‭NP3‬ ‭D. Inform her daughter about the fall risks.

‭ ituation:‬‭Izzie Stevens has been admitted in the‬‭cancer‬

S ‭ ituation:‬‭An essential component of a nursing care‬‭plan‬
S
‭center.‬ ‭is documentation. It entails recording the nurses'‬
‭assessment, nursing diagnosis, planning, interventions,‬
‭ . Izzie is for possible radiation therapy. Which of the‬
1 ‭and evaluation. You have a surgical assignment, and‬
‭following is‬‭not included‬‭as a radiation precaution‬‭to be‬ ‭there are patients who need your care after surgery.‬
‭observed?‬
‭ . Upon carrying a doctor's order, you have noticed that‬
6
‭ . Assigns a rotating health care provider to the patient.‬
A ‭you forgot to chart the medication given to one client.‬
‭B. Wash gloves before removing and place in a‬ ‭What priority nursing action would you perform?‬
‭designated container.‬
‭C. Wash hands with soap and water after removing the‬ ‭ . Report the oversight you committed and write time‬
A
‭gloves.‬ ‭order to nurse supervisor.‬
‭D. Assign a permanent health care provider to the‬ ‭B. Insert information into your earlier charting and write‬
‭patient. → RISKY‬ ‭late entry.‬
‭C. Document the information and label late entry and‬
‭ . The nurse formulated a nursing diagnosis for Izzie‬
2 ‭write time.‬
‭which was risk for impaired skin integrity with‬ ‭D. Chart in kardex and first relay to the incoming shift.‬
‭erythematous and desquamation‬‭reactions to radiation‬
‭therapy. Which nursing action is‬‭not recommended‬‭?‬ ‭ . Nurse Amelia started documenting the nursing‬
7
‭interventions she has done on her shift. According to the‬
‭ . Wash the affected area with lukewarm water.‬
A ‭documentation standards, which of the following is‬‭not‬
‭B. Wash the affected area with cold water.‬ ‭acceptable‬‭?‬
‭C. Apply Vitamin A and D ointment to the erythematous‬
‭area.‬ ‭ . “Ms. Shen‬‭appears‬‭dyspneic and drowsy.” →‬
A
‭D. Advise the patient to wear cotton clothing.‬ ‭OPINIONATED → ASSUMED ✖️ ‬
‭B. “The IV fluid is running based on doctor’s order.”‬
‭ . Nurse Olivia performs her daily assessment for signs of‬
3 ‭C. Dr. Park was informed at 6:00 AM regarding the blood‬
‭infection in her patient, who is on IV therapy. Which of the‬ ‭pressure of Ms. Shen which 80/60.‬
‭following interventions would help in‬‭preventing‬ ‭D. Ms. Shen said “she wants to go home at 11 o’clock in‬
‭nosocomial staphylococcal septicemia‬‭from occurring?‬ ‭the evening without doctor’s order.”‬

‭ . Cleanse skin with‬‭povidone iodine‬‭before venipuncture.‬

A ‭ . Lex, who was assigned to the night shift, has‬
8
‭→‬‭70% ALCOHOL‬ ‭completed her documentation of her five assigned‬
‭B. Change central venous catheter dressings every‬‭4‬ ‭patients. She now prepares to give her intershift report.‬
‭hours‬‭. →‬‭2 DAYS‬ ‭Which of the following data should be included?‬
‭C. Change all solutions and infusion sets every 3-4‬
‭days.‬ ‭ . Client’s profile‬
1
‭D. Change peripheral short-term IV sites‬‭every other‬‭day‬‭.‬ ‭2. Nursing assessment during the shift‬
‭→‬‭72-96 HRS‬ ‭3. Response to medications‬
‭4. Laboratory studies and results‬
‭ . Nurse Olivia was receiving an endorsement from the‬
4
‭evening shift when she noticed a black smoke coming out‬ ‭ . 1, 2, 3 and 4‬
A
‭of Mr. Duquette's room. Which of the following actions in‬ ‭B. 1 only‬
‭the fire safety guidelines should Nurse Olivia‬‭first‬ ‭C. 2 and 3‬
‭implement‬‭in response to the situation?‬ ‭D. 3 and 4‬

‭ . Pull the nearest alarm and/or call emergency numbers‬

A ‭ . Cristina was assigned to the cardiovascular unit, where‬
9
‭B. Rescue, protect and evacuate patient away from‬ ‭many clients are receiving therapy. She has finished all‬
‭the fire.‬ ‭the nursing interventions and is preparing to record the‬
‭C. Extinguish the fire using appropriate extinguisher.‬ ‭data on the chart. Which of the following data should be‬
‭D. Close all doors and windows to contain the fire‬ ‭included?‬

‭ ituation:‬‭Ms. Grey, a widowed 68-year-old, was sent‬‭to‬

S ‭ . Name of the fluid ordered.‬
1
‭the hospital with a complaint of a severe headache and‬ ‭2. Time the fluid was inserted and ended‬
‭easy fatiguability. Her history of hypertension dates back‬ ‭3. Who administered the fluid‬
‭to the age of 45. Two hours prior to admission, the patient‬ ‭4. Drops per minute required for the patient‬
‭tripped and fell in the restroom, according to information‬
‭provided by her daughter.‬ ‭ . 3, 4 and 5‬
A
‭B. 2, 3 and 5‬
‭ . When a client has a history of falls, Nurse April should‬
5 ‭C. 1 and 2‬
‭take what nursing action FIRST?‬ ‭D. 1, 2, 3 and 4‬

