PHILIPPINE NURSING

LICENSURE EXAM (PNLE)

Nursing Practice III

SITUATION 1: Laws require citizens to uphold standards and behave in accordance with guidelines of complex state
statutes, regulations, court decisions and legal procedures. Nurses should be aware and practice safety measures for
nursing practice.
1. Nurses are protected from legal action when they
A. Provide health teaching regarding family planning
B. Administer CPR measures to an unconscious child pulled from a pool
C. Report incidents of suspected child abuse to the authorities
D. Offer first aid at the scene of a collision between a car and an automobile
2. Beth is a two year old child admitted with a diagnosis of pneumonia and is given with antibiotics, fluid and
oxygen. The child’s temperature rises until it reaches 40 C. The nurse calls the doctor at the mother’s
request, but the doctor sees no need to change the treatment, even though the child has a history of febrile
seizures. Although concerned, the nurse takes no further action. Later the child develops convulsion that
results in neurologic impairment. Legally
A. The doctor is totally responsible for the patient’s health history and treatment regimen
B. High fevers are common in children thus presents little cause for concern
C. Doctor’s decision takes precedence over the nurse’s concern
D. Nurse’s failure to further question the doctor placed the child at risk
3. A patient with rheumatoid arthritis does not want cortisone even if it is prescribed and informs the nurse.
Later the nurse gives the drug ordered by the doctor. When the patient asks what the medication is, the
nurse gives an evasive answer. The patient takes the medication and later finds that it is cortisone. The
patient states an intent to sue. The decision in this suit should take into consideration the fact that the
A. The nurse is required to answer the patient truthfully
B. The Nurse should have notified the doctor
C. Doctor’s order takes precedence over the patient’s preference
D. The Patient has insufficient knowledge to make such a decision
4. The Board of Nursing disciplines a nurse with a public reprimand. How should the nurse interpret this
disciplinary action?
A. Nurse does not have an infraction against his nursing license
B. Nurse is not allowed to practice in the area where the incident occurred
C. Nurse may practice but has an infraction against his nursing license
D. Nurse must practice only in public hospitals
5. The nurse wrongfully administers potassium by intravenous push route and the patient experiences cardiac
arrest and cannot be resuscitated. The head nurse counsels the nurse that which types of law are likely to be
applied in this case?
1. Criminal law 3. Civil law
2. Statutory law 4. Common law
A. 1 only B. 1 and 3 C. 1,2 and 3 D. 1,2,3 and 4
SITUATION 2: COPD remains to be a perennial problem because of its permanent damage and the chronicity of
the condition affecting much the activities of daily living of affected individual. The nurse plays a significant role
in reducing the disturbing pathological effects.
6. Which of the following assessment findings is commonly seen in patients with chronic bronchitis?
A. Dyspnea C. Clubbing of fingers
B. Copious sputum D. Thin and cachectic
7. In the early stage of chronic bronchitis, which of the following are commonly seen in the radiologic film of
patients?
A. Hyperinflation of airways C. Prominent vessels
B. Infiltrations D. No significant findings
8. The doctor ordered cold humidification rather than steam was ordered for a patient with COPD’s treatment
because
A. Cold humidity reduces mucosal edema
B. Cool water vapor easily absorbed in the mucosa
C. Cold humidity loosens secretions to a greater degree
D. Steam humidifier is more hazardous
9. The nurse is taking the history of a patient with COPD. The patient reports often sleeping in a chair that
allows his head to be elevated rather than going to bed. The patient’s behavior is a strategy to deal with
which condition?
A. Paroxysmal nocturnal dyspnea C. Tachypnea
B. Orthopnea D. Cheyne stokes
10. A patient with COPD has meal-related dyspnea. To address this issue, which drug does the nurse offer the
patient 30 minutes before the meal?
A. Albuterol B. Fluticasone C. Guaifenesin D. Cromolyn
SITUATION 3: Mang Ipe had been experiencing weakness and easy fatigue lately with significant loss of appetite.
Two days ago he started to develop low grade fever and starts to notice significant yellowing of his sclera and
skin. He was sen at the ER and a liver disease was suspected from Mang Ipe.
11. Mang Ipe was evaluated for Hepatitis A. Which among the following activities places him at the highest risk
for contracting the disease?
