ARETE REVIEW AND TUTORIAL CENTER

“EXCELLENCE BEYOND IMPOSSIBLE”

SITUATIONAL
Situational 1- you are a staff nurse in the ear unit of a government hospital. As such, you taking care of patients with
different ear conditions.
1. Mariel, a 25-years old radio announcer came in for consult with the chief complaints of not being able to hear
well and inability to discriminate sounds he is hearing. An otoscopic examination was done to her, which
revealed that there is sensorineural loss. This condition is due to damage to what part of the ear?
a. Cochlea and auditory nerve
b. Vestibular nerve and cochlea
c. Middle ear and auditory nerve
d. Outer ear and cochlea
2. Which of the following is a predisposing factor for sensory hearing loss?
a. Serous otitis media
b. Ototoxic agents
c. Otosclerosis
d. Perforation of the eardrum
3. Which of the following is useful in correcting a sensorineural hearing loss?
a. Nothing, the damage is irreversible
b. Myringotomy
c. Stapedectomy
d. Tympanolasty
4. One of your patients underwent tympancplasty. Which of the following intervention is the MOST APPROPRIATE
after a tympanoplasty?
a. Applying ear drops as ordered by the physician
b. Teaching the patient to avoid heavy physical activity for at least three weeks
c. Rising the ear three times a day using hydrogen peroxide as ordered
d. Avoiding the use of cotton cleaning the ears
5. A patient came in with the chief complaints of ringing In the ears and a feeling of whirling around. The attending
physician suspects meneire’s syndrome. To arrive at a correct diagnosis, the patient must be manifesting these
three symptoms: paroxysmal whirling vertigo; tinnitus; and _______.
a. Conductive hearing loss
b. Bilateral symptoms
c. Vomiting
d. Sensorineural hearing loss
Situation 2- you are a staff nurse in the psychiatric unit of the hospital taking care of patients with manic disorder. The
following question relate to this statement.
6. What would be your MOST therapeutic response to a manic patient demanding that you call his attending
physician to make an order for a pass to go out at the middle of the night?
a. “You go to the recreation hall now while I call your attending physician”
b. “You must really be upset to want a pass immediately. I will give you a medication to make you calm”
c. “I can’t call your physician now but you can talk to me about your request to pass”
d. “Don’t be unreasonable. I can’t call your attending physician in the middle of the night”
7. One of your patients lacks food and fluid intake due to poor appetite. What foods would BEST meet the patient’s
nutritional needs?
a. Steak and spaghetti
b. Peanuts butter, sandwich and milk
c. Carrots, celery, raisins, apple
d. Beef ad non-diet soda
8. During lunchtime you have observed that a patient with mania taking food from other patient. What principle
would guide you in determining the appropriate intervention in this situation?
a. The patient needs food and fluids any way possible
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b. The patient will calm down as soon as lunchtime is over
c. The intrusive behavior of a manic patient is not a threat to other patients
d. Other patients need to be protected from the intrusive behavior of other patients
9. A patient is manifesting some manic depression. Which of the following activities would you provide to distract
such patient?
a. You let the patient go for a walk
b. Give him a book to read
c. Let him watch the final game of the UAAP
d. Let him play checkers with another patient
10. What therapeutic activity would you provide patient with mania?
a. Doing ceramics and whittling
b. Playing cards and checkers
c. Playing bingo and knitting
d. Drawing and folding towels
Situation 3- you are a staff nurse in a rehabilitation center for substance abuse.
