Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF NURSING
Nurse Licensure Examination
NURSING PRACTICE V – CARE OF CLIENTS WITH PHYSIOLOGIC AND
PSYCHOSOCIAL ALTERATIONS (PART C)
INSTRUCTION: Select the correct answer for each of the following
questions. Mark only one answer for each item by shading the box
corresponding to the letter of your choice on the answer sheet
provided.
STRICTLY NO ERASURES ALLOWED.

In an outpatient psychiatric unit, Nurse Bella is assigned to a cluster

of patients with personality disorders. The following questions pertain
to different presentations of personality disorders and its nursing
interventions.
1. Nurse Bella is assessing an outpatient client. As she suspects
narcissistic personality disorder, what are the clinical manifestations
and behaviors she expects that the client manifests?
1. Modesty
2. Apathy on other’s feelings
3. Necessitates constant emotional affirmation and nurturance
4. Conceited and pompous
5. Felonious conduct
6. Stringent behavior and actions
7. Extravagance and flamboyant
a. 1, 2, 4, 7
b. 3, 5, 6
c. 2, 4, 7
d. 4, 5, 6, 7
2. A newly-admitted client with histrionic personality disorder is being
assessed in the clinic by Nurse Bella. Which of the following is/are not
behavior/s manifested by a client with such disorder?
1. Provocative and deliberate
2. Stable emotional status
3. Grandiosity
4. Satisfaction is associated with group and social gatherings
5. Solitary and egoist
6. Tribute and compliment seeking-behavior
7. Panegyric on oneself
a. 4, 7
b. 2, 6, 7
c. 2, 3, 5
d. 1, 3, 5, 7

3. Nurse Bella is creating a plan of care for a client with schizoid

personality disorder. One of her interventions is a health teaching.
What is the most appropriate approach that should be used by Nurse Bella
to provide the client a conducive environment for learning?
a. Provide the teaching in a large-group setting to encourage
socialization among the client and other patients
b. Establish a therapeutic relationship with the client before providing
the education needed
c. Provide the education individually in a brief and succinct manner
d. Use a theoretical and comprehensive approach in educating the client

4. A client who is diagnosed with dissociative identity disorder came

into the psychiatric unit. During the admission what is priority goal
of the nurse in taking care of the client?
a. Calm the client and assist the client to forget the cause of stress
b. Limit self from discussing stress-producing events with the client
c. Meet the safety and security needs of the client
d. Reorient the client to the true identity
5. Rose is a 15-year old client diagnosed with obsessive-compulsive
disorder. During a group therapy, Nurse Bella observed that before the
activity starts the client cannot focus as she goes back and forth to
her room to check on her belongings. This behavior bothers other clients
engaging in the activity. What should be the initial action of Nurse
Bella?
a. Approach Rose and tell her to stop what she is doing as she bothers
other patients in the activity area.
b. Ignore the behavior of Rose as stopping her would cause anxiety and
ask the group to bear with Rose.
c. Let Rose finish her rituals and tell her to go back to the activity
area when she is ready to focus on the activity.
d. Talk to Rose in front of other clients and tell her to stop what she
is doing or else she will be punished.

Situation: Nurse Manzano, a registered nurse is assigned to a psychiatric

unit of a well-known hospital. His first patient, James, 19-year old is
diagnosed with major depression. The following questions apply to the
case of James.
6. James spends most of his time in bed facing the wall. Upon initiating
a conversation, Nurse Manzano observed that the patient pulled his sheet
over his head. What will be the most appropriate response of the nurse
to the client’s action?
a. “Fine, if you would not want to talk, I will just look over my other
patients”
b. “I’ll be back later, but if you need someone to talk to, I will be
available at the nurses’ station anytime”
c. “I will sit here with you for 15 minutes”
d. “I will sit outside your room, if you wish to talk, you could call
over anytime”

7. During assessment, Nurse Manzano observed the client using a treatment

of Kakawate leaves prescribed by a traditional healer from their
community. James explained that it is being used to prevent “bales” from
a complimentary greeting made by another patient earlier on that day.
What should be the best action of the nurse?
a. Negate the client’s belief and ask him to stop what he is doing.
b. Avoid talking about the traditional healer and ignore the client’s
behavior.
c. Explain to the client that such beliefs have no scientific basis and
that he needs to comply only with the treatment prescribed by the
physician.
d. Arrange a client consultation with the traditional healer, physician
and the nurse.

8. While sitting beside the client, James angrily asks the nurse, “Why
are you still here and wait for me to talk? Go and talk to someone else!”
What is the most appropriate response of the nurse to the client’s
remarks?
a. “I am interested in you and I wish to help you.”
b. “If that is what you wish, I will come back later when you already
feel better.”
c. “I am the nurse assigned to you and it is my duty to help you. I hope
you’ll let me.”
d. “Okay. I will now go.”

9. Annually, there is an estimated of 500,000 cases of suicide attempts

among teenagers globally. Upon assessment and interview with the client,
Nurse Manzano observed the presence of fresh cuts on both wrists. What
is the most appropriate action of the nurse?
a. Ignore the observation and continue with the assessment.
b. Explore the reason behind having the cuts and document the findings.
c. Appropriately document the observation.
d. Ask the client to stop hurting himself and never cut his wrists again.