A. Helping his wife with an epistaxis episode
B. Receiving an elective blood transfusion two years ago
C. Having sexual intercourse with his neighbor’s wife
D. Eating a shrimp platter at a local karinderia
12. The test yielded negative and the doctor entertains cirrhosis. When Mang Ipe is scheduled for liver biopsy,
the nurse helps assure safety by assessing the results of which test?
A. Coagulation studies C. Serum chemistries
B. Liver enzyme levels D. White blood cell count
13. The test confirms the presence of cirrhosis and a large bleeding esophageal varices. The doctor ordered
balloon tamponade. If the doctor orders that Mang Ipe be given feedings through the tube, the nurse should
A. Chill the liquid until ice crystals form on its surface before giving the drug
B. Advance the tube a few millimeters before giving fluid to avoid trauma to varices
C. Give the fluid slowly and in small quantities to avoid regurgitation
D. Deflate the balloon to allow passage of fluid to stomach
14. The fine tremors on Mang Ipe observed by the nurse may probably be the result of
A. Muscular weakness due to low caloric intake
B. Peripehral neuritis due to lack of fat soluble vitamins
C. Increased metabolic rate due to infection
D. Irritation of nervous tissue by toxic metabolites
15. Two weeks after the admission, Mang Ipe developed ascites, and a paracentesis was done. Which of the
following should be determined frequently while paracentesis is being done?
A. Pulse rate and volume C. Urine specific gravity
B. Oral temperature D. Pupillary reaction
SITUATION 4: Nick is admitted with acute depression. Assessment data revealed that she was terminated from her
job as a secretary two months ago.
16. In the initial nurse-client interaction, Jing says to the nurse, “I’m a worthless person. I should be dead.”
The nurse appropriately responds by saying:
A. “Don’t say that, you are not a worthless person.”
B. “We are trying to help you with your feelings.”
C. “What makes You feel worthless? It must be awful to feel that way.”
D. “What you are feeling is part of your illness. It will lessen as you get better.”
17. The therapeutic environment for a depressed client is one which:
A. Allows her to verbalize her feelings. C. Provides opportunities for interacting with others.
B. Pace particular attention to her physical needs. D. Allows freedom to select her own daily activities.
18. The appropriate nursing is diagnosis is:
A. Sensory-perceptual alteration C. Impaired adjustment
B. Altered though process D. Self-esteem disturbance
19. MAO inhibitor anti-depressant drug was ordered. These is:
A. Diazepam (Valium) C. Phenelzina sulfate (Nardel
B. Imipramina HOL (Tofranil) D. Amitryptyline (Elavil)
20. Nick is being prepared discharge. The nurse instructs her husband to observe signs of depression. The following
behavior indicate recurrence of depression, except:
A. Grandiosity C. Psychomotor retardation
B. Insomnia D. Feeling of hopelessness
SITUATION 5: Mrs. Calachuchi is a cancer patient who was admitted in the ward for palliative care. Because of
her bone cancer, pain management is the priority nursing care for her.
21. Which of the following information would be most helpful in assessing pain from Mrs. Calachuchi?
A. Previous pain experience C. Pain history
B. Actual response to pain D. Physical examination
22. Which of the following independent nursing actions for cutaneous stimulation in pain could be applied for
the patient?
A. Application of counter irritants C. Electric wave stimulation
B. Acupuncture D. Pressure, rubbing and massage
23. The Wong Baker FACES rating scale is a visual pain scale that is used to assess pain in children. This scale
identifies the
A. Time when pain ocurs C. Radiation of pain
B. Location of pain D. Intensity and duration of pain
24. Mrs. Calachuchi was placed on patient controlled analgesia (PCA). To reduce her anxiety regarding receiving
adequate pain relief, the patient was most likely told that
A. PCA is always effective D. Most treatment are better than IM
B. Additional IM medication will be given injections
C. Comfort will be assessed frequently
25. Mrs. Calachuchi’s family was concerned that the patient could overdose with a PCA. What protective
mechanism prevents drug overdose with a PCA?
A. After a bolus is administered, there is a mandatory waiting period To prevent overdose - PRE-SET meds
B. The patient can stop drug administration but not initiate it
C. Extensive patient teaching precedes its use
D. The nurse controls the amount administered with each dose
SITUATION 6: Aling Juana, G5P4, had been diagnosed to have multiple gestation and was admitted in the unit
for a possibility of cesarian delivery. The admitting nurse prepares her for the surgery.