11. You admitted an intoxicated patient for alcohol withdrawal. Which of the following intervention should you
implement to help the client become sober?
a. Have the patient take a cold shower
b. Walk the patient around the unit
c. Provide the patient a quiet room to sleep in
d. Give patient a black coffee to drink
12. While obtaining the history of a patient with several cases of driving under the influence of alcohol, yuy asked
about the amount of alcohol the patient consumes daily. He answered “I just gave a few drinks with the guys
after work”. Which of the following would be your MOST therapeutic response?
a. “that’s all the patients here say at first”
b. “you say you have a few drinks, but you have multiple arrests”
c. “I think you cannot handle a few drinks”
d. “then you should have somebody driving for you”
13. Which of the following assessment data provides the best information on the patient’s physiologic response and
the effectiveness of the medication prescribed for alcohol withdrawal?
a. Sleep pattern
b. Evidence of tremors
c. Vital signs
d. Nutritional status
14. One of your patients is manifesting signs and symptoms of alcohol withdrawal such as: tremors, diaphoresis, and
hyperactivity. Blood pressure is 190/92 mm. Hg and pulse rate of 92 beats/min. which of the following
medications should you expect to be ordered for this patient?
a. Lorazepam ( Ativan )
b. Naloxone ( Narcan )
c. Haloperidol ( Haldol )
d. Benztropin ( Cogentin )
15. A patient discharged from an alcohol rehabilitation program was on clonazepam (Klonopin) 0.5 mg. three times
a day. Several months later he reported having insomnia, shakiness, sweating, and one seizure. Which of the
following questions should you ask FIRST? Ask if the _________.
a. Has stopped taking the Klonopin suddenly
b. Has been drinking alcohol with the Klonopin
c. Has developed tolerance to the Klonopin and needs to increase the dose
d. Is having a panic attack and needs to take extra Klonopin
Situation 4- you are a staff nurse in the eye unit of the hospital. I the regular quality circle meeting one of the matters
discussed was the increasing complaints of patients who under eye surgery In relation to instillation of eye drops. The
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case of Claudia who had cataract surgery was presented as a frame of reference in reviewing the procedure on eye
drops instillation.
16. Which of the following is the rationale for instilling eye drops to patient who had eye surgery?
a. To help control the intra-ocular pressure
b. To dilate the patient’s pupils
c. To treat an eye infection
d. To constrict the patient’s pupils
17. You have observed presence of drainage in Claudia’s eyes. Which of the following eye solutions would you use
cleaning her eyes?
a. Hydrochloric acid
b. Normal saline solution
c. Mineral water
d. Soapsuds solutions
18. In instilling the eye drops you have to tilt the back slightly Claudia’s head. Which of the following is the rationale
for this nursing action?
a. To prevent any spill from the eye during the procedure
b. To keep ay debris away from the lacrimal duct
c. To facilitate the procedure
d. To reach the conjunctival sac easily
19. You accidentally touch Claudia’s eyelid during eye drop instillation causing her to blink. What should have you
done to prevent this from occurring?
a. Touch the inner side of the medicine cap
b. Tilt back claudia’s head slightly
c. Hold the dropper close to the eye but do not allow the medication to fall into the cornea
d. Have Claudia look up and focus on something
20. You cannot open Claudia’s eye due to dried crust. Which of the following actions would you do?
a. Apply the eye drops the next day
b. Apply eye ointment to soften the crust
c. Instill eye drops
d. Place a warm wet wash cloth over her eyes for at least three minutes
Situation 5- nurse Fatima who is on-duty in a psychiatric unit is assigned to care for patients at- risk for suicide.
21. Nurse Fatima should pursue assessment of suicide risk for individuals who display tendencies to be _______.
a. Compulsive , obsessive, or weal
b. Risk-taking, aggressive, or controlling
c. Hostile, impulsive, or depressed
d. Blaming, abusive, or confused
22. On admission, the nursing diagnosis for gringo, who is depressed and suicidal is, “Risk for suicide”. An
appropriate outcome for this diagnosis at discharge from the hospital is, “The patients will ______.
a. Not harm self while hospitalized
b. Be able to problem-solve effectively
c. Increase feelings of self-worth
d. Develop a trusting relationship with the nursing staff
23. Which of the following statements would BEST represent Nurse Fatima’s attempt to assess a patient’s current
ability to organize and enact a suicide wish?
a. “What is your educational background?”
b. “What plan do you have for commuting suicide”
c. “Have you ever thought about hurting yourself?”
d. “Are you self-destructive thoughts frequent?”