10. During nurses' rounds, Nurse Manzano observed James lying on his
bed, facing the wall, rocking himself on fetal position while humming a
song. The nurse notes this behavior as:
a. Flat affect and apathy
b. Severe regression
c. A side effect of antidepressant
d. Autism
Situation: Nurse Gelo is assigned in the Psychiatry unit. In dealing
with several clients, therapeutic communication is a vital skill that a
nurse should possess. This includes the interpretation of both verbal
and nonverbal cues portrayed by the client and using theracomm as a
nursing intervention.
11. Jana, one of Nurse Gelo’s clients, reports having thoughts of being
followed by several dwarves to get him for his treasures. Given that
this shows the client’s disturbed thought process, which is the most
appropriate response by the nurse?
a. “It seems that these thoughts are frightening you.”
b. “You need to calm down, come with me, you better join the group
activity now.”
c. “I do not see any dwarves in here right now”
d. “Are you okay? Tell me more about it.”

12. During a one-on-one session, Clara, a newly admitted person, told

Nurse Gelo: “My calling is to eliminate all the provocative sluts in
this world. I will be able to protect my husband with that”. Knowing
that the unit has several attractive women in it, what should the nurse
do initially after he has heard this statement from the patient?
a. Organize a group meeting and tell all the female clients to dress
simple and less provocatively.
b. Ask the other female clients to avoid Clara for their safety.
c. Ask Clara to inform the staff if she has negative thoughts and feelings
toward other clients in the unit.
d. Tell Clara that if she hurts anyone in the group, she will be
restrained and kept in a separate room alone.

13. A client is observed to be talking alone, looking frightened, and

backing away from the window. He then signaled Nurse Gelo to run away
from the window. Which of the following reasons explain why doing as the
client requests is contraindicated?
a. The action will make the client feel complete control over the nurse.
b. This will give the client an idea that the action is a nonverbal
agreement to his false ideas.
c. The nurse will spoil the client by responding that way to his request.
d. The client might think that the nurse is making fun of him.
14. A female client is being admitted to the Psychiatry Emergency
Department at 2 o’clock in the morning. During the assessment, the client
is very depressed and showed a history of sleeping pills, non accidental
overdose, weight loss of 12 pounds in the past two weeks, sleeping 2
hours a night and poor hygiene. She then verbalized, “I will never be
good enough for everyone, they are all better off without me.” Which of
the following should be the initial reply of the nurse client’s
statement?
a. “Oh no. I see that you are a very great person and I think everyone
loves you!”
b. “What makes you think that way?”
c. “Are you thinking about hurting yourself?”
d. “What do you mean when you say you are not good enough?”

15. An old client who is diagnosed with paranoid schizophrenia is found

pacing back and forth in the hall. He then stopped and looked outside
the window and returned back to pacing even faster with a worrisome face.
What is the most appropriate statement for the nurse to make?
a. “I can see that you’ve been pacing and looking afraid. Can you tell
me how you feel?”
b. “Are you okay? I can tell something is wrong. Tell me something about
it.”
c. “Please stop pacing back and forth, you might be bothering other
clients.”
d. “Would you like to join the ball game in the court right now? Looks
like you have a lot of energy today.”

Situation: In the year 2013, Typhoon Haiyan, one of the strongest

typhoons in the Philippine history, hit the country. An approximate of
6,000 casualties was recorded and has caused unimaginable damages never
been seen before on almost one-third of the country.
16. In dealing with clients experiencing post-traumatic stress disorder,
which of the following approaches is inappropriate?
a. Statements of reassurance and simple reorientation to the client to
prevent ideas of self-mutilation and suicide
b. Establishment of a trusting relationship which conveys a sense of
respect and consistent empathic approach to help the client tolerate the
pain felt
c. Promote the client’s highest level of functioning and maintenance of
emotional and psychological dependence
d. Acceptance of the client’s reaction to the event and his ongoing
distress

17. The following are diagnostic criteria for PTSD. Which one is
incorrect?
a. Aloof and feeling numb
b. Daydreaming and imagery
c. Onset 6 months after the traumatic event
d. Presence of intrusive reenactment of the events in memories

18. During the rescue of victims in such disastrous events, some clients
remain silent and refuse to talk. In this case, it will be non-
therapeutic and ineffective if the nurse would:
a. Acknowledge that the reaction is normal and they are not to blame as
you understand them
b. Tell the client that they need to speak up immediately about how they
feel so that they can already feel better
c. Maintain regular contact with the victims, greet them and offer help
once in a while
d. Even if they did not talk, tell the victims that you are not angry
or upset

19. Red Cross is one of the rescuing organization who responded during
the Typhoon Haiyan. After the rescuing process, the organization
undergone a formal and routine evaluation of what went well and what
should be refined in the future processes in their emergency response.
This process provides overall meaning and a degree of closure to the
involved parties. This is called the:
a. Critical Incidence Stress Debriefing
b. Operational debriefing
c. Stress debriefing
d. Large-scale demobilization and informational briefings
20. Critical Incident Stress Debriefing (CISD) is a formalized,
structured method whereby a group of rescue and response workers reviews
the stressful experience of a disaster. It is used to assist first
responders such as policemen, firefighters and rescuers and not the
victims themselves. It was designed to be delivered in a group format
and meant to be incorporated into a larger, multi-component crisis
intervention system labeled Critical Incident Stress Management (CISM).
The following are components of CISM except:
a. Pre-crisis intervention
b. disaster or large-scale demobilization and informational briefings
(town meetings)
c. Crisis Incident Stress Debriefing
d. Stress debriefing