26. The nurse is preparing the sterile field using surgical aseptic technique in preparation for the caesarian
delivery of a patient. The nurse gathers the supply. Which option correctly describes how the nurse should
set up the sterile field?
A. Donning sterile gloves before opening the package sterile drape
B. Cleansing the bottle of irrigating solution with alcohol
C. Holding items 6 inches above the field and dropping them on the sterile field
D. Leaving the sterile field unattended to obtain supplies not in the area
27. In preparing for preoperative skin preparation, the nurse should assemble which of the following equipment
1. Safety razor 3. Small hand brush
2. Sterile basin 4. Sterile gauze pledgets
A. 1 and 3 B. 1, 2 and 3 C. 1,2 and 4 D. 1 and 2
28. Nurses who work in the operating room are expected to wear special shoes that will
A. Conduct static electricity to the floor C. Discourage the transportation of bacteria
B. Provide additional traction on slick floors D. Prevent relaxation of the arch of foot
29. To pick up her sterile gown prior to putting it on, the scrub nurse should
A. Seize it by neck band, lift it up and hold it at arm’s length
B. Use sterile transfer forced to remove the gown from the sterile pack
C. Wrap one hand with a sterile towel and grasp the gown with that hand
D. Don one sterile glove and use that to lift the gown from the table
30. As the circulating nurse, which of the following actions should be taken before the birth of the babies?
A. Count the number of sterile sponges C. Notify the pediatric staff
B. Perform the sterile scrub D. Assemble the sterile instrument
SITUATION 7: Winnie is a patient with peripheral vascular disease in the lower extremities. She works as a
teacher in a big university in Matalam and been complaining of discoloration on her lower extremities with mild
pain on prolonged standing. She had been hypertensive for two years.
31. Which intervention would decrease congestion and improve venous return?
A. Increase the amount of time the patient stands
B. Elevate the extremities above the level of the heart
C. Use constrictive clothing to decrease the swelling
D. Encourage decreased ambulation until swelling decreases
32. Which of the following statements about the use of garlic as a therapy for Winnie’s condition?
A. It promotes blood pressure reduction through vasodilation of vessels
B. Lowers cholesterol by interfering with absorption of substance in the GI tract
C. Increases platelet aggregation and promotes clotting
D. Inhibits synthesis of prostaglandin and promotes an anti-inflammatory effect
33. Which intervention would be appropriate for the nurse to include when discussing foot care with Winnie
with peripheral vascular disease?
A. Use heating pads to improve circulation on the leg
B. Cut off all corns and calluses
C. Wash the feet with warm water and mild soap
D. Sit with legs crossed to reduce swelling
34. Which among the following is the best measurement and indicator of tissue perfusion?
A. Systolic blood pressure C. Diastolic blood pressure
B. Mean arterial blood pressure D. Pulse pressure
35. Reduction of sodium intake is one type of non pharmacologic treatment for hypertension. What is the
expected effect of this treatment?
A. Promote weight loss by dieresis C. Stimulate parasympathetic nervous system
B. Increases serum osmolality D. Decreases vascular fluid volume
SITUATION 8: Twenty years after Mrs. Salazar was first diagnosed with rheumatoid arthritis, she is admitted for
a right total hip replacement. She has experienced severe right hip pain that has not responded to treatment for
several years, and has had increasing difficulty moving about because of damage to the right hip joint.
36. Preoperative teaching for Mrs. Salazar should include
A. Isometric exercises of the quadriceps and gluteal muscles
B. Instructions on the necessity for keeping the right leg perfectly straight after surgery
C. The need to flex the involved hip postoperatively to maintain mobility
D. The avoidance of aspirin for 4 days prior to surgery
37. In the post operative phase. Mrs. Salazar should be instructed to avoid
A. Adduction of her right leg C. Abduction of her right leg
B. Bearing any weight on her right leg D. The prone position in bed
38. The nurse and Mrs. Salazar plan for her rehabilitation. Mrs. Salazar asks the nurse, “What do I have to do in
therapy?” Which reply by the nurse most accurately describes the task of the patient in rehabilitation?
A. Follow the instructions of the rehabilitation team
B. Regain some function that was lost
C. Prevent further loss of your ability to function
D. Learn to deal realistically with your disability
39. Which of the following should the nurse consider to be most significant if noted when checking Mrs. Salazar
three days postoperatively?
