RECALLS 5: NURING PRACTICE V
that older adults have a high incidence of hip
Situation: In a Nursing Practice you are directly
involved in conducting a comprehensive physical
assessment especially to older clients with
sensory limitations.
1. When formulating nursing care plans for older
adults, Nurse Trisia should include special
measures to accommodate for age-related
sensory losses such as: *
A. difficulty in swallowing
B. increased sensitivity to heat
C. diminished sensation of pain
D. heightened response to stimuli
2. The client with head injury is having problems
with several sensory functions. Nurse Trisia should
understand that the structure that acts as a relay
center for sensory impulses is the: *
A. thalamus
B. cerebellum
C. hypothalamus
D. medulla oblongata
3. After a brain attack a client remains
unresponsive to sensory stimulation. Nurse Trisia
understands general sensations such as heat,
cold, pain, and touch are registered in the: *
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
4. The novice nurse who is administering a beta
blocker asks the Senior Staff Nurse about its effect
on the Autonomic Nervous System. When
formulating a response the nurse should
understand which common misconception about
the Autonomic Nervous System? *
A. both sympathetic and parasympathetic
impulses continually affect most visceral effectors
B. the autonomic nervous systems is regulated by
impulses from the hypothalamus and other parts
of the brain
C. sympathetic impulses stimulate while
parasympathetic impulses inhibit the functioning
of any visceral effector
D. visceral effectors (e.g., cardiac muscle, smooth
muscle, glandular epithelial tissue) receive
impulses only via autonomic
5. Visual Acuity declines with age. Presbyopia is a
progressive decline in: *
A. Distinguishing between blues and greens and
among pastel shades
B. Ability to see in darkness
C. The ability of the eyes to accommodate for
close detailed work
D. Adaptation to abrupt changes from dark areas
to light areas
Situation: Injury to one part of the Musculoskeletal
system results in malfunction of muscles, joints
and affects mobility of injured area. As an
Orthopedic Nurse you devise a nursing care that
addresses the following situations.
6. A 78 year old adult is admitted to the hospital
after
This studysustaining hip fracture
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When caring for this client the nurse understands
fractures because of: *
A. carelessness
B. fragility of bone
C. sedentary existence
D. rheumatoid disease
7. The client is placed in a Buck’s extension
traction with a 5 lb. weight and scheduled for
surgery the following morning. Initial assessment
of this client would most likely reveal: *
A. Internal rotation and abduction of the right leg,
which is shorter than the left leg
B. Lateral rotation and adduction of the right leg ,
which is shorter than the left leg
C. Hat and redness over the fracture site
D. Fever chills and elevated white blood cell
(WBC) count
8. A medical Nurse admitted a client with
Osteoporosis. Which piece of information from the
client’s history does the nurse identify as a risk
factor for developing Osteoporosis? The client: *
A. receives long-term steroid therapy
B. has a history of hypoparathyroidism
C. engages in strenuous physical activity
D. consumes high doses of the hormone estrogen
9. Mrs. Felipa 72 years old with degenerative joint
disease asks the nurse, “My doctor mentioned
something about synovial fluid and the joint. What
is that?” What is the nurse’s best response?” The
synovial fluid of the joints minimizes: *
A. Efficiency
B. Work output
C. Friction in the joints
D. Velocity of movements
10. A Nurse has given dietary instructions to Mrs.
Felipa to minimize the risk of Osteoporosis. The
Nurse would evaluate that the client understands
the recommended dietary changes if the client
stated she should increase intake of which food? *
A. Rice
B. Yogurt
C. Sardines
D. Chicken
Situation; Cataracts develop at any age for a
variety of causes. Visual impairment progresses at
the same rate in both eyes over many years or in
a matter of months.
11. A client’s child asks Nurse Weng what a
cataract is. What explanation should the nurse
provide? “A cataract is a / an: *
A. Opacity of the lens.”
B. Thin film over the cornea.”
C. Crystallinization of the pupil.”
D. Increase in the density of the conjunctiva.”
12. In preparation for cataract surgery Nurse
Weng is to administer a prescribed cmedication..