Situation: As a new nurse in the Psychiatric Unit, Nurse Jane is expected

to familiarize herself to different psychiatric drugs as part of
functional nursing. This includes their indications, common side effects
and nursing interventions.
21. A 65-year old male diagnosed with anxiety disorder is prescribed
Lorazepam. With the laboratory findings, it was shown that the client
has a 3:1 AST/ALT ratio and granulocyte count of > 2,500. Which of the
following actions needs an immediate intervention by the nurse?
a. Keeping Flumazenil at the bedside
b. Abruptly stopping the anxiolytic
c. Going to malls and other crowded places
d. Letting the wife drive for the client

22. A 70-year old female client diagnosed with Alzheimer’s disease

suffers from sun downing syndrome. Which of the following drugs should
does the nurse anticipate to be given in such condition?
a. Oxazepam
b. Bromocriptine
c. Fluoxamine
d. Amitryptylline
23. A client with depression being given Luvox (Fluoxamine) has recently
suffered from a serotonin crisis and a need to change the current
antidepressant was deemed necessary by the attending physician. Which
of the following drugs will be anticipated to be given to the client?
a. Paxil
b. Zoloft
c. Elavil
d. Marplan

24. Which of the following actions, if done by the nurse, requires

immediate correction in administering Chlorpromazine (Thorazine) 300mg
QID to a client diagnosed with Schizophrenia?
a. Continuous monitoring of complete blood count (CBC)
b. Keeping a standing prescription of Cogentin 1mg
c. Administering the drug post prandial
d. Giving the drug on empty stomach

25. A client with pseudo parkinsonism secondary to the long term use of
typical antipsychotics is receiving a dopaminergic drug. Upon
assessment, Nurse Jane observed that the client has constant hyperthermia
not corrected by antipyretics and increased vital signs. Which of the
following actions if done by Nurse Jane should be questioned by the nurse
supervisor?
a. Providing tepid sponge bath to the client
b. Increasing client’s oral fluid intake
c. Administration of Dantrolene
d. Immersing the client to a cold tub

Situation: Parkinson’s disease is a progressive neurologic movement

disorder with an unknown etiology. Different studies have shown several
causative factors such as genetics, atherosclerosis, excessive free
radicals accumulation in the body, viral infections, head trauma, long-
term use of antipsychotic medications and some external factors. This
disease eventually leads to disability.
26. All but one characterizes Parkinson’s disease as a progressive
neurologic disorder. Parkinson’s disease, a progressive neurologic
disorder is characterized by:
A. Bradykinesia
B. Tremors
C. None of the above
D. Muscle rigidity

27. This known treatment for Parkinson’s disease is an antiviral agent

which releases dopamine from the neuronal storage sites.
A. Artane
B. Symmetrel
C. Benadryl
D. Sinemet

28. The nurse evaluates the effect of the administered Cogentin 1mg p.o.
as effective if she observes which of the following. Which finding
suggests its desired side effect?
A. Decreased muscle tremors
B. Decreased muscle rigidity
C. Decreased confusion and anxiety
D. Increased endurance and energy

29. The client reports that his resting tremors causes frustration in
his activities of daily living. Which of the following advice would the
nurse give the client?
A. Grasp an object
B. Immerse self into a warm tub
C. Take diazepam as deemed necessary
D. Provide cold compress to the hands
30. A patient with Parkinson’s disease has a nursing diagnosis of
Impaired Physical Mobility related to neuromuscular impairment. You
observe a nursing assistant performing all of these actions. For which
action must you intervene?
A. The NA performs the client’s complete bed bath and oral care
B. The NA assists the patient in ambulating back and forth the hallway
as his daily physical activity
C. The NA reminds the patient to avoid looking at his feet when he is
walking.
D. The NA sets up the patient’s food tray at the bedside and encourages
patient to feed himself

Situation: Nurse Danj is assigned to the emergency department. Triage

and first aid are expected competencies in this area to maximize the
utilization of resources. The following questions apply.
31. Nurse Danj is assessing a client who has sustained a cat bite to the
hand. The cat’s immunizations are up to date. The date of the client’s
last tetanus shot is unknown. Which is the priority nursing diagnosis
for the client?
a. Risk for infection related to organisms specific to cat bites
b. Impaired skin integrity related to puncture wounds
c. Ineffective health maintenance related to immunization status
d. Risk for impaired physical mobility related to potential tendon damage