A. Pain in the operative site C. Swelling of the operative sites
B. Pain and tenderness in the calf D. Orthostatic hypotension
40. The physical therapist orders exercises of Mrs. Salazars’s right hip, knee, and foot to gradually increase the
range of motion to the right hip. The nurse can best assist Mrs. Salazar by
A. Administering an analgesic before the exercises
B. Stopping the exercises if Mrs. Salazar experiences pain
C. Performing the exercises for Mrs. Salazar
D. Observing Mrs. Salazar’s ability to perform the exercises
SITUATION 9: Harry Patter a 62 year old magician with a family history of colorectal cancer has a positive guaiac
test and was admitted in the hospital. He is scheduled for a series of additional diagnostic test.
41. Harry is scheduled for a colonoscopy. Which statement by Harry indicates a need for further teaching?
A. “I am afraid to have general anesthesia for the procedure”
B. “I will be conscious but sedated during the procedure”
C. “I will be taking laxative and enema before the test”
D. “A flexible tube will be inserted in my rectum”
42. Harry receives Midazolam and Fentanyl for conscious sedation during colonoscopy. After the drug is given
the next nursing priority will be
A. Assessing the return of motor function C. Assessesing for decreased bowel function
B. Assessing for respiratory depression D. Managing abdominal discomfort
43. Harry was diagnosed with bowel cancer requiring surgical intervention. When developing a colostomy care
teaching plan, the nurse should recognize that teaching success can be greatly influenced by which of the
following factors?
A. Acceptance of impotence due to surgery C. Acceptance of colostomy
B. Ability to return to work and support family D. Wife’s acceptance of altered image
44. The nurse is teaching Harry about how to control gas and odor from colostomy. Which information will the
nurse include?
A. Avoid eating buttermilk and parsley C. Place aspirin in the colostomy
B. Encouraged use of activated charcoal D. Do not chew gum
45. The nurse immediately reports to the surgeon all but which sign or symptoms related to colostomy?
A. Mucocutaneous separation C. Sign of ischemia and necrosis
B. Liquid stool after surgery D. Unusual bleeding
SITUATION 10: Laws require citizens to uphold standards and behave in accordance with guidelines of complex
state statutes, regulations, court decisions and legal procedures. Nurses should be aware and practice safety
measures for nursing practice.
46. Nurses are protected from legal action when they
A. Provide health teaching regarding family planning
B. Administer CPR measures to an unconscious child pulled from a pool
C. Report incidents of suspected child abuse to the authorities
D. Offer first aid at the scene of a collision between a car and an automobile
47. Beth is a two year old child admitted with a diagnosis of pneumonia and is given with antibiotics, fluid and
oxygen. The child’s temperature rises until it reaches 40 C. The nurse calls the doctor at the mother’s
request, but the doctor sees no need to change the treatment, even though the child has a history of febrile
seizures. Although concerned, the nurse takes no further action. Later the child develops convulsion that
results in neurologic impairment. Legally
A. The doctor is totally responsible for the patient’s health history and treatment regimen
B. High fevers are common in children thus presents little cause for concern
C. Doctor’s decision takes precedence over the nurse’s concern
D. Nurse’s failure to further question the doctor placed the child at risk
48. A patient with rheumatoid arthritis does not want cortisone even if it is prescribed and informs the nurse.
Later the nurse gives the drug ordered by the doctor. When the patient asks what the medication is, the
nurse gives an evasive answer. The patient takes the medication and later finds that it was cortisone. The
patient states an intent to sue. The decision in this suit should take into consideration the fact that the
A. Nurse is required to answer the patient truthfully
B. Nurse should have notified the doctor
C. Doctor’s order takes precedence over the patient’s preference
D. Patienthas insufficient knowledge to make such a decision
49. The Board of Nursing disciplines a nurse with a public reprimand. How should the nurse interpret this
disciplinary action?
A. Nurse does not have an infraction against his nursing license
B. Nurse is not allowed to practice in the area the incident occurred
C. Nurse may practice but has an infraction against his nursing license
D. Nurse must practice only in public hospitals
50. The nurse wrongfully administers potassium by intravenous push route and the patient experience cardiac
arrest and cannot be resuscitated. The head nurse counsels the nurse that which types of law are likely to be
applied in this case?