‭ . Complete a fall risk assessment.‬

A ‭ 0. Mr. Webber says to Nurse Jan, “I can’t believe that‬
1
‭B. Inspect the patient’s room‬ ‭God is doing this.” Which of the following should be Nurse‬
‭C. Conduct a focus assessment.‬ ‭Jan’s response?‬
‭ . “Is that a Bible you are reading?”‬
A ‭ 5. To prevent her from contracting nosocomial infection,‬
1
‭B. “It sounds that you are upset.”‬ ‭Nurse Grace would place her on _______________?‬
‭C. “Would you wish to speak more to me or a chaplain‬
‭about our spiritual concerns?”‬ ‭ . Together with normal OB patients‬
A
‭D. Listen attentively and respectively to Mr. Webber‬ ‭B. On reverse isolation‬
‭C. On isolation‬
‭ 1. Nurse Nicole knows that spiritual care is needed‬
1 ‭D. In a general non-infectious ward‬
‭because ___________.‬
‭ 6. Nurse Grace should instruct Mary that while in the‬
1
‭ . it is associated with patient coping‬
1 ‭hospital that she should wear __________.‬
‭2. patient wants it‬
‭3. it affects their decision making‬ ‭ . Mask‬
A
‭4. it is associated with clinical outcome‬ ‭B. Gloves‬
‭C. Foot wear‬
‭ . 2 only‬
A ‭D. Apron‬
‭B. 1 and 4‬
‭C. 1, 3, and 4‬ ‭ 7. What should Nurse Grace emphasize to the family‬
1
‭D. 1, 2, 3, and 4‬ ‭members as a top priority in order to prevent Mary from‬
‭contracting respiratory infections while she is in the‬
‭ 2. Nurses should be able to provide appropriate‬
1 ‭hospital?‬
‭responses to which of the spiritual issues contemplated‬
‭by the dying patients?‬ ‭ . Stay only for 5 minutes at the room‬
A
‭B. Limit visits‬
‭ . “Why do people have to suffer?”‬
1 ‭C. Wear masks during visits‬
‭2. “Why do people live?”‬ ‭D. Refrain from bringing food from the outside‬
‭3. “Is there a higher being such as God?”‬
‭4. “What does life mean?”‬ ‭ 8. To prevent infection during the delivery of‬
1
‭chemotherapy, Nurse Grace must begin the procedure by‬
‭ . 3 only‬
A ‭______.‬
‭B. 3 and 4‬
‭C. 1, 2 and 4‬ ‭ . Washing their hands‬
A
‭D. 1, 2, 3 and 4‬ ‭B. Checking the order of the physician‬
‭C. Preparing drug aseptically‬
‭ 3. Which of the behaviors depict‬‭bargaining‬‭in the‬‭five‬
1 ‭D. Wearing gloves and masks‬
‭stages of dying according to Kubler-Ross (1969)?‬
‭ 9. When Nurse Grace applies tourniquet on Mary to‬
1
‭ . “Lord, I will donate monthly to the Charity Ward of‬
A ‭expose her veins for the IV chemotherapy, she should use‬
‭Hospital X if given another chance.”‬ ‭one that is _____________.‬
‭B. “Why do you have to leave us at this point of our‬
‭married life?”‬ ‭ . Clean‬
A
‭C. “Well, life has to go on.”‬ ‭B. Sterile‬
‭D. “Please, leave me alone. I don’t feel like talking to‬ ‭C. Non-sterile‬
‭anyone.”‬ ‭D. None of the above‬

‭14. The key activities in spiritual caring are __________.‬ ‭ ituation:‬‭Nurse Mariel is taking care of Angel, a‬
S
‭65-year-old woman who was admitted due to‬
‭ . reading the bible for the patient‬
1 ‭cardiopulmonary disease.‬
‭2. being with patients in their experiences during pain,‬
‭sufferings and other problems‬ ‭ 0. The most effective position for clients with COPD is‬
2
‭3. listening to patients when they verbally express‬ ‭_______.‬
‭anxieties or emotions, such as fear, anger, loneliness,‬
‭depression, or sorrow, which may be hindering the‬ ‭ . High-fowler’s‬
A
‭achievement of wellness.‬ ‭B. Dorsal‬
‭4. touching patients either physically, emotionally, or‬ ‭C. Dorsal recumbent‬
‭spiritually to assure them of their connectedness with‬ ‭D. Sim’s‬
‭other in the family of God‬
‭ 1. Which of the following is not a vital role of a nurse in‬
2
‭ . 1, 2 and 3‬
A ‭caring for a COPD patient to achieve and maintain an‬
‭B. 1, 3 and 4‬ ‭optimal level of health?‬
‭C. 1, 2, 3, and 4‬
‭D. 2, 3, and 4‬ ‭ . Gym enrolment for the physical exercise‬
A
‭B. Prescription of oxygen and medication‬
‭ ituation:‬‭Cancer patients are considered to be among‬
S ‭C. Relaxation and stress management techniques‬
‭the immunocompromised population. Mary, 40 years old‬ ‭D. Nutrition counseling‬
‭was diagnosed with colon cancer stage 3B.‬
‭ 2. What is the most appropriate intervention for Mr.‬
2 ‭ 8. Nurse Andrew informs Jose that he will be performing‬
2
‭Santos who is refusing his medication dose?‬ ‭the sputum specimen collection before breakfast the next‬
‭morning, as this is the best time to perform the procedure.‬
‭ . Have the patient sign a waiver that he has refused to‬
A ‭Jose asks why, specifically before breakfast and not any‬
‭take the medication‬ ‭time of the day. What will be Nurse Andrew's most‬
‭B. Offer option to patient to take the oral medication or‬ ‭appropriate response?‬
‭medication through intravenous infusion‬
‭C. Inform the physician and suggest to give another form‬ ‭ . He has rested to cough out sputum‬
A
‭of medication‬ ‭B. Lesser people are around‬
‭D. Document the patient’s refusal to take the‬ ‭C. Secretions tends to accumulate during the night‬
‭medication and include the reason for the refusal‬ ‭D. Cooperation is better‬