24. A male suicidal patient is found by Nurse Fatima as he tries to hang himself in the bathroom. What nursing
intervention would address the patient’s need for safety while maintaining his self-esteem?
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a. Advise him to use the bathroom only with staff supervision
b. Tell him that the police is coming to rescue him
c. Place him in the seclusion room with 15-minute checks
d. Assign a nursing staff to remain with him at all times
25. In evaluating the effectiveness of the care provided for a self-destructive patient, the BEST approach is to_____.
a. Modify the plan as little as possible to avoid confusing the patient
b. Make sure the staff has followed the original care plan
c. Involve the patient in the process of evaluation
d. Identify maladaptive coping behaviors
Situation 6- the nurse’s work environment plays a vital role in her ability to provide quality patient care. Inadequate
resource in health care and unhealthy conditions in the workplace result to nurse’s work stress.
26. Burnout is phenomenon that is BEST characterized by______.
a. Emotional exhaustion; depersonalization; and reduced personal accomplishment
b. Growing dissatisfaction among nurses due to changing career expectations
c. Increased absenteeism and fast turnover of nurses due to toxic work environment
d. Conflict between demands of work and family
27. A common response to unhealthy work environment is physical tension. This can be overcome by progressive
muscle relaxation which basically involves________.
a. Focusing on an image to relax
b. Active physical exercise like aerobics
c. Releasing muscle from tension
d. Listening to a relaxation audio program
28. Bio-behavioral interventions are being used increasingly by both nurses and patients in stress management. The
following are examples of such intervention EXCEPT________.
a. Progressive muscle relaxation
b. Pharmacotherapy
c. Guided imagery
d. Mindful meditation
29. Ace, a young overweight nurse, is smoking five to ten sticks of cigarettes a day. He claimed that he learned to
smoke to relieve his he stress caused by toxic assignments in the ward. Along with smoking he became a stress-
eater. He decided to undergo a lifestyle modification which begins with_____.
a. Eating the right kind of foods
b. A recognition of the impact of unhealthy habits
c. Doing a regular daily exercise
d. A constructive and positive attitude in life
30. Ace is a well-informed nurse on the smoking cessation program of the department of health. As a next step to
his decision to stop smoking, ace needs _______.
a. Commitment
b. Motivation
c. Information
d. Skills to implement change
Situation 7- Mrs. Andrea Santos, a 43-years old Female came in for consult with the chief complaint of severe pain of
both eyes. She claimed she sometimes sees rainbow halos around lights. She also experiences nausea and vomiting. The
attending physician gave an impression of acute angle-closure glaucoma.
31. In assessing Mrs. Santos, what demographic data is/are RELEVANT to ocular assessment?
A. Gender
B. Age at menarche
C. Age and gender
D. Race
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32. An ophthalmoscopic examination was done to Mrs. Santos. The following results are expected EXCEPT
_______.
a. Nonreactive pupil
b. Corneal cloudiness
c. Erythematous conjunctiva
d. Decreased intraocular pressure
33. Vision loss for Mrs. Santos may progress as days go by and this is irreparable. An appropriate nursing diagnosis
would be _______.
a. Disturbed sensory perception related to severe pain
b. Risk for ineffective therapeutic regimen
c. Disturbed sensory perception related to recent loss of vision
d. Grieving related to loss of vision
34. Select the medication that should be discussed by the nurse with the attending physician before administering it
to Mrs. Santos.
a. Isoptocarpine eyedrops
b. Corticosporin ophthalmic
c. Mannitol
d. Atropine
35. In a medically-managed patient with glaucoma, independent self-care is the area for evaluation. Which of the
following is a short-term outcome for Mrs. Santos?
a. Ability to recognize clinical manifestations of complications
b. Mrs. Santos self-care ability
c. Compliance with the medical management
d. Mrs. Santos ability to instill eye drops
Situation 8- Marites is a beginning nurse in a government hospital. She still needs enhancement of her competencies in
charting.