The Nurse reviews the Physician’s orders,
expecting which type of eye drops to be
prescribed? *
A. An Osmotic diuretic
B. A Miotic agent
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 D. A thiazide diuretic
13. After a client has cataract surgery, what should
Nurse Weng do? *
A. instruct the client to avoid driving for 2 weeks
B. teach the client coughing and deep-breathing
techniques
C. encourage eye exercises to strengthen the
ocular musculature
D. advise the client to refrain from vigorous
brushing of teeth and hair
14. Nurse Weng is performing an admission
assessment to Mr. Kan with diagnosis of detached
retina. Which of the following is associated with
this eye disorder? *
A. Pain in the affected eye
B. Total loss of vision
C. A sense of curtain falling across the field of
vision
D. A yellow discoloration of the sclera
15. Mr. Kan is scheduled for surgery for a
detached retina. Which client statement indicates
that se Weng preoperative teaching is effective?
“The goal of surgery is to : *
A. Promote growth of new retinal cells.”
B. Adhere the sclera to the choroid layer.”
C. Graft a healthy piece of retina in place.”
D. Create a scar that aids in healing retinal holes.”
Situation: Mrs. Kate 48 years old is admitted
because of extreme fatigue on exertion . Her
Physician suspects Myasthenia Gravis.
16. A client with Myasthenia Gravis asks the
nurse, “What is going to happen to me and to my
family?” When formulating a response, the nurse
should understand that the prognosis for
Myasthenia Gravis generally is: *
A. excellent with proper treatment
B. slowly progressive without remissions
C. chronic with exacerbations and remissions
D. poor, with death occurring in a few months
17. Mrs. Kate asks the nurse why the disease has
occurred. What pathology underlies the nurse’s
reply? *
A. a genetic defect in the population of
acetylcholine
B. an inefficient use of the neurotransmitter
acetylcholine
C. a decreased number of functioning
acetylcholine receptor sites
D. an inhibition of enzyme AChE, leaving the end-
plates folded
18. Nurse Thelma is leading a support group for
clients affected by Myasthenia Gravis. For what
group of individuals does Nurse Thelma
understand that the incidence of Myasthenia
Gravis is highest? *
A. males ages 15 to 35
B. children ages 5 to 15
C. females ages 20 to 30
D. both sexes equally before age 40
19. Mrs. Kate becomes increasingly weaker. The
Physician prepares to identify whether the client is
reacting to an overdose of medication (Cholinergic
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(Myasthenic Crisis ). An injection of the
Edrophonium ( Tensilon ) is administered . Which
of the following indicate that the client is in
cholinergic crisis? *
A. An improvement of the weakness
B. A temporary worsening of the condition
C. No change in the condition
D. Complaints of muscle spasm
20. What does Nurse Thelma understands that
clients with Myasthenia Gravis, Guillain-Barre
syndrome, and Amyotropic Lateral Sclerosis share
in common? *
A. progressive deterioration until death
B. deficiencies of essential neurotransmitters
C. increased risk for respiratory complications
D. involuntary twitching of small muscle groups
Situation: Many patients with problems in Central
Nervous System will result to disruption of normal
sensory and motor pathways. Nurses can better
manage the needs of the client if they understand
the course of the disorders. Neurologic
assessment and diagnostic tests are conducted to
plan effective nursing interventions.
21. When performing a Neurologic assessment of
a client, Nurse Avida identifies that the client has a
dilated right pupil. The nurse understands that this
suggests a problem with which Cranial nerve? *
A. third cranial nerve
B. second cranial nerve
C. fourth cranial nerve
D. seventh cranial nerve
22. The mouth of a client is drawn over the left.
Nurse Avida understands that this suggests injury
to which cranial nerve? *
A. left facial nerve
B. right facial nerve
C. left abducent nerve
D. right trigeminal nerve
23. Nurse Avida is assigned in a special unit with
clients having problems in Neurologic disorders
like Meningitis. A Physician performs a Lumbar
Puncture. The client asks if the needle goes into
the spinal cord. Nurse Avida bases a response on
the understanding that the Physician must insert a
needle into the: *
A. pia mater
B. foramen avale
C. subarachnoid space
D. aqueduct of sylvius
24. A client is having lumbar puncture performed.
Nurse Avida would plan to place the client in which
position for the procedure? *
A. Side lying with legs pulled up and head bent
down onto chest L3-L5
B. Side lying with a pillow under the hip
C. Prone in slight Trendelenburg position
D. Prone with a pillow under the abdomen
25. Nurse Avida assists the Physician in
performing a lumbar puncture. When the pressure
is placed on the jugular vein during a lumbar
puncture, the spinal fluid pressure is expected to
increase. What sign should the nurse expect the
physician to document? *
 A. Abadie’s sign
B. Hannington-Kiff’s sign
C. Peabody’s sign
D. Queckenstedt’s sign
Situation: Impaired Sensorineural function (vision ,
hearing , balance disorders ) may affect the clients
independence in self care work and lifestyle
choices. Nurses in all setting assess patients at
risk and implement measures to prevent further
complications. Nurse Gigi is assigned to these
clients.