32. The following clients come to the ED reporting acute abdominal pain.
Prioritize them for care in order of the severity of their conditions.
i. 35 year old man reporting severe intermittent cramps with three
episodes of watery diarrhea 2 hours after eating
ii. 11 year old boy with low grade fever, right lower quadrant
tenderness, nausea, and anorexia for the past 2 days
iii. 40 year old woman with moderate right upper quadrant pain who has
vomited small amounts of yellow bile and whose symptoms have worsened
over the past week
iv. 65 year old man with pulsating abdominal mass and sudden onset of
tearing pain in the abdomen and flank within the past hour
v. 23 year old woman reporting dizziness and severe left lower quadrant
pain who states she is possibly pregnant
vi. 50 year old woman who reports gnawing midepigastric pain that is
worse between meals and during the night
a. iv, v, iii, ii, i, vi
b. iv, v, ii, i, iii, vi
c. iv, v, ii, iii, i, vi
d. iv, v, ii, iii, vi, i

33. Nurse Danj is caring for a client with multiple injuries sustained
during a head on car collision. Which assessment finding takes priority?
a. A deviated trachea
b. Unequal pupils
c. Ecchymosis in the flank area
d. Irregular apical pulse

34. A client involved in a one-care rollover comes in with multiple

injuries. List in order of priority the interventions that must be
initiated for this client.
i. Secure two large bore IV lines and infuse normal saline
ii. Use the chin lift or jaw thrust maneuver to open airway
iii. Assess for spontaneous respirations
iv. Give supplemental oxygen via mask
v. Obtain a full set of VS
vi. Remove the client’s clothing
vii. Insert foley catheter if not contraindicated
a. iii, ii, iv, v, i, vi, vii
b. iii, ii, iv, i, v, vi, vii
c. vi, iii, ii, iv, i, v, vii
d. vi, iii, ii, iv, v, i, vii
35. Nurse Danj was about to end his shift when six injured clients have
arrived at the hospital from a fire in a local church. Using disaster
triage principles, place the following six clients in the order in which
they should receive medical attention.
i. 52 year old man in full cardiac arrest who has been receiving CPR
continuously for the past 60 minutes
ii. Firefighter who is showing combative behaviour and has respiratory
stridor
iii. 60 year old woman with full thickness burns to the hands and forearms
iv. Teenager with a crushed leg that is very swollen who is anxious and
has tachycardia
v. 3 year old child with respiratory distress and burns over more than
70% of the anterior body vi. 12 year old with wheezing and very labored
respirations unrelieved by an asthma inhaler
a. ii, vi, iii, iv, v, i
b. ii, vi, iii, iv, v, i
c. vi, ii, iv, v, iii, i
d. vi, ii, iv, iii, v, i

Situation: Angelica is a 45-year old female client who is recently

diagnosed with schizophrenia is assigned to Nurse Bryan. The following
questions apply to schizophrenia.
36. Nurse Bryan is assigned to educate a newly-hired nurse in the
psychiatric unit about schizophrenia. In discussing the dopamine
hypothesis of psychosis, Nurse Bryan is correct when he says:
a. Decreased level of circulating dopamine in the system causes
hallucinations and delusions
b. Excessive amounts of dopamine in the body is caused by the abnormal
excretion of the kidneys which causes the positive symptoms of psychosis
c. The structural brain abnormalities is caused by the abnormally low
levels of dopamine which cause positive symptoms of psychosis
d. There is an abnormally high level of dopamine in the synaptic clefts
of the brain
37. Delusion is one of the positive symptoms associated with
schizophrenia. Which of the following interventions should the nurse
include in a client with delusions? Select all that apply.
1. Provide recreation with the use of animals (pet therapy)
2. Avoid touching the client without permission
3. Decrease environmental stimulation of the client as well as activity
involvement
4. Refrain self from whispering and laughing in front of the client
5. Constantly orient the client to date, time, place and person
6. Engage client to a cognitively-motivating activity
7. Avoid sending nonverbal cues which can be interpreted as an agreement
to false ideas
a) 1, 2, 4, 5, 7
b) 2, 3, 5, 7
c) 2, 4, 5, 7
d) 1, 3, 4, 5, 7

38. An actively psychotic, agitated and disoriented client came pacing

in the hallway screaming as if he is about to punch another client. When
the nurse saw this, which of the following actions is unacceptable and
will require an intervention?
a) Approach the agitated client and reorient him to reality
b) Approach the client and try to talk him down, and if not effective,
immediately call for assistance in physically restraining the patient
c) Reorient the client, if not effective, put a physical restraint before
the administration of a prescribed chemical restraint
d) Talk to the client and reorient him to reality. If not effective,
administer the prescribed tranquilizer and put him on physical restraint.

39. The long-term use of major tranquilizers may cause extrapyramidal

symptoms as side effect. The following statements are true about acute
dystonia except:
a) Includes laryngospasm is a life-threatening effect and should be a
priority
b) Manifests 1-5 days after the start of the treatment
c) With involuntary extraocular muscle movements
d) Takes for about at least eight months before it manifests

40. Which of the following is not true about Prolixin (Fluphenazine)?

a) A parenteral medication with 2-4 weeks duration of effect
b) Best absorbed in an acidic environment
c) May cause dermatitis
d) Considered as a major tranquilizer

Situation: Nurse Alice is currently conducting a research study as a

requirement in her Master’s degree. She wants to determine the
intellectual quotient of Down’s syndrome residents of Ms. Peregrine’s
Home for Special Children.
41. After identifying the research problem, Nurse Alice should?
a. Establish the blueprint of the research study.
b. Review relevant literature and studies.
c. Determine the appropriate tool for data collection.
d. Identify the appropriate sample size.