36. Marites should know that in narrative charting, documentation of patient care should be_________.
a. Extensive
b. Formatted
c. Chronologic
d. Descriptive
37. Which statement is NOT true about medical record that Marites must understand? Charts_________.
a. Contents must be kept confidential
b. Can be borrowed by any nursing student
c. Can be accessed by a researcher
d. Can be given out only with patient’s consent
38. The following are the methods of charting, EXCEPT_______.
a. Sequential
b. Narrative
c. POMR
d. Focus
39. In the PIE method of charting, P is for needs, EXCEPT___________.
a. Admission
b. Problem
c. Teaching
d. Discharge
40. In charting neurologic assessment, Marites must understand that the following should be indicated. SELECT all
that apply. 1. Orientation; 2. Pupil’s movement; 3. Sensation; 4. Quality of speech
a. 3 and 4
b. 1 and 2
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c. 1,2,3 and 4
d. 1,3, and 4
Situation 9- on of your programs as community health nurse is related to substance abuse addiction. You spearheaded
an educational collaborative activity to address the increasing drug and alcohol problems in the community. A multi-
sectorial committee was formed and an initial organizational committee meeting was held. The following questions
apply to this situation.
41. To motivate and spark the interest of prospective participants in the proposed program, which of the following
activities will you introduce as an initial activity of the group?
a. Lecture-forum on alarming danger of drug and alcohol use
b. A summer sports fest involving all age group
c. Values- formation program
d. Lecture-forum to increase awareness of unhealthy lifestyle
42. To assess the prevalence and incidence of substance abuse, a community survey was done by the barangay
health workers. Using purposive sampling, what age-group is at MOST risk to be considered as the survey
respondents?
a. Pre- schoolers
b. Older adults
c. Older children
d. Adolescents
43. A self-help support group for educational and caring approach for alcoholics is:
a. Halfway homes
b. Psychiatric treatment and rehabilitation centers
c. Alcoholic anonymous
d. Detoxification treatment programs
44. The LEAST effective education and preventive measure for drug abuse is:
a. Activity workshop for out of school youth
b. Family enrichment programs
c. Regular advocacy meeting to include families, store, restaurant, bar owners
d. Leaflets and brochures for mass distribution
45. The committee organized parent education classes. A representative from the local police department was
invited to discuss:
a. Stress management
b. Parent effectiveness training
c. The legal implications of illicit drug use
d. Recognition of deviant child and adolescent behavior
Situation 10- as a beginning professional nurse one of the competencies expected of you is to engage in research. Basic
knowledge in research, therefore, is very important. The following questions relate to this statement.
46. What element distinguishes a true experimental research from a quasi-experimental research?
a. The use of non-probability sampling
b. Lack of random assignment of subject to group
c. Size of the sample
d. The introduction of experimental treatment
47. You want to determine the effect of a planned exercise on low-back pain. Which of the following research
designs would be MOST APPROPRIATE to use in this study?
a. Posttest only control group design
b. One-shot case study
c. Pretest-posttest control group design
d. One group pretest-posttest design
48. Which of the following is a type of probability sampling?
a. Cluster
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b. Purposive
c. Quota
d. Convenience
49. You want all people who are currently institutionalized for psychiatric problems to participate in your study.
This is an example of _________.
a. Universal population
b. Target population
c. Element
d. Sample
50. You want to determine the difference of the anxiety level between male and female patients scheduled for
abdominal surgery. The first 30 males and the first 30 females who are admitted to the hospital at the time of
the study would be asked as study participants. This is an example of what sampling technique?
a. Fish ball technique
b. Simple random
c. Quota sampling
d. Purposive sampling
Situation 11- Rebecca, 35 years old nurse has two children aged 2 and 5 respectively. She is separated from her husband.