1. Criminal law 3. Civil law
2. Statutory law 4. Common law
A. 1 only B. 1 and 3 C. 1,2 and 3 D. 1,2,3 and 4
SITUATION 11: Nurse Luke had been working in the STD (sexually transmitted disease) Department of a tertiary
hospital and had been meeting a variety of patients from all walks of life. He is aware that for the past two
decades there had been a rise of cases among teenagers and is planning to educate and create a program for
this target population.
51. While interviewing a patient with newly diagnosed syphilis, Nurse Luke should be aware that the spread of
disease can be controlled by
A. Reassuring the patient that records are confidential
B. Increasing the patient’s knowledge of the disease
C. Motivating the patient to undergo treatment
D. Obtaining the patient’s list of sexual contact
52. Nurse Luke’s priority nursing diagnosis for a patient with primary syphilis is
A. Knowledge deficit C. Alteration in comfort
B. Disturbed body image D. Ineffective tissue perfusion
53. When counseling a woman who is having difficulty conceiving, the nurse will be most concerned about a
history of infection with
A. Condyloma acuminata C. Gonorrhea
B. Trichomoniasis D. Herpes simplex virus
54. A woman in the STD clinic tells Nurse Luke that she is concerned she may have been exposed to gonorrhea
by her partner. To determine whether the patient has gonorrhea, the nurse will plan to
A. Interview the patient about symptoms of gonorrhea
B. Obtain a cervical specimen for an enzyme immunoassay
C. Draw a blood specimen or rapid plasma regain (RPR) testing
D. Take a sample of vaginal discharge for Gram staining
55. A college student goes to the STD Clinic and asks Nurse Luke the best way to avoid contacting an STD. Which
statement by the student indicates the need for additional instruction?
A. “There is no guarantee that I won’t contact an STD if I become sexually active”
B. “Abstinence is the only sure way to avoid an STD”
C. “If I question my partner about past sexual encounters, I can avoid STD”
D. “If I use a condom with spermicide, I will be safer than if I don’t use one”
SITUATION 12: Jordan was a full term baby delivered without complication who was found to have a heart
murmur during an early well baby check up. The pediatrician told Jordan’s parents that the murmur indicated a
possible cardiac defect and was referred to a cardiac clinic for follow up and complete cardiac work up. Between
his second and fourth years, Jordan experienced two episodes of cyanosis, on fifth year a more pronounced
fatigue and clubbing of fingers. He was diagnosed with Tetralogy of Fallot.
56. Jordan was seen by a nurse at the emergency room and noticed club liked appearance of the patient’s finger
which could be due to
A. Edema and fibrous tissue proliferation due to peripheral hypoxia
B. Increased amounts of red bone marrow in terminal phalanges
C. Scar tissue repair of infarctions produced by thrombosed capillaries
D. Exudation of serum proteins through necrotic blood vessels
57. The x-ray findings of right ventricular hypertrophy combined with decreased pulmonary blood flow are
suggestive of
A. Tricuspid insufficiency C. Mitral stenosis
B. Pulmonary stenosis D. Aortic insufficiency
58. Jordan was scheduled for surgery to correct his cardiac problems. The purpose for inducing hypothermia
before beginning his operation was to
A. Decrease his pain perception by reducing sensory impulse transmission
B. Induced sleep by decreasing oxygen and glucose supply to the brain
C. Decrease tissue oxygen need by lowering the rate of cellular metabolism
D. Reduce operative blood loss by causing forceful and prolonged vasoconstriction
59. When assessing Jordan after heart surgery to correct Tetralogy of Fallot,which of the following should alert
the nurse to suspect a low cardiac output?
A. Bounding pulse and mottled skin
B. Pale skin with extremities warm to touch
C. Two seconds capillary refill and irritability
D. Thready pulse and altered level of consciousness
60. The nurse is transferring Jordan who had open heart surgery from PICu to the pediatric ward. His blood
pressure had been fluctuating but has been stable for the past two hours. The nurse from PICU should
include which of the following information in the report to the nurse on the pediatric ward?
1. Medication being used 4. Drip rate of the intravenous infusion
2. Current vital signs 5. Time of most recent dose of pain meds
3. Potential for BP to drop
A. 1,2,4 and 5 B. 2,3,4 and 5 C. 1,3,4 and 5 D. 1,2,3,4 and 5
SITUATION 13: Nurse Rene works in a geriatric wing of a community center in Barangay Bansalan and have been
caring several patients complaining of osteoarthritis. He is very aware of the discomfort and its impact on the
mobility as well as quality of life of patients.
