Situation: Lexie, 52 years of age, was brought
Inserting a urinary catheter
to the ED due to numbness on her left face
and a confused mental state. The physician’s
initial diagnosis is ischemic stroke.
1.The following are true regarding brain
attack except:
A. It can be caused by thrombosis or
embolism
B. The use of oral contraceptive increases the
risk of having a brain attack
C. Cerebral anoxia lasting longer than 20
minutes causes irreversible damage = longer
than 10 minutes
D. Airway patency is always a priority.
2.Lexie’s father, Thatcher, asks the nurse if his
daughter’s initial diagnosis is different from
“hemorrhagic stroke” which his late
grandfather experienced years ago. The
nurse answers correctly if she answers:
A. Yes, ischemic stroke patients may
experience severe headaches, while
hemorrhagic patients may not.
B. Yes, ischemic stroke is more common and
occurs when a blood vessel is blocked by a
clot or thrombosis; while hemorrhagic stroke
occurs when a blood vessel bursts and bleeds
into the brain causing hemorrhage.
C. No, they are generally the same.
D. No, because manifestations of different
types of strokes are similar.
3. The nurse is aware that the following
should be implemented during the acute
phase of stroke except:
A. Maintaining a quiet environment
B. Placing antiembolism stockings
C. Administering oxygen
D.
4. Visual-perceptual disturbances can occur
in stroke. The nurse should encourage the
client to: (homonymous hemianopsia =
blindness in the same eye)
A. Provide eye care for visual deficits
B. Approach from the affected side
C. Approach from the unaffected side
D. Turn the head to scan the complete range
of vision
5.What is the most ideal position of Lexie
when eating?
A. Sitting in a chair or up in bed, with the head
and neck positioned slightly forward and
flexed.
B. Sitting in a chair or up in bed, with the head
positioned slightly forward and flexed.
C. Sitting in a chair or up in bed, with the neck
positioned slightly forward and flexed.
D. High-fowler
Situation: Nurses have an important role in
establishing an environment that satisfies the
biological, psychosocial, and spiritual needs
of clients. They are often challenged with
issues and problems in creating therapeutic
environment for clients
6.In structuring a therapeutic environment, it
is MOST important for the nurse to:
A. Safeguard physical safety and psychological
security.
B. Keep an effective social order that
recognizes authority.
C. Keep a restrictive environment to prevent
patient assaultiveness.
D. Maintain a closed-door policy to instill
order and disciple.
 7. Environment as referred to in ‘milieu
therapy’ refers to the:
A. Building and grounds where patients
interact.
B. People with different personalities who
relate with one another.
C. Physical environment and relationships of
people within.
D. Immediate physical surroundings that
create an ambience for the patients
A. Have team leaders to check physical
presence and attendance of patients in ward
activities.
B. Constantly monitor implementation of ward
policies and rules.
C. Encourage patient interactions, group
problem solving and decision making.
D. Encourage patients to police themselves
and impose sanctions on ward violations.

Situation: A nurse researcher in the

Psychiatric unit is undertaking a study on the
8. Attitude therapy safeguards the
relationship between depressive symptoms
therapeutic application of attitudes toward
and motivation to lose weight among high
patients. Rico, seeks attention from the staff
school overweight teens in selected schools
by repeatedly deviating and not participating
at the National Capital Region.
in structured activities. It is BEST for the
nurse to:

A. Respond: “it is okay for as long as you don't 11. The study design to be used by the
bother anyone” researcher is:

B. Have a patient watcher monitor him closely. A. Experimental

C. Ignore the behavior. B. Predictive correlational

D. Respond: “we have agreed on a schedule. I C. Non-experimental

expect you to follow.”
D. Descriptive correlational

9. The nurse is aware that these patients are

12. Which of the following is true about the
likely to be exploited in a group setting.
study design being used by the researchers?
These are the patients who are:
A. There is no researcher intervention = non
A. Suspicious
experimental
B. Sociable = their social attributes are highly
B. It is safe to infer causal relationships in this
valued in activities that involve in group
study design
setting
C. It proves causation.
C. Withdrawn
D. Effective means of collecting data
D. Hostile

13. Which of the following inclusion criteria

10. A therapeutic community aims to:
should be observed by the researcher in
selecting the subjects?
A. Current diagnosis of major depression. 16. From the behavior of Justine, the nurse
infers that a fundamental issue is Justine’s:
B. High school students with body mass index
of 25 or greater. A. Difficulty developing stable relationships

C. Enrolled in high school in NCR. B. Inability to learn from past experiences

D. High school students with aged limit of 16 – C. Withdrawn attention

20 years.
D. Suspiciousness and mistrustful of others

14. The independent variable for this study

17. With other children in the unit, Justine
is:
smiles with glee watching adult staff struggle
A. Weight loss to take time to fix the place and put things in
order every time she and other children
B. Not applicable
create chaos. This pattern of behavior is:
C. Depressive symptoms
A. Assaultive
D. Motivation
B. Demanding

C. Hostile
15. One of the statistical approaches to be
D. Manipulative = feels like he is in control
used by the researcher in analyzing whether
a relationship exists between the number of
depressive symptoms and motivation to lose
18. The psychodynamics of Justine’s behavior
weight is:
most likely would point to:
A. Chi square test
A. Lack of social support for growing children
B. Analysis of covariance from the local government.