She has been in the hospital for one month now with a diagnosis of obsessive- compulsive disorder. You are the nurse
assigned to her.
51. You have observed Rebecca to be repeatedly washing her hands for a long period of time. This is a manifestation
of _________.
a. Ritualistic behavior
b. Aggressive behavior
c. Compulsive behavior
d. Truancy
52. The MOST basic function of Rebecca’s repeated hand washing is to __________.
a. Manipulate her environment
b. Occupy her mind with purposeful activity
c. Relieve her anxiety
d. Reduce the possibility of nosocomial infection
53. Which of the following statement is true of Rebecca exhibiting such behavior?
a. Rebecca is likely to be aware of her repeated handwashing
b. The frequency of her repeated handwashing is unrelated to the degree of her anxiety
c. Rebecca can be made to understand that her behavior is unreasonable but acceptable
d. Rebecca may have an awareness that her behavior is illogical but she is helpless to stop it
54. One night you interrupted Rebecca from her handwashing ritual and attempted to escort her to her room. She
slapped you. The MOST probable reason for Rebecca behavior is her_______.
a. Hate of hospital regulations such as bedtime
b. Ritual of handwashing is usually followed by aggressive behavior
c. Experience of severe anxiety because you stopped her from what she is doing
d. Dislike of you as her nurse
55. Rebecca approached you later and said “I’m sorry I slapped you. I cannot understand what made me do it.” Your
MOST APPROPRIATE response would be _________.
a. “I am glad you realize that slapping me was unacceptable”
b. “Not to worry. It is forgotten”
c. “It’s not pleasant to be slapped. Let’s talk about how you felt”
d. “I was really surprised you did it to me. I thought we were friends”
Situation 12- you are a staff nurse at the emergency room. Renato, a 32 years old employee in a business processing
outsourcing company, was brought- in, in a company car with the chief complaints of severe headache, inability to move
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his eyes upward, and restlessness. Vital signs upon admission: BP= 160/100; Cheyne - Stokes respiration was noted.
Water manometer test revealed increased intracranial pressure (IICP)
56. Renato was started on Mannitol therapy. What is the rationale for this treatment?
a. To prevent seizures
b. To prevent dehydration
c. To prevent serious fluid and electrolyte imbalance
d. To increase the osmolality of the blood
57. Select the PRIORITY nursing responsibility for taking care of patient n Mannitol therapy like Renato. Monitoring
of _____.
a. Respiratory rate
b. Urine output
c. Renal function
d. Muscle function
58. Decreased level of consciousness ( LOC ) is one of the results of IICP. Which of the following is NOT an early
manifestation of decreased LOC?
a. Lethargy
b. Comatose which no response to painful stimuli
c. Restlessness
d. Disorientation
59. Renato has been observed to manifest signs of disorientation. Which of the following occurs FIRST in the state of
disorientation? Disorientation to __________.
a. Place
b. Environment
c. People
d. Time
60. On admission to the ER, a variety of laboratory tests, for diagnostic purposes, were done to Renato who has
been assessed to have decreased
a. Urinalysis for WBC
b. Blood and urine toxicology
c. Blood glucose
d. Serum electrolytes
Situation 13- you are a staff nurse In a government hospital. In the tour of your duty you encounter situations that have
legal implications.