61. Lolo Jose is 60-year-old patient has osteoarthritis (OA) of the left knee. A finding that the nurse would expect
to be present on examination of the patient’s knee
A. Heberden’s nodules C. Redness and swelling of the knee joint
B. Pain upon joint movement D. Stiffness that increases with movement
62. When screening patients at a community center, Nurse Rene will plan to teach ways to reduce risk factors
for osteoarthritis to a
A. 49-year-old woman who works on an factory as a seamstress
B. 24-year-old man who participates in a summer softball team.
C. 36-year-old woman who is newly diagnosed with diabetes mellitus
D. 56-year-old man who is a member of a construction crew
63. When teaching a patient with osteoarthritis (OA) of the left hip and lower lumbar vertebrae about
management of the condition, Nurse Rene determines that additional instruction is needed when the
patient says
A. “I can use a cane if I find it helpful in relieving the pressure on my back”
B. “Warm shower in the morning will help relieve stiffness I have when I get up.”
C. “I should stay active throughout the day to keep joints from becoming stiff.”
D. “I should take no more than 1 g of Aspirin four times a day to control the pain.”
64. Mr. Hodios is a 58-year-old patient has been diagnosed with osteoarthritis (OA) of the hands and feet. The
patient tells the nurse, “I am afraid that I will be hopelessly crippled in just a few years!” The best response
by the nurse is that
A. Progression of OA can be prevented with a regimen of exercise, diet, and drugs
B. OA is an inflammatory process with periods of exacerbation and remission.
C. Joint degeneration with pain and deformity occurs with OA by age 60 to 70
D. OA is common with aging, usually it is localized and does not cause deformity
65. Mrs. Del Mundo is a 71-year-old obese patient has bilateral osteoarthritis (OA) of the hips. Nurse Rene
teaches the patient that the most beneficial measure to protect the joints is to
A. Eat according to a weight-reduction diet to obtain a healthy body weight.
B. Sit in chairs that do not cause the hips to be lower than the knees
C. Use a wheelchair to avoid walking as much as possible
D. Use a walker for ambulation to relieve the pressure on the hips
Sit. 14: Nursing practice today had greatly evolved significantly that most nurses assume an expanded role in the
care of their patients based on the existing general principles and evidenced base practices.
66. When the nurse explains to the patient that together they will plan the patient’s care and set goals to
achieve by discharge, the patient says, “How is that different from what the doctor does?” Which response
by the nurse is most appropriate?
A. “The nurse helps the doctor to diagnose and treat patients.”
B. “Nursing is focused on the human response to health problems.”
C. “Nurses perform many of the procedures done by physicians.”
D. “The role of the nurse is to provide prescribed patient care.”
67. Adaptations used by the nurse when performing a physical examination on an 86-year-old patient will
include
A. Using slightly more pressure for palpation of the liver
B. Avoiding the use of touch as much as possible
C. Speaking slowly when directing the patient
D. Organizing the sequence to minimize position changes.
68. A patient has just been diagnosed with breast cancer following a needle biopsy of a breast lump. The nurse
plans teaching for the patient to meet the goal of
A. Selecting and using treatment options C. Preventing the recurrence of the tumor
B. Learning skills to live with the disease D. Minimizing adverse effects of treatment
69. When assessing patients for the possible health impact of stressors, the most important information to
obtain is
A. Medications that the patient is taking to control anxiety
B. The importance of religious influences for the patient.
C. How long the patient has been exposed to the stressor
D. Any family history of stress-related physical illnesses.
70. The health care provider tells a patient to use ibuprofen (Motrin, Advil) to relieve pain after treating a
laceration on the patient’s forearm from a dog bite. The patient asks the nurse how ibuprofen will control
the pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the
A. Modulating effect of descending nerves. C. Spinal cord transmission of pain impulses.
B. Sensitivity of the brain to painful stimuli. D. Production of pain-sensitizing chemicals
SITUATION 15: Jose is a schizophrenic delusional patient. He has been on pharmacotherapy as part of his
medical management. Following are situations that are Nurses concern for safety and accurate documentation
of patient care.
71. Chlorpromazine (Thorazine) 300 mg QID has been ordered for Jose. Nurse Vixen, the team leader is
responsible for reviewing nurse’s notes. Which observations would alert her as MOST serious side effects of
this drug?