‭ 3. At endorsement time, Mr. Santos was complaining of‬

2 ‭ 9. If Nurse Andrew fails to obtain the minimum‬
2
‭nausea and vomiting‬‭. What is the most appropriate‬‭action‬ ‭requirement of 15 mL of sputum, other methods to induce‬
‭of the nurse?‬ ‭sputum may be ordered,‬‭except‬‭:‬

‭ . Conduct an assessment on Mr. Santos‬

A ‭ . Postural Drainage‬
A
‭B. Offer a glass of ice water for oral rinse‬ ‭B. Bronchoscopy‬
‭C. Inform the Head nurse about Mr. Santos’ nausea and‬ ‭C. Use of sterile water via nebulizer‬
‭vomiting‬ ‭D. Nasotracheal suctioning‬
‭D.Refer the client to the attending physician‬
‭ ituation:‬‭Mrs. Wells, a 55-year-old saleswoman,‬
S
‭ 4. The main goal of oxygen therapy for COPD patients is‬
2 ‭complained of swelling in her left leg for a week. She was‬
‭to prevent ____________.‬ ‭diagnosed with deep vein thrombosis (DVT). The nurse‬
‭made his assessment and found her left thigh 3‬
‭ . Dyspepsia‬
A ‭inches larger in circumference than the right thigh.‬
‭B. Hypoxia‬
‭C. Hyperventilation‬
‭D. Hypoventilation‬ ‭ 0. Which of the following justifies the use of‬‭intravenous‬
3
‭treatment‬‭to administer medication to Mrs. Wells?‬‭Select‬
‭ 5. There are two types of oxygen delivery systems: low‬
2 ‭all that apply.‬
‭flow and high flow. Low flow administration examples‬
‭include all except for one.‬ ‭ . Administer non-diluted medications at a‬‭faster‬‭rate.‬
1
‭2. Facilitate for large volume infusion of IV fluids. (+)‬
‭ . Nasal cannula‬
A ‭3. Volume controlled infusion (+)‬
‭B. Oxygen mask‬ ‭4. Pave the way for intravenous push of bolus (+)‬
‭C. Oxygen tent → MORE THAN 7L/MIN‬ ‭5. Administer diluted medications at a‬‭faster‬‭rate‬
‭D. Oxygen hood incubator‬
‭ . 3, 4, and 5‬
A
‭ 6. The only way to ensure that patients with respiratory‬
2 ‭B. 1, 3, and 5‬
‭disease receive a correct diagnosis is to be able to‬ ‭C. 2, 3, and 4‬
‭accurately collect a sputum sample, which is an important‬ ‭D. 1, 2, and 3‬
‭skill. Nurse Andrew must adhere to the standards for‬
‭specimen collection. The specimen collection's proper‬ ‭ 1. Mrs. Wells will continue receiving heparin‬
3
‭order is ____________.‬ ‭subcutaneously in three days to treat her deep vein‬
‭thrombosis. Mrs. Wells was administered heparin‬
‭ . Check the order, review the specimen procedure,‬
A ‭subcutaneously for the MAIN reason that _________.‬
‭assess patient and gather the equipment, explain‬
‭procedure to patient and perform sputum collection‬ ‭ . To rapidly absorb the drug to produce faster effect‬
A
‭B. Gather the equipment, explain procedure to patient,‬ ‭B. To provide an alternate route when drug is irritating to‬
‭make patient comfortable and perform the procedure‬ ‭tissues‬
‭C. Assess the patient, explain the procedure to patient,‬ ‭C. To provide a rapid long absorption of the drug to‬
‭gather equipment and perform the procedure‬ ‭prevent pain‬
‭D. Check the order, assess the patient, explain procedure‬ ‭D. To slow down the absorption of drugs to produce a‬
‭to patient and perform sputum collection.‬ ‭sustained effect‬

‭ 7. How many‬‭sputum specimens‬‭are needed to‬

2 ‭ 2. Upon performing the nursing assessment on Mrs.‬
3
‭determine the pathogen involved and to start appropriate‬ ‭Wells, the salient concerns that should be considered are‬
‭treatment for patients suspected of having Koch's‬ ‭the following,‬‭EXCEPT‬‭____________.‬
‭infection?‬
‭ . Functional impairment‬
A
‭ . One‬
A ‭B. Increase temperature of the calf or ankle‬
‭B. Two‬ ‭C. Anxiety related to her condition‬
‭C. Three →‬‭8-24 HOURS APART‬ ‭D. Feeling of heaviness‬
‭D. Five‬
‭ ituation:‬‭Callie, 3 years old, is diagnosed with nephrotic‬
S
‭syndrome and manifesting massive proteinuria resulting‬
‭to‬‭decreased of albumin‬‭in blood.‬
‭ 0. What would the physician order when‬‭thrombocyte‬
4
‭count falls below‬‭20,000/cu mm‬‭?‬

‭ 3. The nurse understand that the passage of the protein‬

3 ‭ . complete bed rest‬
A
‭in the urine is the result of ____.‬ ‭B. strict aseptic technique‬
‭C. limit visitors‬
‭ . inherited kidney disorder‬
A ‭D. platelet transfusion‬
‭B. intrinsic kidney disease‬
‭C. increased glomerular permeability‬ ‭ 1. On the basis of his leukocyte count, which of the‬
4
‭D. increased albumin production‬ ‭following should the nurse instruct the patient‬‭not‬‭to do‬‭?‬

