To stop the progression of the disease c. To maintain optimal body function . when the client s energy level is high b. When family members will be available 77. When does the nurse encourage a client with Parkinson s disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? a. Wearing eye patches for the first 72 hours b. Engaging in diversional activity 76. as ordered 73. Akinesia 75. To begin preparations for terminal care d. Early in the morning. Enhancing the immune system c. Which of the following topics that the nurse plans to discuss is the most important? a. Bending with the waist is acceptable if slowly done SITUATION 16: A client is admitted with a diagnosis of Parkinson s disease. Rigidity b. Bending with the knees and keep the head straight d. To coincide with the peak action of drug therapy c. Which of the following is an initial sign of Parkinson s disease? a. Explain that this is a common feeling that will pass quickly c.represents the nurse s best course of action? a. Immediately after a rest period d. Discharge planning would include: a. Bradykinesia d. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson s disease? a. Maintaining a balanced nutritional diet b.

but she becomes annoyed when the nurse offers assistance and refuses all help. Praise the client for her desire to be independent and give her extra time and encouragement c. it can become dry and irritated. she should at least modify her routine SITUATION 17: A client is admitted to the hospital with Bell s Palsy. When your affected eye fails to make tears. Tell the client firmly that she needs assistance and help her with her care b. Risk for chronic low self-esteem d. The client needs a long time to complete her morning hygiene. Suggest to the client that if she insists on self care.78. What would be an important teaching to the patient? a. d. Risk for impaired physical mobility 81. Which nursing diagnosis takes priority for the patient with Bell s palsy? a. a. b. which speeds healing. Risk for dysfunctional grieving b. The nurse observes that the client s right eye does not close completely. c. Risk for injury related to corneal laceration c. The client has a feeling of stiffness and a drawing sensation of the face. A client with Bell s Palsy asks the nurse why artificial tears were ordered by the physician. Tell the client that she is being unrealistic about her abilities and accept that she needs help d. the eye can become irritated and ulcerated. Cleansing the eye with a clean washcloth every shift 82. Select the best reply by the nurse. Cleaning the eye will prevent ulceration d. 79. Based on this. Instilling artificial tears once every shift d. All of the above . which of the following nursing interventions would be most appropriate? a. Because you cannot blink the affected eye. Eye is susceptible to injury when eyelid does not close b. Making sure the client wears her eyeglasses at all times b. Placing an eye patch over her eye c. Because your eye remains closed. Artificial tears will remove the purulent drainage from your eye. Drooling from an increased saliva on the affected area may occur c. 80. foreign matter can be trapped beneath the lid. Which statement is the nurse s best initial response in this situation? a.

Provide ample time for her to complete her rituals 84. Lock the door to her room and restrict access to the bathroom d. Tell her to stop each time she is observed doing it 86. Drinking Ensure between meals b. Allow her a certain amount of time each shift to engage in this behavior b. The most effective way for the nurse to intervene with her hand and face washing is to: a. Upon admission she was also dehydrated and underweight. A structured schedule of activities c. Drinking extra fluids with meals c. Is able to start talking about her guilt and anxiety d. Drinking adequate amounts of fluid during the day 87. Her family reports she washes her hands at least 30 times each day. Intense counseling d. The main nursing goal is to: a. Interrupt the activity briefly and frequently c. The nurse noticed the client s hands are reddened. Negative reinforcement every time she performs her rituals 85. The nurse and the client will know That discharge planning is appropriate when the client: a. An unstructured schedule of activities b. Expresses a desire to leave the hospital c. Limit the number of hand washings c. Which nursing intervention would the client be most likely to comply with? a. Regains her normal body weight b.SITUATION 18: A 46-year old is admitted to the hospital because her family is unable to manage her constant hand washing rituals. scaly. Limits her hand and face washing to a few times a day . Tell her it is her responsibility to be there on time d. and cracked. The client is also constipated and dehydrated. 83. Remind the client several times of her appointment b. Which of the following is an appropriate treatment for this client? a. Drinking 8 oz water every hour between meals d.

Moderate c. The nurse asks the client if something upsetting happens. a racing heart. and the client response is vague and not focused on nurse s question. Speak to the client in short. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder d. Hyperventilation d. The client is pacing and complains of racing thoughts. Tachycardia c. The client has a generalized anxiety disorder. Suspecting a psychological component to these symptoms. Panic b. Nitropusside d. simple sentences c. except: a. Severe d. 88. and there is no need to panic b. Proton pump inhibitors c. Relaxation techniques and psychotherapy are necessary for care c.SITUATION 19: The nurse is caring for a client who is experiencing panic attack. Which intervention would be most appropriate? a. Tell the client he s all right. Lithium carbonate 90. All of these symptoms have occurred almost daily for the past 3 months. Which statement is true about this client? a. Benzodiazepines b. Give the client a detailed explanation of his panic reaction 89. The nurse assesses the client s level of anxiety as: a. Explain to the client that there s no need to worry because he s safe d. Which of the following is a behavior manifestation of anxiety. Mild b. Panic 92. Tachypnea SITUATION 20: Defense Mechanisms . what would the nurse anticipate administering? a. dizziness and fearfulness. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months 91. The client has regular obsessions b. The client reports that she often feels a choking sensation in her throat.

released from prison for selling narcotics has been rehabilitated and now works for a youth drug prevention agency. When the significance of this is explained to her. Projection d. Passive-aggression b. The defense mechanism utilized by manic patients to cover up depression is: a. No way. an abnormal ECG. Dissociation d. and elevated enzymes. Reaction formation c. Repression 97. I can t be having a heart attack. Sam is diagnosed with cancer does not talk about or acknowledge the diagnosis. Identification c. Reaction formation SITUATION 21: Psychosomatic disorders 98. Compensation d. In patients with dissociative disorders. You must be mistaken. The nurse assesses . Which of the following defense mechanism is Sam using? a. Sublimation b. Denial c. The nurse suspects the client is using which defense mechanism? a.93. she says. Nathaniel. Denial b. Displacement b. Denial d. Denial b. He has been seen by many medical specialists in the past without discovery of organic pathology. Displacement c. Nina is admitted to the ICU with chest pain. Rationalization 94. Denial 96. Darwin is reflecting which of the following defense mechanism? a. A man s family brought him onto the hospital because of his many somatic complaints. Sublimation 95. the defense mechanism most often used to block traumatic experiences is: a. Identification d. Regression c.

that the client is probably experiencing which of the following problems? a. Express feelings about conflict d. Develop an increased sense of relatedness to others 100. Cope effectively with stress without using conversion b. She seems unconcerned about her paralysis. Conversion disorder b. Identify stressors c. An appropriate long term goal for the nurse to formulate is that client will: a. A patient who reports paralysis with no specific cause but has a history of a recent stressful event has a probable diagnosis of: a. Amie is hospitalized for treatment of conversion disorder. Body dysmorphic disorder c. Hypochondriasis 99. Malingering d. Somatic illness c. Conversion disorder d. Hypochondriasis b. She complained of paralysis of her right side after her husband threatened to leave her and their children. Pain disorder .

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