A. Postural hypotension C. Inhibition of ejaculation, decreased libido
B. Photosensitivity and skin rashes D. Agranulocytosis and jaundice
72. With administrator of Chlorpromazine, Jose complains of dry mouth and constipation. Which of the
following nursing action would Nurse Vixen write in the nursing care plan?
A. Question the client about the amount and type of daily exercise
B. Consult with the client’s physician about changing antipsychotic medications
C. Advise the client to chew sugarless gum and eliminate gas forming foods
D. Encourage the client to rinse mouth with water and drink 6-8 glasses each day
73. During the nurse-patient interaction, Jose remarked “Ants are crawling over my body.” The nurse would
record this in which part of the mental status?
A. Emotional state C. Sensorium or orientation
B. Characteristics of talk D. Content of thought
74. A 19-year-old client regularly abuses dextromethorphan (DXM). Which activity, if performed under the
influence of dextromethorphan, places the client at highest risk for complications related to DXM abuse?
A. Fishing on the shore of a lake. C. Wake boarding during summer.
B. Competing in a swim meet. D. Dancing at a night club.
75. A nurse is conducting an admission interview with a client who is under the influence of cocaine. The nurse
interprets that which finding is attributable to the client being under the influence of cocaine at the time of
the interview?
A. Underreporting the amount of cocaine used on a regular basis.
B. Decreased blood pressure and heart rate.
C. Hypersensitivity in response to personal questions.
D. Lack of attention to the interview process.
SITUATION 16: John Lloyd has a history of marginally socially acceptable behavior is admitted to the hospital for
evaluation. The patient tells the nurse that he has been married multiple times but never loved nor would he
support any women of the children he fathered. He was in the observation room waiting for his doctor.
76. The nurse identifies that John Lloyd’s behavior according to the psychoanalytic model demonstrates a defect
in the
A. Superego development C. Ego development
B. Id development D. Sexual development
77. When working with patients who use manipulative, socially acting out behaviors, the nurse should be
A. Nurturing, encouraging and sympathetic C. Consistent, cautious and sincere
B. Restrictive, punishing and strict D. Friendly, supportive and accepting
78. John Lloyd is observed smoking in a non smoking area. Which initial nursing intervention is appropriate?
A. Confront him on his behavior
B. Tell his nurse about this
C. Remind all patients of the no smoking policy
D. Teach alternative coping mechanism for his anxiety
79. Which of the following are elements of the nurse-patient contract?
A. Pre interactin phase where the roles are established
B. Orientation stage, the purpose of the interaction is established
C. Working stage, the conditions for termination are established
D. Termination stage, the criteria for discharge are established
80. Which of the following behaviors exemplifies the concept of counter transference?
A. The nurse defends the patient’s inappropriate behavior to the doctor
B. The nurse emphatizes with the aptient’s loss
C. The nurse subjectively appreciates the patient’s feelings
D. The nurse recognized the patient emotionally attached to the social worker
SITUATION 17: Mara Clara a community health nurse of Dona Imelda Health Center is a dedicated health
worker.
81. Her aim as a health worker is to preserve the eyes of their patients. These are the following except
A. Consult an opthalmologist for symptoms indicating eye problem
B. Render first aid for indicating possible eye problem
C. Administration of eye drops if the eye gets irritated
D. Educating the public about proper care of the eyes and proper diet
82. She emphasized to the patient to seek professional advice. Which of the following symptoms have the least
priority for the need of immediate eye consultation?
A. Pupil irregularities C. Presence of stye
B. Visual disturbances D. Tearing of the eye
83. A patient in the eye clinic is scheduled for refractometry. Which information will be included in patient
teaching?
A. “You should not take any eye medications before the examination”
B. “The surface of the eye will be numb as the doctor examines your eye”
C. “The doctor will shine a bright eye into your eye during the exam”
D. “You will need to wear a sunglasses for a few hours after the exams”
84. The patient who has long-standing hypothyroidism is at particular risk to develop what additional health
problem?
A. Type I diabetes C. Graves' disease
B. Coronary artery disease D. Addison's disease
85. A care plan is formulated for the patient with Cushing's syndrome. In prioritizing the nursing diagnoses, the
nurse gives the greatest priority to the following nursing diagnosis:
A. Risk for injury related to weakness
B. Disturbed body image related to changes in physical appearance
C. Risk for loneliness related to disturbed body image
D. Fatigue related to sleep disturbances
SITUATION 18: Mrs. Marie Cruz, a 30-year old married woman, had an ileostomy for ulcerative colitis.