‭ 4. Upon clinical assessment, the nurse observes that the‬

3 ‭ . be in the private room with the doors always closed‬
A
‭OUTSTANDING‬‭manifestation‬‭of the patient is _______.‬ ‭B. limit the number of staff entering the room‬
‭C. receive immunization with live attenuated virus‬
‭ . edema‬
A ‭D. use antimicrobial soap when bathing‬
‭B. weight gain‬
‭C. obesity‬ ‭ 2. During the period of exacerbation, the patient‬
4
‭D. emaciation‬ ‭hemoglobin’s is markedly decreased‬‭. Which of the‬
‭following instructions is appropriate?‬
‭ 5. What is the common physical‬‭appearance of urine‬‭in‬
3
‭patients with nephrotic syndrome?‬ ‭ . perform only activities of daily living‬
A
‭B. serve pork and liver barbeque →‬‭RICH IN IRON‬
‭ . cloudy‬
A ‭C. allow exercise as long as tolerated‬
‭B. frothy‬ ‭D. let the patient perform self-care independently‬
‭C. clear‬
‭D. whitish‬ ‭ ituation:‬‭Nurses must continually grow as a person‬‭and‬
S
‭as a professional‬
‭ 6. The patient with nephrotic syndrome is ordered‬
3
‭corticosteroids. Who among the following are‬‭not allowed‬ ‭ 3. You are expected to participate in the Continuing‬
4
‭in the patient’s room?‬ ‭Professional Development program as a newly licensed‬
‭nurse working at a tertiary hospital. When the training‬
‭ . parents with diabetes‬
A ‭program is the enhancement of the competencies of‬
‭B. visitors with upper respiratory tract infection‬ ‭nurses employed in the hospital, it is called?‬
‭C. visitors with mild asthma‬
‭D. visitors with allergy‬ ‭ . informal training program‬
A
‭B. formal educational program‬
‭ 7. The main treatments for nephrotic syndrome include‬
3 ‭C. self-directed‬
‭corticosteroids. Which of the following common‬‭adverse‬ ‭D. in-service training program‬
‭effects‬‭should nurses be on the lookout for?‬
‭ 4. The professional career development of nurse can be‬
4
‭ . Loss of appetite‬
A ‭achieved through various ways, such as.‬
‭B. Loss of weight‬
‭C. Lowering blood pressure‬ ‭ . participating in political rallies‬
A
‭D. Increase in body hair‬ ‭B. attending culinary courses‬
‭C. attendance in socio-civic activities‬
‭ ituation:‬‭Harry, a 26-year-old patient, is pale and‬
S ‭D. engaging in CPD programs‬
‭complains of being easily fatigued. He has undergone a‬
‭complete blood count where abnormal cells were found.‬ ‭ 5. What kind of response is anticipated of a concerned‬
4
‭He was diagnosed with acute lymphocytic leukemia‬ ‭nurse when nurses are portrayed as sex symbols in‬
‭(ALL).‬ ‭television advertisements?‬