26. Mr. Goma 68 years old is admitted with
Glaucoma. Which desired effect of therapy should
Nurse Gigi explain to the client with primary Angle-
Closure Glaucoma? *
A. dilating the pupil
B. resting the eye muscles
C. controlling intraocular pressure
D. preventing secondary infections
27. Which clinical indicator would Nurse Gigi most
likely to identify when exploring the history of Mr.
Goma with Open-angle glaucoma? *
A. constant blurred vision
B. sudden attacks of acute pain
C. impairment for peripheral vision
D. sudden, complete loss of vision
28. Nurse Gigi notice that many of the patients
whom she had interviewed have some type of
hearing impairment. One of the clients has a
conductive hearing loss. Nurse Gigi explains that
the bones that transmit vibrations to the oval
window of the cochlea are located in which
structure? *
A. earlobe
B. eardrum
C. inner ear
D. middle ear
29. Berto a 68 year old with a hearing loss asks
Nurse GIgi to explain the cause of nerve deafness.
The nurse explains that deafness is most likely
caused by an injury or infection that damages
the: *
A. vagus nerve
B. cochlear nerve
C. vesticular nerve
D. trigeminal nerve
30. Nurse Gigi is caring for an older adult with a
hearing loss secondary to aging. What can the
nurse expect to identify when assessing this
client? *
A. copious, moist cerumen
B. tears on the tympanic membrane
C. difficulty hearing in women’s voices
D. overgrowth of the epithelial auditory lining
Situations: The diverse Neurologic disorders
present a unique challenges of nursing care. The
Nurse must have a clear understanding of the
pathologic processes for appropriate nursing
management. Nurse Marco is attending to clients
in the ward with Multiple Sclerosis.
31. Which statement by a client with Multiple
Sclerosis indicates to Nurse Marco that the client
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needs further teaching? *
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A. “I use a straw to drink liquids.”
B. “I will take a hot bath to help relax my
muscles.”
C. “I plan to use an incontinence pad when I go
out.”
D. “I may be having a rough time now, but I hope
tomorrow will be better.”
32. A recently hospitalized client with Multiple
Sclerosis is concerned about generalized
weakness and a fluctuating physical status. What
is the priority nursing intervention for this client? *
A. encourage bed rest
B. space activities throughout the day
C. teach the limitations imposed by the disease
D. have one of the client’s relatives stay at the
bedside
33. Marco is excited to be assigned in a Neuro –
Ward after his extensive training. He is preparing
to conduct a Neurologic examination. What
nursing intervention is anticipated for a client in
the plateau phase of Guillain-Barre syndrome? *
A. providing a straw to stimulate the facial
muscles
B. inserting an indwelling catheter to monitor
urinary output
C. encouraging aerobic exercises to avoid muscle
atrophy
D. administering antibiotic medication to prevent
pneumonia
34. Mr. Rod a 48 year old client carpenter admitted
after a spinal cord injury and the Physician
indicates that a client is a Paraplegic. The family
asks Nurse Marco what this means. What
explanation should the nurse give to the family? *
A. upper extremities are paralyzed
B. lower extremities are paralyzed
C. one side of the body is paralyzed
D. both lower and upper extremities are paralyzed
35. Which clinical indicator does Nurse Marco
identify when assessing a client with hemiplegia? *
A. paresis of both lower extremities
B. paralysis of one side of the body
C. paralysis of both lower extremities
D. paresis of upper and lower extremities
Situation: Caring for a patient with Spinal Cord
Injury (SCI) requires a patient centered
collaborative approach to help meet the patient’s
expected outcomes.