61. Mrs. S. an older adult with dementia fell from her bed because the nurse on duty did not install the side rails.
Which of the following criteria can establish a malpractice lawsuit againt the nurse?
a. The nurse owed a duty to the client
b. The nurse on duty did not follow the protocol on the standards of care on the use of side rails
c. The nurse on duty followed the protocol on the use of side rails
d. The patient was not injured
62. You are a staff nurse at the emergency room. You have an uncooperative patient that made you yelled at him,
saying “ if you do not take off those dirty, smelly clothes, I will do it myself” , moving towards the client. You may
be sued for _______.
a. Assault
b. Physical injury
c. Libel
d. Character defamation
63. You tell Mr. Castro “ I will give your injection now, Mr. Castro “. He holds out his arm to you which means Mr.
Castro is giving/ not giving you his ______.
a. Permission
b. Written consent
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c. Consent
d. Implied consent
64. You touch a patient having EEG without her consent. The patient may file against you a complaint of ________.
a. Sexual harassment
b. Physical consent
c. Battery
d. Assault
65. Which of the following is not a FACTOR to be verified for consent to be valid? The person giving the consent
must________.
a. Be legally an adult
b. Be mentally and physically competent
c. Have a diagnosis of a communicable disease
d. Be giving it voluntarily
Situation 14- as a new licensed nurse, you deem it appropriate to continuously gain competence in your professional
practice and to enhance your personal growth.
66. Which if the following is the MOST important attribute of a true professional?
a. Personal graces
b. Critical thinking
c. Assertiveness
d. Self-regulation
67. You are committed to improve your competence in order to provide safe and quality care to your patients.
Which of the following with this personal desire?
a. Participating in the activities of the professional nursing organization
b. Taking the foreign examination for nurses as preparation to working abroad
c. Joining the health workers union in your hospital and attending their safety education classes.
d. Attending relevant continuing education development programs
68. Which of the following situation do you consider your PRIMARY responsibility while performing your nursing
duty?
a. Attend to the call for help of a patient who needs total nursing care
b. Assist the doctor in making rounds
c. Delegate to the nursing assistant vital signs-taking
d. Answer the telephone call of the attending doctor.
69. You have a professional duty to be a member of the accredited organization of nurses. This organization has the
mission to undertake the following, EXCEPT:
a. Advocate for favorable policy positions to relevant government agencies
b. Initiate public discussion on health issues and the nursing profession.
c. Explore foreign labor market for employment of Filipino nurses
d. Adopt measure for the improvement of nursing practice
70. You dream of pursuing a career of becoming a clinical faculty. Which of the following qualifications is NOT
mandatory?
a. Member of good standing in the accredited professional organization
b. Must have one year clinical practice in a field of specialization
c. Must have five years of clinical practice in the field of nursing
d. Be a registered nurse in the Philippines
Situation 15- you are a stuff nurse in the psychiatric unit. You are taking care of Rona, an 8 year old child diagnosed with
separation anxiety. You scheduled a psycho-education program for her parents.
71. The focus of psycho-education program is _______.
a. Assessing for the parent’s belief systems
b. Determining the long-term effects of the medication
c. Helping rona maintain regular school attendance
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d. Teaching the parent’s how to support Rona without reinforcing her maladaptive behavior
72. Which would be your PRIORITY nursing intervention in helping the parents understand their role in reducing
Rona’s symptoms?
a. Administer anti- depressants to the parents
b. Encourage the parents to express their feelings about Rona’s symptoms
c. Make referrals to different support groups
d. Assess the parents understanding of separation anxiety
73. Which of these psycho-education activities is NOT an anxiety producing situation for the parents or care-givers?
a. The child riding the school bus
b. Child getting off the school bus at home
c. Going to the mall
d. Parents dropping off the child in school
74. Which of the following is NOT a cognitive-behavioral approach in giving family psycho-education?
a. Psycho-therapy
b. Progressive relaxation
c. Desensitization approach
d. Exposure-based approach
75. Information on primary environmental reinforcers that result to symptoms of anxiety is part of psycho-
education. Which of the following is NOT considered anxiety-producing reinforcers?
a. Riding the bus
b. Letting the child to stay at home when complaining of headache
c. Allowing the child to miss school
d. Promising her McDonald twisters when she cries
Situation 16- Ms. Marga , an 18 year old female student in a private university came in for consultation at the university
health service with the chief complaints of poor attention span, poor concentration, hearing some voice calling her, and
sometimes seeing people following her. She claimed she started to experience all these since three months ago. The
attending physician’s impression is schizophrenia.