42. This research of Nurse Alice can be classified as:

a. Applied
b. Pure
c. Action
d. Methodological

43. What is the independent variable in this study?

a. IQ level
b. Resident with Down’s syndrome
c. Down’s syndrome
d. Special Children of Ms. Peregrine’s Home
44. The sampling technique that may be used in the study to identify the
subjects among the residents of Ms. Peregrine’s Home for Special Children
with Down’s syndrome is:
a. Convenience
b. Simple
c. Purposive
d. Snowball

45. Nurse Alice’s research would like to accomplish what purpose?

a. To develop a learning module for IQ improvement
b. To establish an activity that would improve the behaviour of the
clients
c. To serve as a reference for planning program development for Down’s
syndrome clients
d. To compare the IQ of Down’s syndrome clients with those having other
syndrome

Situation: Julius, a nurse researcher, is conducting a study on the

differences between the skill performance of emergency room nurses from
private and government-based hospitals in Metro Manila. He wanted to
have all the ER nurses from the randomly selected hospitals.
46. The most appropriate sampling technique that he may use for his study
to achieve the required sample is:
a. Purposive Sampling Technique
b. Cluster Sampling Technique
c. Incidental Sampling Technique
d. Simple Random Sampling Technique

47. One of the factors that may affect Julius’ study is the education
and competency enhancement of the ER nurses, which may not be prevented
during the process of the research. This is further known as:
a. Effector variable
b. Criterion variable
c. Extraneous variable
d. Moderator variable

48. Which of the following is the antecedent variable for Jason’s study?
a. Type of hospital
b. Metro Manila
c. Skill performance
d. ER nurses

49. On the other hand, the resultant variable in the study is:
a. Metro Manila
b. Skill performance
c. Type of hospital
d. ER nurses

50. Suppose Julius had rejected the null hypothesis in his study when
it is actually true, he committed?
a. Type II error
b. Sampling bias
c. Systematic error
d. Type I error

Situation: Nurse Mike is assigned to Jinkee who is a 17-year old

diagnosed with major depression for 3 years and who is on her lucid
state. She is currently residing with her partner and their 6-month
child. Aside from taking anti-depressants, her physician plans her to
undergo electroconvulsive therapy. These questions apply to ECT and
antidepressants.
51. The nurse should be knowledgeable about electroconvulsive therapy
to be able to provide safety for the client. Which of the following is
true about ECT?
a) ECT is considered as an invasive procedure which needs client consent
b) It induces grand mal seizures which lasts for 60-75 sec
c) 75-150 volts of electricity is used in the therapy which lasts for
0.5-2 sec
d) The mode of action of ECT in depression is unknown

52. Prior to the client’s electroconvulsive therapy, the nurse is one

of the vital people in the preparation for the said therapy. Which of
the following if done by the nurse would indicate a need for immediate
intervention by the supervisor?
a) Keeping the client nothing per orem for 6-8 hours
b) Preparing equipment for IV line insertion post therapy
c) Assisting the client in voiding before the procedure
d) Assesses the client for signs and symptoms of increased IOP

53. In using electroconvulsive therapy, consent is one of the

requirements before the initiation of the therapy. Given the demographic
of the client, which of the following statement is true regarding
consenting in ECT?
a) Since the client has a psychological condition, her next of kin shall
always be the one to sign the consent for the therapy
b) Since the client is considered as an adolescent minor, the next of
kin should seek for the client’s assent first before signing the consent
c) The client is considered an emancipated minor and can sign her own
consent
d) Since the client is emancipated, the next of kin shall never sign the
consent for the client

54. Extended time of induced grand mal seizures of a client during

electroconvulsive therapy may pose a threat on her acid-base balance.
In such situation, which of the following drugs shall be anticipated by
the nurse to be given to the patient post-procedure?
a) Sodium bicarbonate
b) Phentolamine
c) Barbiturates
d) Magnesium sulfate
55. The client is currently taking tranylcypromine (Parnate) after an
unsuccessful treatment with amitriptyline (Elavil). Which statement if
said by the client indicates need further teaching on the side effects
of Parnate?
a) “I could engage to different physical activities as I would want to.”
b) “It is alright for me to drink wine and eat aged cheese.”
c) “I can take the medication before meal time.”
d) “I should consult my physician if I experience sudden sensitivity to
light and headache.”