36. A client with a spinal cord injury has
Paraplegia. Nurse Marco assesses for which
major problem the client may experience early in
the recovery period? *
A. bladder control
B. nutritional intake
C. quadriceps setting
D. use of aids for ambulation
37. Another client has Paraplegia as a result of a
motorcycle accident. What is the reason the
nursing care plan should include turning the client
every 1 to 2 hours? *
A. prevent pressure ulcers
B. keep the client comfortable
C. prevent flexion
 D. improve venous circulation in the lower
extremities
38. Maya a 48 year old, fell from a 5 steps
staircase and was diagnosed of a spinal cord
injury. Nurse Marco encourages the client to drink
fluids primarily to prevent: *
A. dehydration
B. skin breakdown
C. electrolyte imbalances
D. urinary tract infections
39. In a Rehabilitation Center a client with
quadriplegia is placed on a tilt table daily. Each
day the angle of the head of the table is gradually
increased. When the client asks the reason for the
tilt table, what is the nurse’s best response? “The
tilt table is used to: *
A. Facilitate turning.”
B. Prevent pressure sores.”
C. Promote hyperextension of the spine.”
D. Limit loss of calcium from the bones.”
40. The nurse in a rehabilitation center teaches
clients with quadriplegia to use an adaptive
wheelchair. Why is it important that the nurse
provide this instruction? *
A. it prepares them for bracing and crutch walking
B. they usually are not, and never will be,
functional walkers
C. they have the strength in the upper extremities
for self-transfer
D. it assists them in overcoming orthostatic
hypotension
Situation: Anxiety is a subjective and individual
experience characterized by feelings of
apprehension and uncertainty. A Psychiatric Nurse
is preparing to interview a client with anxiety
disorders.
41. The nurse teaches the client that the level of
anxiety that best enhances an individual’s power
of perception is: *
A. Mild
B. Panic
C. Severe
D. Moderate
42. A client attending a Mental Health facility is
scheduled for several diagnostic studies. Which
client behavior best indicates to the nurse that the
client has received adequate preparation for these
studies? *
A. The client requests that the tests be
reexplained
B. The client checks the appointment card
repeatedly
C. The client paces the hallway the morning
before the tests
D. The clients arrives early, waiting quietly to be
called for the tests
43. Before discharge, the nurse should teach the
family of an anxious client that anxiety can be
recognized as: *
A. A totally unique feeling
B. Consciously motivated thoughts and wishes
C. Fears that are related to the total environment
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D. A behavior pattern observed in ourselves and
others
44. Another client a 35 year old is admitted for an
amputation of the left leg. Before surgery the
nurse observes that the clients is diaphoretic,
voiding frequently, having difficulty understanding
what is being said, and complaining of
palpitations. What should the nurse do first after
making these assessments? *
A. Have a stat ECG done on the client
B. Ask the client to talk about feelings
C. Obtain a urine specimen for culture and
sensitivity
D. Ask the physician for a stat order for an IM
tranquilizer
45. When planning care for a group of children,
the nurse understands that the problem of
separation anxiety becomes most problematic for
children hospitalized during the age of: *
A. 5 to 11 ½ years
B. 12 to 18 years
C. 6 to 30 months
D. 36 to 59 months
Situation: Nurse Helen is aware that seizures are
the results of abnormal paroxysmal small
discharges in the cerebral cortex which then
manifest as an alteration in sensation, movement
and perceptions.
46. What is the primary responsibility of Nurse
Helen during a client’s generalized motor
seizure? *
A. inserting a plastic airway between the teeth
B. determining whether an aura was experienced
C. administering the prescribed PRN
anticonvulsant
D. clearing the immediate environment for client
safety
47. A male client who has a history of seizure is
scheduled for an anteriogram at 10 AM and he is
to receive Phenytoin (Dilantin) at 9 AM. What
should Nurse Helen do? *
A. omit the 9 AM dose of the drug
B. give the same dosage of the drug rectally
C. ask the physician if the drug can be given IV
D. administer the drug with 30 mL of water at 9
AM
48. Nurse Helen is planning to institute a seizure
precaution. Which of the following measures
would the Nurse avoid in planning for the client’s
safety? *
A. Placing an airway , oxygen and suction
equipment at the bedside
B. Padding the side rails of the bed
C. Putting a padded tongue blade at the head of
the bed
D. Having intravenous equipment ready for
insertion of an intravenous catheter
49. A client, who is receiving Phenytoin (Dilantin)
to control a seizure disorder, questions Nurse
Helen regarding this medication after discharge.
Which is the nurse’s best response? “This
medication: *
A. Prevents
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 B. Will probably have to be continued for life.”
C. Needs to be taken during periods of emotional
stress.”
D. Can usually be stopped after a year’s absence
of seizures.”