86. Psychophysiologic disorder such as ulcerative colitis differs from psychoneurotic reaction in that:
A. They are characterized by periods of exacerbation and remissions
B. They can be treated by psychotherapy
C. They are short term illnesses
D. They produce symptoms that can be life threatening if untreated
87. Five days after operation, Mrs. Cruz started to be very demanding and constantly complains fretfully. Which
of the following would be an effective nursing intervention for this behavior:
A. Compliment Mrs. Cruz every time she cooperates
B. Try to understand what she is trying to communicate to the staff
C. Remind Mrs. Cruz that there are other patients to attend to
D. Encourage Mrs. Cruz to divert her attention from her illness by reading
88. A relevant nursing diagnosis based on her demanding behavior would be:
A. Ineffective denial C. Defensive coping
B. Impaired adjustment D. Impaired social interaction
89. The appropriate nursing intervention to deal with the demanding behavior:
A. Set firm limits on her behavior
B. Help her understand that self help would be therapeutic for her
C. Help her to realize that there are other patients to be attended to
D. Accept her unconditionally at the same time assess her complaints objectively
90. The staff can help Mrs. Cruz modify her behavior pattern by doing one of the following:
A. Involving her family in her care
B. Consistency of approach by the staff in the implementation of plan
C. Reorganizing of her basic personality structure
D. Development to insight into the cause of her behavior
SITUATION 19: Bam developed business worries and chronic dyspepsia. He consulted the doctor when nausea
and vomiting cause him to lose sleep at night with occasional epigastric pain.
91. Which of the following emotional factors is thought to contribute to the production of acid pepsin related
disorder?
A. Chronic inhibition of hostile aggressive drives
B. Anxiety relating to the identification of sexual role
C. Strong unconscious passive dependent oral needs
D. Threat of separation from a mother figure
92. Which of the following results of Bam’s blood count would best support the diagnosis of peptic ulcer?
A. Neutrophilic leukocytes C. Blast cell proliferation
B. Hypochromic anemia D. Marked thrombocytopenia
93. The pharmacologic effect of Lanzoprazole in the treatment of ulcer is to
A. Neutralize hydrochloric acid C. Inhibit GI motility
B. Coat mucous membrane D. Cease acid production
94. A vagotomy was planned as part of surgical treatment. Continuous GI decompression most likely would
result to produce
A. Alkalosis C. Hemorrhage
B. Hiccoughs D. Malnutrition
95. As part of nutrition plan, the nurse omitted the inclusion of milk from a clear liquid diet because it
A. Contains calories C. Produces gas
B. Coats the mucosa D. Produces nausea
SITUATION 20: Pine was admitted in the Critical Care Unit with diagnosis of myocardial infarction affecting the
left descending branch of his heart. He was on Dopamine drip and is critical in condition when blood pressure
started to drop with waning level of consciousness.
96. Several of the life-supporting systems of the body are involved in shock. However, shock itself results from
failure of the
A. Circulatory system C. Neurological system
B. Endocrine system D. Respiratory system
97. Because of the falling blood pressure and movement of blood around the body during the compensatory
stage, the nurse will expect Pine’s respiration to be
A. Rapid and shallow C. Rapid and deep
B. Slow and deep D. Slow and shallow
98. The nurse is administering heparin, subcutaneous twice daily, for a patient in cardiogenic shock. The
expected action of this drug is as:
A. An inotropic to improve cardiac contractibility.
B. An anticoagulant to prevent blood clots.
C. An antidysrhythmic to restore normal cardiac contractibility.
D. A vasopressor to increase blood pressure.
99. Which of the following shock types share a common pathophysiologic basis?
A. Cardiogenic shock and Septic shock C. Septic and Neurogenic shock
B. Cardiac tamponade and Anaphylactic shock D. Myocardial infarction and Neurogenic shock
100. In an effort to improve Pine’s condition the doctor started to insert Intra-aortic balloon pump (IABP).
The expected outcome of the procedure is
A. Faciltate healing of necrotic tissue C. Increase cardiac output
B. Reduce contractility of the heart D. Elevate afterload of the heart