Situation: Substance abuse is one cause of different psychological

disorders. A competent nurse should be knowledgeable about the different
effects of various substances in the body.
56. A client who drinks a large amount of alcohol daily for the past 2
years was rushed into the Psychiatric ED. He abruptly stopped his alcohol
intake at 1300. As a competent nurse who has the knowledge on substance
abuse, when should the nurse begin assessing for the clinical
manifestations of alcohol withdrawal?
a) 2100 to 2500
b) 1600 to 0000
c) 2000 to 0300
d) 1400 to 2000

57. Which of the following should be included in the plan of care of a

client with Morphine sulfate withdrawal?
a) Administration of phenytoin
b) Fluid restriction to 1500mL/ day
c) Administration of clonidine
d) Decreased external stimuli
58. A 23-year old male client who was rushed in the ED is suspected of
cannabis intoxication. Which of the following are the manifestations of
such condition? Select all that apply.
1. Elation
2. Xerostomia
3. Excessive hunger
4. Anorexia
5. Bradycardia
6. Drowsiness
7. Delayed time of sensation
a) 2, 3, 5, 7
b) 1, 2, 4, 7
c) 1, 2, 3, 7
d) 2, 5, 6, 7

59. A nurse is being asked by a group of student nurses about a life-

threatening complication of cocaine intoxication. Which of the following
is the correct answer?
a) Cardiac arrhythmias
b) Laryngospasms
c) Hypothermia
d) Increased CVP

60. A client who is experiencing cocaine intoxication is having

tachycardia, hyperthermia, chest pain, palpitation and is unable to talk.
The nurse should prioritize which of the following actions?
a) Provide the client an education about medical complication of cocaine
intoxication
b) Provide oxygen via face mask
c) Establish airway patency
d) Position client on Trendelenburg
Situation: Anna is received by Nurse Gina in the school clinic
complaining of nausea. As she assists the client to the clinic bed, she
noticed a number of bruises on her arms. Anna eventually vomits and
soiled her uniform. When Nurse Gina removes Anna’s blouse, more bruises
were observed on her torso with small scars on her abdomen. The nurse
also observed the client’s abdomen is protruding on her small and thin
frame.
61. Nurse Gina is aware that any type of abuse is currently on the rise
in the society. One of the most common type of abuse is rape. The nurse
knows that the most likely reason for that kind of abuse is due to:
a) The aggressor has no sexual relations for a long time
b) That rape is induced by poverty and economic deprivation
c) By sexual aggression, the aggressor is able to express his power and
dominance
d) Rape is usually caused by too much alcohol intake and incontrollable
behavior

62. During the admission of the client in the school clinic, Anna refuses
to talk about her bruises. To be able to obtain the needed information
about the client, Nurse Gina could safely implement which of the
following interventions?
a) Milieu therapy
b) Family therapy
c) Aversion therapy
d) Play therapy

63. Based on the physical assessment done by Nurse Gina, she would
suspect that Jill might be experiencing:
a) Physical abuse and neglect
b) Physical and sexual abuse
c) Emotional and physical abuse
d) Sexual abuse and neglect
64. When the nurse suspects that the client is a victim of domestic
violence, the nurse should be knowledgeable that there is an increased
risk for violence when:
a) They seek for law enforcement interventions
b) They start fighting against their aggressor
c) They plan to remove themselves from the abusive environment
d) They first experience a violent attack

65. An agitated client who was recently raped was admitted in the
Psychiatric ED. During assessment, the client reported that she has
witnessed her best friend being murdered after getting raped and lost
her sight after then. The client is experiencing:
a) Conversion
b) Suppression
c) Panic
d) Anxiety

SITUATION: Bipolar mood disorder consists of different subtypes. The

following questions are about bipolar disorder, its manifestations and
nursing interventions associated to it.
66. Kat, a 23-year client diagnosed with Bipolar Type I is in a manic
state. Nurse Genie knows that all but one should be included in her plan
of care for Kat.
a) Provide a puzzle-building activity to the client
b) Decrease environmental stimuli
c) Offer finger foods such as biscuits and drop cookies
d) Use a firm and consistent approach with the client

67. Nurse Jojie is currently taking care of a client diagnosed with

Bipolar Type I and is taking lithium as a mood stabilizer. Which of the
following if stated by the client indicates a need for further teaching?
a) ”I shall avoid engaging into strenuous activities.”
b) “If I experience that my hands are shaking, I need to consult my
doctor immediately.”
c) “I shall restrict my fluid intake from 2L/day to 1L/day.”
d) “If I miss my dose due at 6am and the next dose is already within 6
hours before the next dose, I should already skip the missed dose and
resume to the usual schedule.”

68. Clara, who has a due lithium medication was found to have a serum
lithium level of 1.3 meq/L done a 2 hours before the due time. Upon
knowing this, what shall be the initial action of the nurse?
a) Administer the prescribed dose
b) Hold the due medication and refer to the client’s physician
c) Do another blood extraction to the client to verify the findings
d) Hold the medication and document the findings

69. Based on the assessment finding of the psychiatrist, a recently

confined client had at least one major depressive episode which was
accompanied by at least one episode of hypomania. The nurse knows that
this is what subtype of Bipolar Disorder?
a) Bipolar Type II
b) Mixed-type Bipolar
c) Bipolar Type II
d) Dysthymia

70. A female client on a manic state with sexual preoccupations suddenly

approaches the nurse and tries to kiss him while screaming, “I want you
to be my boyfriend!” What is the most appropriate response of the nurse
to the client?
a) “Stop what you are doing! This is embarrassing.”
b) “I am your nurse and you are my client. This is an inappropriate and
uncomfortable act.”
c) “Okay. Tell me more about how you feel.”
d) “Can you please elaborate how you are feeling right now?”