50. Nurse Helen is preparing an intravenous
infusion of Dilantin as Prescribed by the Physician
for clients with seizures. Which of the following
solutions will the Nurse plan to use to dilute this
medication ? *
A. Lactated Ringer’s solution
B. 5% Dextrose
C. 5% Dextrose and ½ Normal Saline
D. Normal Saline Solution
Situation: Nurse Alexis has been taking care of
patients in Ward A with different personality
disorders.
51. In determining the plan of care for clients with
schizoid personality disorder, which of the
following should the nurse consider? The client *
a. Quickly become attached to the group leader
b. Displays behavior lacking social tact or grace in
a group
c. Becomes overly emotional in the group setting
d. Attempts to build intimate relationships with
other group members
52. Which of the following should the nurse
consider when planning the care of a client who
has antisocial personality disorder? *
a. The client’s lack of ability to engage with the
nurse
b. The client’s attempts to manipulate the nurse
c. The client’s hindered ability to justify actions
d. The client’s openness and honesty about past
experiences
53. The nurse is caring for a client who is seeing
UFOs, and asks if the nurse is also afraid of the
UFOs. Which of the following would be an
appropriate response from the nurse? *
a. “I don’t know what are you talking about, I don’t
see any UFOs”
b. “I can tell that what you’re seeing frightens you,
how can I help to make you more comfortable?’
c. “I see the UFOs too, and they scare me, what
are we going to do?”
d. “I don’t see the UFOs, too, are you ready to
come to group?”
54. Which of the following is an appropriate goal
for the nurse caring for the client who has a
diagnosis of the borderline personality disorder? *
a. To identify irrational thoughts and beliefs that
the client’s decision- making is founded on
b. To eliminate boundaries between the client and
nurse so the client can more easily share
problems
c. To eliminate the immediate focus on the client
by encouraging the client to focus on the
relationships with others
d. To eliminate the clients involvement in the
treatment planning because of the accompanying
irrational thoughts and beliefs.
55. The nurse is collecting a nursing history on a
client
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disorder. Which of the following assessments
would the nurse expect to find? *
a. A style of speech that lacks detail
b. An unconscious dependent to others
c. A lack of empathy for others
d. Attempts to promote self-esteem in others
Situation: The student nurse is reviewing for his
admission exam for a prestigious hospital in
Taguig City. He is answering questions related to
eye disorders.
56. A patient is due to undergo tonometry for
confirmation of the diagnosis of glaucoma. The
nurse advices the patient against which of the
following, except: *
a. Squinting
b. Breathing through open glottis
c. Coughing
d. Bending at the hips
57. In the clinic, the school health nurse is
conducting a vision screening to incoming Grade 1
and Grade 4 students. One of the students was
able to read at 10 ft, what a normal eye sees at 20
feet. She documents this finding as: *
a. 10/20
b. 20/10
c. 2/1
d. 1/2
58. A student was not able to read the letters in the
20/20 level. How should the nurse proceed with
the visual assessment? *
a. Document this finding as visual impairment.
b. Allow the student to come nearer at a distance
of 10 ft.
c. Ask the student to squint, and try reading the
level again.
d. Remind the student to avoid guessing at letters
to have an accurate finding
59. The nurse is performing an admission
assessment on a client with a diagnosis of
detached retina. Which of the following is
associated with this eye disorder? *
a. Total loss of vision
b. Pain in the affected eye
c. A yellow discoloration of the sclera
d. A sense of a curtain falling across the field of
vision
60. The nurse is caring for a client following
enucleation. The nurse notes the presence of
bright red drainage on the dressing. Which nursing
action is appropriate? *
a. Notify the physician.
b. Document the finding.
c. Continue to monitor the drainage.
d. Mark the drainage on the dressing and monitor
for any increase in bleeding.
Situation: In the PGH Ear Unit, the staff nurse is
attending to several outpatient clients seeking
follow-up care.