76. What is the lifetime risk of developing schizophrenia in the general population?
a. 1%
b. 15%
c. 5%
d. 10%
77. Which of the following marks the INITIAL PHASE of schizophrenia?
a. Increased energy and motivation
b. Heightened work performance
c. Impaired role functioning and neglect of personal hygiene
d. Increased social interaction
78. Which of the following CLUSTERS of symptoms indicate the presence of schizophrenia?
a. Feeling of hopelessness and helplessness
b. Obsessive thoughts and ritualistic behavior
c. Hallucinations and delusion and decreased ability to function in society
d. Unstable mood and delusions of grandeur
79. Which of the following symptoms of schruzophrenia are likely to be RESPONSIVE to medications?
a. Anhedonia
b. Social withdrawal
c. Hallucinations
d. Apathy
80. Which of the following methods can REDUCE the intensity of auditory hallucinations?
a. Talking to the patient
b. Giving the patient amitrystyline
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c. Advising the patient not to pay attention to the voices
d. Encouraging the patient to read
Situation 17- you are a staff nurse in the musculoskeletal unit of the hospital. Are such you are taking care of patients
with varied musculoskeletal conditions? The following questions apply to this statement.
81. A patient is being admitted with a spinal cord transection at C7. Upon the patient’s arrival, what assessment
data take priority? Select all that apply.
1. Temperature
2. Respiration
3. Blood pressure
4. Bladder function
5. Reflexes
a. 4; 1; 3
b. 1; 4; 5
c. 3; 1; 2
d. 2; 4; 1
82. You plan to move a person with a possible spinal cord injury. What principle should guide you in moving him?
a. Put pillows at the patient’s back to ensure comfort
b. Move the patient gently to reduce pain
c. Wrap the arms next to the body to limit its movement
d. Immobilized the head and neck to prevent further injury
83. Your patient with a spinal cord injury is experiencing blurring of vision and has a blood pressure of 206/104/
mmHg. What would be your PRIORITY nursing action?
a. Decrease stimulation for the patient
b. Position the patient on his left side
c. Administer pain medications
d. Check the patient’s bladder for distention
84. You have a patient with cord transaction at t4. Which of the following is the focus of your nursing assessments?
a. Vascular status
b. Biliary functions
c. Gastrointestinal functions
d. Renal status
85. You are planning to teach the patient with spinal cord injury and intermittent nasogastric suctioning about
interventions to maintain the patient’s integumentary system. You should instruct the patient to _______.
a. Stay in a warm environment to prevent chilling
b. Stay in a cool environment to prevent sweating
c. Eat low- sodium food to prevent edema
d. Eat enough calories to maintain desired weight
Situation 18- below is situations which have some Ethicon- moral and legal implications to you as a professional nurse.
86. You suspect that your co-worker, Mr. B. is manifesting some signs and symptoms of chemical abuse. You have a
duty to report him to your superior in a confidential manner with the PRIORITY issue as ______.
a. Investigation of the case
b. Conduct unbecoming of a professional nurse
c. The goal of treatment for Mr. B
d. Mr. B. is an occupational hazard to his patients
87. You have a neurologic, elderly patient who needs to sign an informed consent for a lumbar puncture. You have
doubts about the patient’s level of comprehension. Which of the following nursing actions is the MOSE
APPROPRIATE for this situation?
a. Le the nearest relative sign the document
b. Do not let the patient sign the informed consent and notify the attending physician
c. Let the patient sign it as it is his right to be informed
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d. Let the head nurse sign the informed consent
88. Which of the following nursing actions is a VIOLATION of patient’s right to privacy?
a. Knocking before entering the patient’s room
b. Draping the patient appropriately during procedures and treatment
c. Accessing patients electronic data
d. Keeping the door of the patient’s room closed
89. You are staff nurse in a regional military hospital in western Mindanao. You overheard an involuntary committed
patients talking over the phone about the plot to assassinate the president. You reported this to the
commanding officer of the regional command of the Philippine Army. The nurse was reprimanded for______.