71. An 18 year old patient with exacerbation of SLE has been receiving
prednisone 20mg daily for 4 days. Which medical order should you
question?
a. Discontinue prednisone after today’s dose
b. Give a catchup dose of varicella vaccine
c. Check the patient’s C reactive protein level
d. Administer ibuprofen 800mg PO

72. The same patient was checked for evaluation and management of acute
joint inflammation. Which information obtained in the admission
laboratory testing concerns you the most?
a. Elevated BUN level
b. Increased CRP level
c. Positive ANA test
d. Positive Lupus erythematosus cell preparation

73. A patient who is HIV positive is taking nucleoside reverse

transcriptase inhibitors and a protease inhibitor is admitted to the
psychiatric unit with a panic attack. Which information about the patient
is most important to discuss with the health care provider?
a. The patient states “I’m afraid I’m going to die right here”
b. The patient has an order for midazolam (Versed) 2mg IV
c. The patient is diaphoretic and tremulous and reports dizziness
d. The patient’s symptoms occurred suddenly while she was driving to
work

74. A patient seen in the sexually transmitted disease clinic has been
tested positive for HIV with rapid HIV test. Which action would you take
next?
a. Ask about patient risk factor for HIV infection
b. Send a blood specimen for western blot testing
c. Provide information about retroviral therapy
d. Discuss the positive test results with the patient
75. Nurse Lianmuel is also the hospital employee health nurse and is
completing a health history for a newly hired staff member. Which
information given by the new employee most indicates for further nursing
action before he or she begins orientation to patient care?
a. The employee takes enalpril for hypertension
b. The employee has an allergy to bananas, avocados, and papayas
c. The employee received a tetanus vaccination 3 years ago
d. TB skin test has a 5mm induration at 48 hours

Situation: Nurse Vera cares for different patients with elimination

problems. The following questions apply.
76. Trina, 25yo, is admitted due to pseudomembranous colitis secondary
to C. difficile infection. As she completes the patient’s history, which
among the following drugs does she expect to have been chronically taken
by the patient?
a. Ceftriaxone
b. Penicillin
c. Ofloxacin
d. Cefazolin

77. Nurse Vera is planning her health teaching for a patient regarding
healthy defecation. Which among the following instructions should she
omit from her teaching plan?
a. Maintain fluid intake of 1000mL daily
b. Avoid chronic use of laxatives to treat constipation.
c. Defecate as soon as the urge is felt.
d. Increase intake of fruits and vegetables in the diet.

78. A diabetic patient complains of excessive gas formation. Intake of

which among the following will only contribute to the patient’s
flatulence?
i. Acarbose
ii. Onions
iii. Egg
iv. Yogurt
v. Cauliflower
vi. Magnesium salts
a. II, III, IV, V
b. I, III, V, VI
c. I, II, V
d. II, V

79. Which among the following enema solutions have the longest time
before onset of action?
a. Sodium phosphate
b. Normal saline
c. Tap water
d. Olive oil

80. Which among the following nasogastric tubes will Nurse Vera not use
for gastric decompression?
a. Salen sump
b. Sengstaken Blakemore
c. Levin
d. A & C only

Situation: Pain is a purely subjective assessment that is one of the

most common reasons for consult.
81. Which among the following is the pathway that conducts pain stimuli
to the brain?
a. Lateral spinothalamic pathway
b. Spinocerebellar pathway
c. Dorsal column medial lemniscus pathway
d. Anterior spinothalamic pathway
82. Which among the following statements about pain is true?
a. All chronic pain is psychological in nature.
b. Administering analgesics regularly leads to drug addiction.
c. Psychogenic pain is real.
d. All of the above.

83. Which among the following scales can an ICU nurse use in assessing
pain in mechanically-ventilated patients?
a. Behavioral pain scale
b. Oucher Pain scale
c. Wong-Baker FACES scale
d. Visual analog scale

84. Paracetamol is prescribed to a patient for his acute pain. What is

the maximum daily dose of paracetamol?
a. 1000 mg
b. 2400 mg
c. 4 g
d. 6 g

85. A patient on patient-controlled analgesia verbalizes worsening pain

despite the treatment. You suspect that the patient is undermedicated.
Which among the following will be your best nursing action?
a. Push the PCA button twice to release additional doses of the
analgesic.
b. Discontinue PCA& administer morphine IV.
c. Increase the dose of the analgesia through the PCA system.
d. Inspect the IV site for possible infiltration.
Situation: Clients with bipolar disorder receives a very high nursing
attention due to the increasing rate of suicide related to the illness.
86. The nurse is assigned to care for a recently admitted client who has
attempted suicide. What should the nurse do?
A. Search the client’s belongings and room carefully for items that could
be used to commit suicide
B. Express trust that the client won’t cause self-harm while in the
facility
C. Respect the client’s belongings and ask if she has objects that she
may use to commit suicide
D. Remind all the staff members to check on the client frequently

87. In planning activities for the depressed client, especially during

the early stages of hospitalization, which of the following plans is
best?
A. Provide activities that are quiet and solitary to avoid increasing
fatigue such as working on a puzzle and reading a book
B. Plan nothing until the client asks to participate in the Milieu
C. Offer the client a menu of daily program of activities and encourage
the client to participate
D. Provide a structured daily program of activities and encourage the
client to participate