61. The nurse assists in an ear irrigation. Which of
the following statements by the nurse is correct? *
a. “Tilt the head towards the unaffected ear.”
b. “Direct the stream of irrigate at the sides of the
personality
ear canal.”
 c. “After the procedure, lie on the unaffected side c. Nausea and vomiting
to allow the irrigate to soften any hardened mass.” d. Muscle pain
d. “This procedure is allowed for otitis media to
clean the canal.” 70. The following are the reasons why many
people abuse caffeine. Choose the exception. *
62. In administering ear drops, the nurse observes a. Relieve fatigue
which of the following principles? * b. Increase mental alertness
a. In a child, pull pinna upward and backward. c. Both A and B
b. Let the ear drops fall on the middle space of the d. Neither A nor B
canal.
c. Lie on the unaffected side to facilitate Situation: The ICU nurse assigned to a 60-year old
absorption. acutely ill client with Parkinson’s disease who was
d. Position unaffected ear uppermost. hospitalized frequently. The initial confinement
was due to electrolyte imbalance. The following
63. Otosclerosis, a disorder of labyrinth function, confinement was due to injury sustained from fall,
constitutes which type of hearing loss? * he became to have incontinent of stools that
a. Perceptive loss further lead to development of skin irritation and
b. Conductive loss breakdown. Currently he was admitted due to
c. Sensorineural loss respiratory infection.
d. Mixed loss
71. Related literatures included case situations
64. Which of the following is a characteristic sign similar to the case of the client. The nurse is
of acute otitis media in children? * interested in gaining further knowledge that can
a. Jumping in pain help the client at risk for fecal incontinence. The
b. Ear tugging nurse should use which of the following method to
c. Painless inflammation strengthen this report? *
d. Difficulty awakening a. Historical research method
b. Qualitative research method
65. What makes children more predisposed to c. Experimental research method
chronic otitis media? * d. Quantitative research method
a. Shorter Eustachian tube
b. Horizontal orientation of the ear canal 72. The review of literature does not only include
c. Primary diaphragmatic breathing published research studies but also theory. In this
d. Both A and B case which theory is least related to the study? *
a. Neuman’s system model
Situation: Addiction disorders are unnecessarily b. Lazarus’ theory of stress and coping
common in the modern lifestyle of Filipinos, c. Nightingale’s environmental theory
especially with the rise of establishments selling d. Roy’s theory of adaptation
products with caffeine. Because of the various
“improvements” in performance, this industry is 73. While the nurse was able to identify the cases
still unwavering. that were studied, it is important to understand the
phenomenological experience of the client. This
66. Which of the following do not have the approach includes the following except: *
potential of addiction, if consumed frequently and a. Exploring the idea expressed by the person
in large amounts? * b. Getting the whole picture of fecal incontinence
a. Chocolate-flavored Cola and its associated factors
b. Apple juice c. Focusing interview on fecal incontinence
c. Green tea d. Interviewing and using of questionnaire on
d. Common cold preparations client’s responses to his situation
67. Caffeine greatly affects which part of the heart, 74. The patient also reports multiple lumbar
as reflected in an ECG? * muscle strains, thus is also looking at using
a. Atrium alternative therapies to reduce the pain. The client
b. Ventricles seeks advice from the nurse as to what type of
c. Purkinje fibers alterative therapy would provide the best pain
d. Interventricular septum relief. How should the nurse respond? *
68. The nurse suspects caffeine intoxication in a a. "I have seen many individuals with your type of
young professional if he notes which finding? * pain be relieved of pain through the use of
a. Decreased flow of thought and speech acupuncture."
b. Psychomotor agitation b. "These types of therapies are more than just
c. Urinary retention therapies; they are really a mind over matter type
d. Pale face of event or game."
c. "Some of my other clients swear by magnet
69. In the previous situation of the young therapy to reduce pain as it is very small and very
professional intoxicated with caffeine, he suddenly easy to use."
was unable to take any caffeine source for 24 d. "You need to choose the alternative therapy
hours already. The nurse expects to note the that is right for you based on research that
following findings, except? * supports the intervention."
a. Headache
b. study
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 75. Which of the following can the nurse use in
protecting the safety of the subjects undergoing
the research study? i. Code for Nurses ii.
Nightingale’s pledge iii. Patient’s Bill of Rights iv.
Human Rights Guidelines *
a. 1, 2, 3, 4
b. 1, 3
c. 1, 2
d. 3 only
Situation: The diverse Neurologic disorders
present a unique challenges of nursing care. The
Nurse must have a clear understanding of the
pathologic processes for appropriate nursing
management. Nurse Marco is attending to clients
in the ward with Multiple Sclerosis.