‭ 8. The nurse identifies that the proper‬‭isolation‬

3 ‭ . condemn the issue in the radio program‬
A
‭precaution applied should be?‬ ‭B. go to the street to manifest displeasure of the nurses’‬
‭portrayal.‬
‭ . protective →‬‭REVERSE ISOLATION‬
A ‭C. report to the concerned agency‬
‭B. standard‬ ‭D. keep your silence, it is the television station’s‬
‭C. airborne precaution‬ ‭prerogative.‬
‭D. strict isolation →‬‭IF PT IS INFECTIOUS‬
‭ 6. What program should a nurse attend to, if she likes to‬
4
‭ 9. Which of the following diagnostic procedures will‬
3 ‭enhance her personality?‬
‭definitely establish the‬‭diagnosis‬‭for the patient‬‭Harry?‬
‭ . gymnastics‬
A
‭ . bone marrow biopsy‬
A ‭B. scuba diving‬
‭B. white blood cell count‬ ‭C. marathon training‬
‭C. complete blood count‬ ‭D. social graces and physical fitness‬
‭D. hemoglobin and hematocrit counts‬
‭ 7. The nurse has finally received approval for her‬
4 ‭ . altered sensory perception‬
C
‭application to move to Canada, and she has been advised‬ ‭D. impaired social interaction‬
‭to depart in three months. She is currently enrolled in‬
‭graduate school. In addition, her mother was recently‬ ‭ 2. During rounds, Nurse Clark finds Zel smoking in the‬
5
‭discharged from the hospital. Which of the following is‬ ‭comfort room. Zel claims that a housekeeping personnel‬
‭best course of action?‬ ‭gave him the lighter and matches. He says,‬‭“I did‬‭not‬
‭bring these matches with me. Scold him, not me!”‬
‭ . inform the agency that she can go anytime as they‬
A ‭Which‬‭defense mechanism‬‭is exhibited by Zel?‬
‭wish‬
‭B. inform family that the money spent in graduate school‬ ‭ . sublimation‬
A
‭can be easily earned in Canada.‬ ‭B. reaction formation‬
‭C. request the recruiter to give her more time to settle‬ ‭C. denial‬
‭her personal concerns.‬ ‭D. projection → BLAMING OTHERS‬
‭D. share with friends that this is her scape from her sad‬
‭life with her family‬ ‭ 3. Zel, having been diagnosed with borderline‬
5
‭personality disorder, must be observed closely for which‬
‭ ituation:‬‭Mike is diagnosed with stroke and suffer‬‭from a‬
S ‭group of‬‭manifestations‬‭?‬
‭number of deficits as a result of injury to her brain. Her‬
‭rehabilitation may be long depending on the extent of‬ ‭ . strong sense of self and independence‬
A
‭brain injury.‬ ‭B. grief, anger and social isolation‬
‭C. altered sensory perception and thought disorder‬
‭ 8. Mike has been intermittently urinating in bed, which‬
4 ‭D. clinging, acting out, mood shifts and impulsivity‬
‭may be caused by a flaccid bladder and difficulties with‬
‭communication. He is exhibiting signs and symptoms of‬ ‭ ituation:‬‭Adam, a 35-year-old senior staff nurse,‬‭was‬
S
‭pressure sores as a result of his immobility and the‬ ‭diagnosed with Chronic Fatigue Syndrome (CFS). He‬
‭constantly wet bedding, which worries the nurse. In order‬ ‭complains of overwhelming fatigue unrelieved by rest and‬
‭to best serve the patient, the nurse chooses to report this‬ ‭having difficulty performing activities of daily living.‬
‭to whom?‬
‭54. Which of the following are the‬‭manifestations‬‭of CFS?‬
‭ . attending physician‬
A
‭B. supervisor-in-charge‬ ‭ . Unrefreshing sleep (+)‬
1
‭C. resident on duty‬ ‭2.‬‭Decrease level of awareness‬
‭D. infectious doctor specialist‬ ‭3. Impairment in memory (+)‬
‭4. Muscle and joint pains (+)‬
‭ 9. Mike’s stroke left him weak on the left side, causing‬
4 ‭5.‬‭Decreased muscle tone‬
‭him to become excessively quiet and reclusive. The nurse‬
‭notices that the patient‬‭appears to be quite depressed‬ ‭SELECT ALL THAT APPLY.‬
‭and informs the doctor, who refers the patient to a‬
‭______.‬ ‭ . 1, 3, 5‬
A
‭B. 1, 3, 4‬
‭ . neurologist‬
A ‭C. 2, 3, 5‬
‭B. psychiatrist‬ ‭D. 2, 4, 5‬