A. Conduct unbecoming of a professional nurse
B. Breach of confidentiality
C. Violation of patient human rights
D. Reporting an unverified
90. The colloquial statement “the nurse was given her day in court” means that the nurse was given a/an _____.
A. Opportunity to present her side
B. Opportunity to present evidence
C. Chance to be heard
D. Due process

SITUATION 19: You are a staff nurse in the musculoskeletal unit of the surgical ward of the hospital. You are assigned to
a group of newly admitted surgical patients. The following questions apply to this situation.

91. You are conversing with a patient who is scheduled for open reduction of a fractured femur and who appears to
be worried. Which of the following nurse responses indicates “active listening”?
A. Nodding her head
B. Telling the patient to take a rest and relax
C. Talking to her patient but looking at the other patient in the ward
D. Asking the patient why he seems worried
92. Giving false reassurance is one of the barriers in a therapeutic communication. Which of the following statement
is an example of this?
A. “you have a surgeon who has done this procedure a lot of times”
B. “your family will be able to see you once you are awake”
C. “your surgeon can do this procedure even with his eyes closed”
D. “ you’ll go through this procedure without any problem”
93. Trust is an important element of a therapeutic communication. You promote trust in your patient when you ___.
A. Act upon what you have committed to do
B. Allow family members to visit anytime they want
C. Assure the patient that he has an excellent surgeon
D. Talk to the patient about his personal life
94. You heard another staff nurse telling a worried patient “cheer up! Just keep the faith”. This communication
technique is an example of __________.
A. Using a cliché
B. A judgmental response
C. Changing the subject
D. Giving advice
95. The following forms of communication techniques are consider effective:
 ARETE REVIEW AND TUTORIAL CENTER
“EXCELLENCE BEYOND IMPOSSIBLE”
1. Giving advice 2. Using silence 3. Clarifying 4. Gentle touch 5. Asking probing question

SELECT ALL THAT APPLY.

A. 1 and 2 B. 3 and 5 C. 2, 3, 4 D. 1, 3, 5
96. Veronica yells at you saying: “they’re all trying to destroy me. You’re all part of it, aren’t you? “Which of the
following shall be your best response to Veronica?
A. “thinking people are out to destroy you must be very frightening”
B. “no, that not true, people here are trying to help you if you’ll let them”
C. “Everyone here is trying to help you. We don’t want to destroy you”
D. “That is absurd. The staff is well trained. No one is trying to destroy you”
97. When planning care for a delusional and paranoid client, it is important for the nurse to consider which of the
following client characteristic?
A. Suspiciousness
B. Euphoric feelings
C. Psychomotor retardation
D. Silly, inappropriate affect
98. Veronica has been placed in a room with a roommate. The night nurse reported that veronica has been awake
for the past three (3) nights. Which of the following is the MOST LIKELY explanation for her wakefulness?
Veronica is:
A. Worrying about his family problem
B. Watching for an opportunity to escape
C. Fearful of what her roommate might do to him while she sleeps
D. A light sleeper and unaccustomed to roommate
99. Veronica tells you about that she tasted poison in her oatmeal this morning at breakfast. She is experiencing
what type of hallucination?
A. Olfactory
B. Tactile
C. Kinesthetic
D. Gustatory
100. Veronica tells you that the hospital staff has poisoned the food, so she isn’t going to eat. Your BEST
nursing intervention in to:
A. Focus on Veronica fear and insecurity
B. Focus on the clients delusion
C. Challenge the clients delusion
D. Agree with veronicas decision