88. A client with a diagnosis of major depression, recurrent with

psychotic features, is admitted to the mental health unit. To create a
safe environment for the client, the nurse most importantly devices a
plan of care that deals especially with the client’s:
A. Disturbed thought process
B. Self-care deficit
C. Imbalanced nutrition
D. Deficient knowledge

89. A client is taking a Tricyclic antidepressant. Which of the following

is an example of TCA?
A. Paxil
B. Zoloft
C. Nardil
D. Pamelor

90. A client visits the physician’s office to seek treatment for

depression, feelings of hopelessness, poor appetite, insomnia, fatigue,
low self-esteem, poor concentration, and difficulty making decisions.
The client states that these symptoms began at least 2 years ago. Based
on this report, the nurse suspects:
A. Cyclothymic disorder
B. Major depression
C. Bipolar disorder
D. Dysthymic disorder

91. The nurse is planning activities for a client who has bipolar
disorder, with aggressive social behavior. Which of the following
activities would be most appropriate for the client?
A. Ping pong
B. Linen delivery
C. Chess
D. Basketball

92. The nurse assesses a client with admitted diagnosis of bipolar

affected disorder, mania. The symptom presented which requires the
nurse’s immediate intervention is the client’s:
A. Outlandish behavior and inappropriate dress
B. Grandiose delusion of being a royal descendant of King Arthur
C. Nonstop physical activity and poor nutritional intake
D. Constant, incessant talking that includes sexual topics and teasing

93. A nurse is conducting a group therapy. During the session, a client

with mania constantly talks and dominates the group. The behavior is
disrupting the group interaction. The nurse would initially:
A. Ask the client to leave the group session
B. Tell the client that she will no longer be allowed to attend group
sessions
C. Tell the client that she needs to allow other clients in the group
to talk
D. Ask another nurse to escort the client out of the group session

94. A professional artist is admitted to the psychiatric unit for

treatment of bipolar disorder. During the last two weeks, the client has
created 160 paintings, slept only 2 to 3 hours every 2 days and lost 18
lbs (8.2 kg.) Based on Maslow’s hierarchy of needs, what should the nurse
provide this client first?
A. The opportunity to explore family dynamics
B. Help with reestablishing a normal sleep pattern
C. Experiences that build self-esteem
D. Art materials and equipments

95. The physician orders Lithium carbonate (Lithonate) for a client who’s
in the manic phase of bipolar disorder. During lithium therapy, the nurse
should watch for which adverse reactions?
A. Anxiety, restlessness, and sleep disturbances
B. Nausea, diarrhea, tremor, and lethargy
C. Constipation, lethargy, and ataxia
D. Weakness, tremor, and urine retention Situation: Lovi has a morbid
fear of heights. She asks the nurse what desensitization therapy is.

96. The accurate information of the nurse of the goal of desensitization

is:
A. To help the client relax and progressively work up a list of anxiety
provoking situation through images
B. To provide corrective emotional experiences through a one-on-one
intensive relationship
C. To help clients in a group therapy setting to take on specific roles
and reenact in front of an audience situations in which interpersonal
conflict is involved
D. To help cope with their problems by learning behaviors that are more
functional and be better equipped to face reality an make decisions
97. It is essential in desensitization for the patient to:
A. Have rapport with the therapist
B. Use deep breathing or any relaxation technique
C. Assess one’s self for the need of an anxiolytic drug
D. Work through unresolved unconscious conflicts

98. In this level of anxiety, cognitive capacity diminishes, focus

becomes limited, and client experiences tunnel vision. Physical signs
of anxiety become more pronounced.
A. Severe anxiety
B. Panic
C. Mild anxiety
D. Moderate anxiety

99. Anti-anxiety medications should be used with extreme caution. Long

term use can lead to:
A. Parkinsonian-like symptoms
B. Hypertensive crisis
C. Hepatic failure
D. Risk of addiction

100. The nursing management of anxiety related with post traumatic stress
disorder includes all of the following except:
A. Encourage participation in recreation or sports activities
B. Reassure client’s safety while touching client
C. Speak in a calm, soothing voice
D. Remain with the client while fear level is high
 KEY TO CORRECTION
1. C 21. C 41. B 61. C 81. A
2. C 22. A 42. B 62. D 82. C
3. C 23. C 43. C 63. A 83. A
4. C 24. C 44. C 64. C 84. C
5. C 25. D 45. 65. A 85. D
6. C 26. C 46. B 66. A 86. A
7. D 27. B 47. C 67. C 87. D
8. A 28. B 48. A 68. A 88. A
9. B 29. A 49. B 69. C 89. D
10. B 30. A 50. D 70. B 90. D
11. A 31. A 51. B 71. B 91. B
12. C 32. C 52. B 72. A 92. C
13. B 33. A 53. C 73. B 93. C
14. C 34. B 54. A 74. D 94. B
15. A 35. D 55. B 75. B 95. B
16. C 36. 56. A 76. C 96. D
17. C 37. C 57. C 77. A 97. A
18. B 38. D 58. C 78. C 98. B
19. B 39. D 59. A 79. D 99. D
20. D 40. B 60. C 80. B 100. B