‭C. psychologist‬
‭D. physiotherapist‬ ‭ 5. Having been diagnosed with CFS, Adam’s functional‬
5
‭abilities are‬‭deteriorating‬‭, brought about by changes‬‭in‬
‭ 0. Mike expressed concerns about continuing to be a‬
5 ‭brain chemistry. This results in a common manifestation of‬
‭father to his daughter after the stroke, especially since he‬ ‭what condition?‬
‭only had one daughter. He wants two boys but‬‭isn't‬
‭confident in his current sexual capability‬‭. Who can‬‭assist‬ ‭ . Decreased musculoskeletal functions‬
A
‭him in this area?‬ ‭B. Depression‬
‭C. Mania‬
‭ . primary consultant‬
A ‭D. Decreased neuromuscular functions‬
‭B. urologist‬
‭C. nurse‬ ‭ 6. What should be the basis for the evaluation of the‬
5
‭D. supervisor in charge‬ ‭outcomes of care to improve‬‭management and quality‬‭of‬
‭life‬‭for Adam?‬
‭ ituation:‬‭Zel, a patient diagnosed with borderline‬
S
‭personality disorder, was admitted to the psychiatric unit‬ ‭ . Absence of common complications of CFS‬
A
‭due to extreme fluctuations in mood, intense reactions,‬ ‭B. Mutual planning with the patient and family‬
‭and persistent hostility. Nurse Clark is assigned to Zel’s‬ ‭→‬‭LONG TERM MANAGEMENT‬
‭plan of care.‬ ‭C. Effectiveness of nursing interventions‬
‭D. Effectiveness of the medical regimen‬
‭ 1. Considering the current condition of Zel, what is the‬
5
‭most appropriate‬‭nursing diagnosis‬‭that Nurse Clark‬ ‭ 7. Marty, a 32-year-old cancer patient who is on‬
5
‭should consider?‬ ‭chemotherapy, complains of easy fatigability, exhaustion,‬
‭A. disturbed personal identity‬ ‭and diminished capacity for mental work. What is the‬
‭B. hallucination‬ ‭most appropriate‬‭nursing diagnosis‬‭for Marty?‬
‭ . Fatigue related to brain chemistry to chemotherapy‬
A ‭ . Conflict between work life and demands of family life.‬
C
‭B. Fatigue related to altered body chemistry‬ ‭D. Increased absenteeism and rapid turnover of nurses‬
‭secondary to chemotherapy‬ ‭due to a toxic work environment.‬
‭C. Fatigue secondary to loss of musculoskeletal functions‬
‭D. Fatigue related to malnutrition‬ ‭ 4.‬‭Physical tension‬‭can result from an unhealthy‬‭work‬
6
‭environment. This can be managed by progressive‬
‭ ituation:‬‭Nurse Tina is planning to conduct a teaching‬
S ‭muscle relaxation, which involves?‬
‭session about common types of abuse. The following‬
‭questions apply.‬ ‭ . Listening to a relaxation-audio program‬
A
‭B. Performing active physical exercise to unwind, like‬
‭ 8. One of the most common types of abuse is child‬
5 ‭aerobic exercise‬
‭maltreatment. The following are‬‭signs of child abuse‬‭,‬ ‭C. Focusing on an image to relax‬
‭except‬‭?‬ ‭D. Releasing muscles from tension‬

‭ . “Stocking and glove” distribution marks → BURNS‬

A ‭ 5.‬‭Stress management techniques‬‭are beneficial‬
6
‭B. Urinary Tract Infection → SEXUAL ABUSE‬ ‭interventions for patients and nurses. The following are‬
‭C. Cigarettes marks (+)‬ ‭part of biobehavioral stress management interventions,‬
‭D. Belt buckle or teeth marks (+)‬ ‭except‬‭?‬

‭59. Which of following is‬‭not a sign‬‭of sexual abuse?‬ ‭ . Guided imagery‬

A
‭B. Meditation‬
‭ . Bruised, red, swollen genitalia‬
A ‭C. Progressive muscle relaxation‬
‭B. Skull fracture‬ ‭D. Pharmacotherapy‬
‭C. Urinary Tract Infection‬
‭D. Rectum tear‬ ‭ 6. Joe, a retired high school teacher, smokes an average‬
6
‭of one (1) pack of cigarettes per day. As a nurse, you‬
‭ 0. The management of abuse deals with the treatment of‬
6 ‭educated him about the Smoking Cessation Program of‬
‭victims and preventing repetitions of such abuse. Which‬ ‭DOH. Which of the following steps does Joe need next to‬
‭among the types of child abuse is‬‭most difficult to‬‭treat‬‭?‬ ‭pursue a change in his lifestyle?‬