76. Which statement by a client with Multiple
Sclerosis indicates to Nurse Marco that the client
needs further teaching? *
a. “I use a straw to drink liquids.”
b. “I will take a hot bath to help relax my muscles.”
c. “I plan to use an incontinence pad when I go
out.”
d. “I may be having a rough time now, but I hope
tomorrow will be better.”
77. A recently hospitalized client with Multiple
Sclerosis is concerned about generalized
weakness and a fluctuating physical status. What
is the priority nursing intervention for this client? *
a. encourage bed rest
b. space activities throughout the day
c. teach the limitations imposed by the disease
d. have one of the client’s relatives stay at the
bedside
78. Marco is excited to be assigned in a Neuro –
Ward after his extensive training. He is preparing
to conduct a Neurologic examination. What
nursing intervention is anticipated for a client in
the plateau phase of Guillain-Barre syndrome? *
a. providing a straw to stimulate the facial
muscles
b. inserting an indwelling catheter to monitor
urinary output
c. encouraging aerobic exercises to avoid muscle
atrophy
d. administering antibiotic medication to prevent
pneumonia
79. Mr. Rod a 48 year old client carpenter admitted
after a spinal cord injury and the Physician
indicates that a client is a Paraplegic. The family
asks Nurse Marco what this means. What
explanation should the nurse give to the family? *
a. upper extremities are paralyzed
b. lower extremities are paralyzed
c. one side of the body is paralyzed
d. both lower and upper extremities are paralyzed
80. Which clinical indicator does Nurse Marco
identify when assessing a client with hemiplegia? *
a. paresis of both lower extremities
b. paralysis of one side of the body
c. paralysis of both lower extremities
d. paresis of upper and lower extremities
Situation: In the Psychiatric ward nurses are
discussing
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Alzheimer’s disease (AD). And they all agree that
it is a degenerative disease of the brain caused by
gradual death and loss of brain cells resulting to
progressive and irreversible Dementia.
81. Which of the following nursing intervention is
most helpful in meeting the needs of an older adult
hospitalized with the diagnosis of Dementia of the
Alzheimer’s type? *
a. providing a nutritious diet high in carbohydrates
and protein
b. simplifying the environment as much as
possible while eliminating the need for choices
c. developing a consistent nursing plan with fixed
time schedules to provide for emotional needs
d. providing an opportunity for many alternative
choices in the daily schedule to stimulate interest
82. The nurse recognizes that Dementia of the
Alzheimer’s type is characterized by: *
a. aggressive acting-out behavior
b. periodic remissions and exacerbations
c. hypoxia of selected areas of brain tissue
d. areas of brain destruction called senile plaques
83. A 75-year-old man with the diagnosis of
Dementia has been cared for by his wife for 5
years. For the past 2 years he has not spoken and
incontinent of urine and feces. During the last
month he has changed from being placid and
easygoing to agitated and aggressive. He is
admitted to a Psychiatric hospital for treatment
with Psychopharmacology. Which is the priority
nursing care while this client is in the psychiatric
facility? *
a. managing his behavior
b. preventing further deterioration
c. focusing on the needs of the wife
d. establishing on the needs of the wife
84. When attempting to understand the behavior
of an older adult diagnosed with Vascular
Dementia, the nurse recognizes that the client is
probably: *
a. not capable of using any defense mechanisms
b. using one method of defense for every situation
c. making exaggerated use of old, familiar
mechanism
d. attempting to develop new defense mechanism
to meet the current situation.
85. The Nurse develops a nursing diagnosis of self
care deficit for an older client with Dementia.
Which of the following is the most appropriate goal
for this client? *
a. The client will be admitted to a long care facility
to have activities of daily living needs met
b. The client will function at the highest level of
independence possible
c. The client will complete all activities of daily
living independently within one (1 ) hour time
frame
d. The Nursing staff will attend to all the client’s
activities of daily living needs during the
hospitalization
Situation: In a Nursing Practice you are directly
involved in conducting a comprehensive physical
assessment especially to older clients with
of
sensory
on 03-04-2024 06:02:40limitations.