‭ . Emotional‬
A ‭ . Commitment‬
A
‭B. Physical‬ ‭B. Skills to implement change‬
‭C. Sexual‬ ‭C. Motivation‬
‭D. Neglect‬ ‭D. Information‬

‭ 1. Which condition may be caused by experiences of‬

6 ‭ 7. To achieve an optimal level of health for Joe, lifestyle‬
6
‭child abuse early in life‬‭?‬ ‭modification must be done. It begins with:‬

‭ . Sociopath Personality‬
A ‭ . Attending lectures on healthy lifestyle‬
A
‭B. Narcissistic Personality‬ ‭B. Constructive and positive attitude in life‬
‭C. Hyperactive Personality‬ ‭C. Regular daily exercise‬
‭D. Dissociative Personality‬ ‭D. Recognizing the impact of unhealthy habits‬

‭ 2. Nurse Lily is a newly hired staff nurse. She told the‬

6 ‭ ituation:‬‭One of the responsibilities of nurses working‬
S
‭head nurse that she cannot handle one patient because‬ ‭in psychiatric or mental health units is participating in‬
‭the patient might be infected with HIV. Which of the‬ ‭developmental research activities about mental health.‬
‭following‬‭ethical principles‬‭did Nurse Lily violate?‬ ‭The following questions apply.‬

‭ . Nonmaleficence‬
A ‭ 8. Nurse Shai is a beginning professional nurse working‬
6
‭B. Beneficence‬ ‭in a psychiatric unit. Considering her level, which activity‬
‭C. Loyalty‬ ‭should she implement?‬
‭D. Respect for human dignity‬
‭ . Engage in research to test knowledge and theories in‬
A
‭ ituation:‬‭Unhealthy workplace, heavy workload, and‬
S ‭nursing‬
‭limited resources cause stress among healthcare‬ ‭B. Identify clinical problems for research study‬
‭professionals such as nurses. A healthy work‬ ‭C. Collaborate with other members of the health team to‬
‭environment plays a vital role in nurses’ provision of‬ ‭undertake research‬
‭quality care.‬ ‭D. Use research findings to improve clinical care‬

‭ 3. Burnout is becoming more prevalent among nurses.‬

6 ‭ 9. Nurse Shai aims to look for evidence on the efficacy of‬
6
‭Which of the following describes‬‭burnout‬‭?‬ ‭psychological interventions for bipolar disorder. Which of‬
‭the following research methodologies will give the best‬
‭ . Growing dissatisfaction among nurses due to changing‬
A ‭evidence on this topic?‬
‭career expectations.‬
‭B. Emotional exhaustion, depersonalization, and‬ ‭ . Comparative studies‬
A
‭reduced personnel accomplishment.‬ ‭B. Meta-synthesis‬
‭ . Meta-analysis‬
C ‭ . Ingest 600 mg of calcium gluconate by mouth for two‬
B
‭D. Critical appraisal of topic‬ ‭weeks before the test‬
‭C. Consume foods and beverages with a high content of‬
‭ 0. Which of the following is the intervention of interest in‬
7 ‭calcium for two days before the test.‬
‭the research question: “Is group therapy more effective‬ ‭D. Remove all metal objects on the day of the scan‬
‭than cognitive-behavioral therapy in preventing relapse‬
‭among depressed patients?”‬ ‭ 6. What should Nurse Mimi assess as part of history and‬
7
‭physical examination of a patient diagnosed with‬
‭ . Prevention‬
A ‭osteoarthritis?‬
‭B. Relapse‬
‭C. Group therapy‬ ‭ . Anemia‬
A
‭D. Cognitive-behavioral therapy‬ ‭B. Local joint pain‬
‭C. Weight loss‬
‭ 1. Which of the following is the outcome in the research‬
7 ‭D. Osteoporosis‬
‭question: “Is group therapy more effective than‬
‭cognitive-behavioral therapy in preventing relapse among‬ ‭ 7. The physician ordered Ibuprofen (Motrin) for a patient‬
7
‭depressed patients?”‬ ‭with right hip pain secondary to osteoarthritis. To‬
‭decrease gastric mucosal irritation associated with the‬
‭ . Preventing relapse‬
A ‭drug, Nurse Mimi should instruct the patient to take the‬
‭B. Depressed patients‬ ‭drug _____.‬
‭C. Group therapy‬
‭D. Cognitive-behavioral therapy‬ ‭ . Upon waking up‬
A
‭B. On an empty stomach‬
‭ 2. Nurse Shai aims to discover the effectiveness of‬
7 ‭C. At bedtime‬
‭psychoeducation for families of teenagers with eating‬ ‭D. Immediately after a meal‬
‭disorders. Which sampling techniques should Nurse Shai‬
‭use?‬ ‭ ituation:‬‭A crisis is a turning point in an individual’s‬
S
‭life that produces an overwhelming emotional response.‬
‭ . Purposive sampling‬
A ‭As a nurse, you encounter patients experiencing different‬
‭B. Quota sampling‬ ‭types of crisis. The following questions apply.‬
‭C. Fish-bowl technique‬
‭D. Simple random sampling‬ ‭ 8. Coleen, a 17-year-old high school student, is admitted‬
7
‭due to signs and symptoms of depression one month after‬
‭ ituation:‬‭Nurse Mimi was hired as a staff nurse at‬‭the‬
S ‭giving birth out of wedlock. Her mother did not accept the‬
‭Orthopedic Ward. Being assigned to patients with various‬ ‭baby and her boyfriend decided not to marry her. She is‬
‭musculoskeletal conditions, Nurse Mimi reviews herself‬ ‭suffering from what type of crisis/es?‬
‭with diagnostic procedures and treatments commonly‬
‭performed in the unit. The following questions apply.‬ ‭ . Maturational and situational‬
A
‭B. Developmental‬
‭ 3. The senior staff nurse asked Nurse Mimi to assess the‬
7 ‭C. Situational‬
‭patient’s peroneal nerve function in relation to movement.‬ ‭D. Maturational and adventitious‬
‭How would Nurse Mimi perform the assessment?‬
‭ 9. Using various therapeutic communication techniques‬
7
‭ . Prick the skin midway between the thumb and second‬
A ‭is important in caring for patients in crisis. The nurse tells‬
‭finger‬ ‭the patient, “I’ve noticed that after you talked with your‬
‭B. Plantar flex toes and foot‬ ‭father, you complained of a headache.” This is an‬
‭C. Dorsiflex the foot and extend the toes‬ ‭example of _____.‬
‭D. Prick the skin midway between the great and second‬
‭toe‬ ‭ . Reinforcement of behavior‬
A
‭B. Exploration of solutions‬
‭ 4. The physician ordered a computed tomography (CT)‬
7 ‭C. Suggestion‬
‭for a patient with suspected musculoskeletal condition.‬ ‭D. Clarification‬
‭Which of the following is not an indication of the‬
‭procedure?‬ ‭ 0. Age-appropriate interventions are most effective to aid‬
8
‭people in crisis return to their previous level of functioning.‬
‭ . To visualize and assess tumors‬
A ‭For an adolescent in crisis, which among the following is‬
‭B. To identity the location and extent of fractures in areas‬ ‭most effective?‬
‭that are difficult to evaluate‬
‭C. To assess severe trauma to the chest‬ ‭ . Individual therapy‬
A
‭D. To measure the girth of an extremity‬ ‭B. Family therapy‬
‭C. Play therapy‬
‭ 5. Mary, a postmenopausal patient, is scheduled for a‬
7 ‭D. Music therapy‬
‭bone density scan. What should Nurse Mimi instruct the‬
‭patient to do?‬ ‭ ituation:‬‭Daniel, a 31-year-old truck driver, was‬
S
‭admitted to the hospital due to abdominal pain. Several‬
‭ . Report any significant pain to the physician at least two‬
A ‭diagnostic studies were done and he was confirmed to be‬
‭days before the test.‬ ‭diagnosed with Pancreatitis.‬
 ‭ ollect blood by heel stick to an infant named Baby G‬
c
‭ 1. Upon assessment, Daniel was observed to have‬
8 ‭born 12 hours ago. This is to assess Baby G’s risk for‬
‭steatorrhea. How will the nurse best describe this?‬ ‭congenital hypothyroidism.‬

‭ . Bright red stool‬

A ‭ 7. Nurse Therese clarifies the order with the physician.‬
8
‭B. Clay-colored stool with minimal blood‬ ‭She knows that‬‭12 hours after birth‬‭is not the ideal‬‭time to‬
‭C. Frothy, foul smelling stool with high fat content‬ ‭collect blood for which‬‭reason‬‭?‬
‭D. Dark tarry stool with fatty content‬
‭ . There is an immediate rise of thyroid stimulating‬
A
‭ 2. To relieve Daniel’s abdominal pain, which of the‬
8 ‭hormone after birth‬
‭following is the preferred medication that produces longer‬ ‭B. The baby needs to digest formula before a blood‬
‭action that the other drugs?‬ ‭sample can be taken‬
‭C. A thyroid scan should be done first‬
‭ . Aspirin‬
A ‭D. At 24 hours, the T4 level will be extremely high‬
‭B. Morphine sulfate‬
‭C. Cimetidine‬ ‭ 8. Baby G was diagnosed with‬‭hypothyroidism‬‭at 4‬
8
‭D. Meperidine hydrochloride‬ ‭months. Nurse Therese educates the mother about signs‬
‭and symptoms consistent with the diagnosis. Select all‬
‭ 3. The nurse, together with the dietitian, is planning the‬
8 ‭that apply.‬
‭prescribed diet for Daniel. Which of the following dietary‬
‭instructions is appropriate?‬ ‭ .‬‭High pitched shrill cry‬
1
‭-‬ ‭LOW PROTEIN‬ ‭2. Prolonged jaundice at birth (+)‬
‭-‬ ‭HIGH CARS‬ ‭3. Rag-doll appearance (+)‬
‭-‬ ‭LOW FAT‬ ‭4. Constipation (+)‬
‭5.‬‭Tall for gestation at birth‬
‭ . High sodium, Low carbohydrate‬
A
‭B. Low calorie, low carbohydrate‬ ‭ . 1,4 and 5‬
A
‭C. High fat, high protein‬ ‭B. 3, 4 and 5‬
‭D. Low protein, high carbohydrate‬ ‭C. 1, 2 and 3‬
‭D. 2, 3 and 4‬
‭ 4. What is the nurse’s priority health teaching for Daniel‬
8
‭to prevent future attacks‬‭of pancreatitis?‬ ‭ 9. What‬‭nursing diagnosis‬‭should Nurse Therese‬
8
‭prioritize for Baby G? →‬‭LONG TERM MANAGEMENT‬
‭ . Engagement in regular exercises‬
A
‭B. Abstinence of alcohol intake‬ ‭ . High risk for ineffective health maintenance‬
A
‭C. Restriction of food high in carbohydrate‬ ‭B. Hyperthermia‬
‭D. Avoidance to stressful events‬ ‭C. Imbalanced Nutrition more than the body requirements‬
‭D. Altered oral mucous membrane‬
‭ 5. Carlo, a 52-year-old smoker, is diagnosed with‬
8
‭Emphysema‬‭. Which of the following manifestations will‬ ‭ 0. If congenital hypothyroidism is detected and‬
9
‭likely‬‭not‬‭be included in assessment findings?‬ ‭diagnosed at a later time, irreversible damage can occur‬
‭to what‬‭major organ‬‭of the body?‬
‭ . Decreased breath sounds‬
A
‭B. Decreased diaphragmatic motion‬ ‭ . Gastrointestinal tract‬
A
‭C. Dullness on percussion →‬‭PNEUMONIA‬‭,‬‭TUMOR‬ ‭B. Liver‬
‭D. Hyperresonance‬ ‭C. Brain →‬‭MENTAL RETARDATION‬
‭D. Thyroid gland‬
‭ 6. Marge, a patient diagnosed with cholecystitis, is‬
8
‭scheduled to undergo laparoscopic cholecystectomy.‬ ‭ 1. Lifetime management of thyroid hormone replacement‬
9
‭What appropriate‬‭nursing diagnosis‬‭can you formulate‬‭to‬ ‭is crucial to eliminate signs of hypothyroidism. The‬
‭include in Marge’s nursing care plan?‬ ‭physician prescribes‬‭Levothyroxine‬‭. Prior to‬
‭administration of the drug, what will the nurse check?‬
‭ . Anxiety related to surgical and environmental concerns‬
1
‭(+)‬ ‭ . Blood pressure‬
A
‭2. Risk for injury related to anesthesia and surgical‬ ‭B. Respiratory rate‬
‭procedures (+)‬ ‭C. Temperature‬
‭3. Risk for pruritus related to anesthesia and surgical‬ ‭D. Pulse rate‬
‭procedures‬
‭4. Risk for poverty related to hospital expenses‬ ‭ ituation:‬‭Nurse Dorothea works at the Outpatient‬
S
‭Department (OPD) of the hospital. The healthcare‬
‭ . 1, 2, 3 and 4‬
A ‭services every Friday of the month are scheduled for‬
‭B. 1 and 2‬ ‭patients with endocrine disorders.‬
‭C. 1 and 3‬
‭D. 2, 3 and 4‬ ‭ 2. Augusta, a 32-year-old patient with suspected‬
9
‭hypothyroidism‬‭, is admitted for further work-up. You‬‭are‬
‭ ituation:‬‭As part of the Newborn Screening (NBS),‬
S ‭assigned to develop a nursing care plan. Which of the‬
‭Nurse Therese has been tasked by the physician to‬ ‭following nursing diagnosis is appropriate?‬
‭ . Disturbed thought processes related to‬‭hypermetabolic‬
A ‭ 9. Patient Inez was advised to undergo surgery. As a‬
9
‭rate‬ ‭nurse, what is your initial responsibility when you‬‭prepare‬
‭B. Constipation related to gastrointestinal‬‭hypermotility‬ ‭a patient‬‭for retinal detachment?‬
‭C. Imbalanced nutrition,‬‭less‬‭body requirements‬
‭D. Activity intolerance related to decreased metabolic‬ ‭ . Teach family members on how to use eye drops‬
A
‭rate‬ ‭B. Let patient and relatives sign consent‬
‭C. Assess level of understanding about retinal‬
‭ 3. After diagnostic tests, Augusta is confirmed to have‬
9 ‭detachment‬
‭hypothyroidism. What possible‬‭complication‬‭might she‬ ‭D. Provide patient with proactive eyeglasses‬
‭experience?‬
‭ 00. Should there be no complications, the physician‬
1
‭ . Iron and folate deficiency‬
A ‭ordered that Patient Inez may go home after the‬‭third‬
‭B. Decreased hematocrit‬ ‭postoperative‬‭day. Which of the following health‬
‭C. Decreased oxygen demand‬ ‭instructions should you give as the nurse?‬
‭D. Increased serum cholesterol‬
‭ . Patient should initially eat small, light meals‬
A
‭ 4. Betty, a patient suspected with a cardiac disorder,‬
9 ‭→‬‭N&V‬‭→‬‭INC INTRAOCULAR PRESSURE‬
‭seeks follow-up check up. Nurse Dorothea educates Betty‬ ‭B. Patient can resume her usual activities‬‭after 48‬‭hours‬
‭the risk factors of developing complications with cardiac‬ ‭C. Patient is allowed to do reading at night after discharge‬
‭disorders by stressing which‬‭risk factors‬‭to watch‬‭out for‬ ‭D. Patient should wear eye patch during the day‬
‭and modify?‬

‭ . Gender, stress, obesity‬

A
‭B. Obesity, inactivity, diet, smoking‬
‭C. Stress, family history, obesity‬
‭D. Inactivity, diet, family history‬

‭ 5. Nurse Dorothea recommends to patient Betty the‬

9
‭precautionary‬‭measures to maintain‬‭a healthy heart.‬
‭Which of the following is‬‭NOT‬‭recommended?‬

‭ . Brisk walking for 15 minutes a day‬

A
‭B. Take 10mL of red wine every night‬
‭C. Smoking not more than a pack of cigarette a day‬
‭D. Take a diet low in saturated fats and low cholesterol‬

‭ 6. Patient Inez came to the hospital with a suspected‬

9
‭eye disorder. Which of the following characteristics should‬
‭you ask as part of the‬‭assessment‬‭?‬

‭ . Is the pain sharp?‬

1
‭2. Is the pain burning in character?‬
‭3. Is there a history of redness?‬
‭4. Is eye discharge present?‬

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

‭ 7. Patient Inez has an initial diagnosis of‬‭retinal‬

9
‭detachment‬‭. Which of the following manifestations‬‭is a‬
‭specific presenting complaint?‬

‭ . Severe pain on the affected area‬

A
‭B. Excessive bleeding on the eye area‬
‭C. Sense of “floaters” in the visual field‬
‭D. Presence of excessive discharge from the eye‬

‭ 8. Which of the following is considered an‬‭effective‬

9
‭method of treatment‬‭for retinal detachment?‬

‭ . Eye implant‬
A
‭B. Radial keratotomy‬
‭C. Scleral buckling‬
‭D. Use of eye drops‬