GMT -06:00
 86. When formulating nursing care plans for older
adults, Nurse Trisia should include special
measures to accommodate for age-related
sensory losses such as: *
A. difficulty in swallowing
B. increased sensitivity to heat
C. diminished sensation of pain
D. heightened response to stimuli
87. The client with head injury is having problems
with several sensory functions. Nurse Trisia should
understand that the structure that acts as a relay
center for sensory impulses is the: *
A. thalamus
B. cerebellum
C. hypothalamus
D. medulla oblongata
88. After a brain attack a client remains
unresponsive to sensory stimulation. Nurse Trisia
understands general sensations such as heat,
cold, pain, and touch are registered in the: *
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe
89. The novice nurse who is administering a beta
blocker asks the Senior Staff Nurse about its effect
on the Autonomic Nervous System. When
formulating a response the nurse should
understand which common misconception about
the Autonomic Nervous System? *
A. both sympathetic and parasympathetic
impulses continually affect most visceral effectors
B. the autonomic nervous systems is regulated by
impulses from the hypothalamus and other parts
of the brain
C. sympathetic impulses stimulate while
parasympathetic impulses inhibit the functioning
of any visceral effector
D. visceral effectors (e.g., cardiac muscle, smooth
muscle, glandular epithelial tissue) receive
impulses only via autonomic neurons
90. Visual Acuity declines with age. Presbyopia is
a progressive decline in: *
E. Distinguishing between blues and greens and
among pastel shades
F. Ability to see in darkness
G. The ability of the eyes to accommodate for
close detailed work
H. Adaptation to abrupt changes from dark areas
to light areas
Situation: The fundamental assumption of theory
of life cycle theories is that development occurs in
successive stages. The different life cycle theories
try to explain personality development as well as
development of Psychiatric disorders. The
following questions refer to this situation.
91. The nurse understands that Freud’s phallic
stage of psychosexual development, which
compares with Erikson’s psychosocial phase of
initiative versus guilt, is seen best at: *
A. adolescent
B. 6 to 12 years
C. 3 to 51/2 years
D. birth to 1 year
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92. A 3 year old boy was brought to a Pediatric
clinic for an indifferent behavior. About a month
after their toddler is diagnosed as moderately
retarded, the parents discuss the toddler’s future,
reflecting specifically on plans for their child’s
independent functioning. The nurse recognizes
that the parents: *
A. Are using denial
B. Accept the child’s diagnoses
C. Are using intellectualization
D. Accept their child’s limitation
93. The nurse understands that problems with
dependence versus independence develop during
the stage of growth and development known as: *
A. Infancy
B. School age
C. Toddlerhood
D. Preschool age
94. When planning to teach about the stages of
growth and development, what stage does the
nurse indicate as basically concerned with role
identification? *
A. Oral stage
B. Genital stage
C. Oedipal stage
D. Latency stage
95. The nurse utilizes play when interacting with
children based on the understanding that play for
the preschool-age child is necessary for the
emotional development of: *
A. Projection
B. Introjection
C. Competition
D. Independence
Situation: Elisa a Psychiatric Nurse responds in a
variety setting to different clients with Personality
disorders.
96. Strict toilet and too early training to a toddler
child will cause problems in personality
development because at this age a child is
learning to: *
A. Satisfy own needs
B. Identify own needs
C. Satisfy parents’ needs
D. Live up to society’s expectations
97. The Psychiatrist orders “Restraints PRN” for a
client who has a history of violent behavior. Nurse
Elisa should: *
A. Utilize the restraint order if the client begins to
act-out
B. Ask the psychiatrist to clarify the type of
restraint order
C. Ensure that the entire staff is aware of the
restraint order
D. Recognize that PRN orders for restraints are
unacceptable
98. A client on the Psychiatric unit asks Nurse
Elisa about Psychiatric Advances Directives
(PAD). The nurse explains that these advances
directives: *
A. Make the appointment of a surrogate decision
maker unnecessary
 B. Permit the client to dictate what treatments will
be given during future hospitalization
C. Eliminate the need for involuntary admissions
when the client is a threat to self or others
D. Allow the client, while having the capacity, to
consent or refuse potential psychiatric treatments
in the event of a future incapacitating mental
health crisis
99. As Depression begins to lift, a client is asked
to join a small discussion group that meets every
evening on the unit. The client is reluctant to join
because, “I have nothing to talk about.” What is
the best response by the nurse? *
A. “Maybe tomorrow you will feel more like
talking.”
B. “Could you start off by talking about your
family?”
C. “A person like you has a great deal to offer the
group.”
D. “You feel you will not be accepted unless you
have something to say?” reflective
100. The nurse encourages a client to join a self-
helping group after being discharged from a
Mental health facility. The purpose of having
people work in a group is to provide: *
A. Support
B. Confrontation
C. Psychotherapy
D. Self-awareness

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