C. Pearson’s coefficient of correlation B. Lack of parenting, stressful and stormy

family life.
D. Product moment correlation
C. Failure of the school system to provide early
education.
Situation: Justine is 12 years old, looks like
D. Excessive media that portray sex and
she is 9 and acts she is 4. She has lightning –
violence in TV programs.
quick hands and can grab things off the desk,
out of the staff’s pockets and off food trays in
the blink of an eye. She is cute and known for
19. In creating a therapeutic environment of
getting black eyes and bruises. Wherever she
Justine and kids of the same situation, it is
is, there is trouble, but according to her, it is
foremost to:
always someone else’s fault. She loves to run
away from the Child and Adolescent Unit of A. Develop a positive self-image.
the hospital and being chased by young staff
members. B. Give high calorie rich nutritional intake.

C. Provide safety and security.

D. Provide remedial education.

20. In the unit, it is not common to hear loud effects and re-experiencing physiological and
bangs and thuds with yelling, screaming, and psychological reactions. The nurse notes that
cursing of these children with the company the duration of these symptoms MUST
of Justine. A therapeutic activity that the persist for at least:
staff can provide is:
A. 2 days
A. Leisurely and active gardening.
B. 1 month
B. Active ball games that are not competitive.
C. 2 weeks
C. Sports that foster cooperation and
D. 3 days
teamwork.

D. Organizing book clubs for interaction.

Situation: Nurses who are helping
professionals and first responders in
psychiatric emergencies and catastrophic
situations often experience trauma and
intense stress. Continuing education offered
to nurses in this field aim to equip nurses’
knowledge and skills related to the important
role in recognizing and responding to peers
and colleagues struggling with maladaptive
responses to trauma and stress.
21. Awareness of the varied responses of
trauma and stress is a primary consideration
in recognizing problems of helping
professionals. Which of the following stress
responses are cognitive in nature?
A. Intrusive thoughts and reliving the incident,
reduced ability to concentrate or mental
confusion.
23. Effects of compassion fatigue can be
observed among emergency mental health
professionals. This easily leads to:
A. Somatic reactions
B. Burnout
C. Psychoses
D. Neuroses
24. The idea of self – medication to cope with
stress and trauma is common in helping
professionals and first responders. This
practice if it becomes pervasive has potential
for:
A. Substance use and abuse
B. Behavioral changes and abuse
C. Malpractice
D. Avoidance behavior

B. Substance use, withdrawal from others, or

acting out behaviors.
25. A group strategy that allows processing of
C. Unfounded or unusual anger, depressive emotional effects of traumatic exposure is:
feelings, or anxiety reactions
A. Alcoholic anonymous
D. Fatigue, recurring headaches, or inability to
B. Milieu therapy
sleep or eat.
C. Psychodrama

D. Avoidance behavior
22. Characteristic features of posttraumatic
stress disorder include hyperarousal, i.e.,
exaggerated startle response, numbing
Situation: Nina, an adolescent, participating
in a behavior therapy group cried while
relating her experience of “cutting” on her
skin, “the pain is so bad, this is the only way
to get it out”. Nina is a survivor of sexual
abuse perpetuated by her own father. She
has history of repeated admission at
Psychiatric Emergency Unit with repeated
history of self – mutilation. She was
diagnosed as borderline personality disorder
28. Nina has a pattern of “cutting” as a self –
mutilating act. All of the following are
therapeutic interventions EXCEPT:
A. Offer sympathy, and additional attention to
the behavior while cleaning the wound
B. Care for the wounds in a matter-of-fact
manner
C. Allow the client to express angry feelings

26. Nina verbalized the intensity of her
emotional pain and anger, desperation and
anxiety that escalate to a feeling of mounting
tension. With this overwhelming anxiety, she
may resort to dissociation which is
characterized by:
D. Problem-solve the situation with the client
29. Which of the following is a necessary
initial step in determining interventions for
Nina?

A. Feelings of emptiness and numbness and A. Explore her coping behaviors = V

experience of depersonalization
B. Retreat to an earlier developmental stage =
regression
C. Use of excessive reasoning rather that
reacting or changing = intellectualization
D. Blame of others for one’s own feelings and
thoughts = projection
B. Determine the meaning of her personal
crisis = IV
C. Assess her developmental level and
experience
D. Let her identify current stressors = III

27. Nurses may perceive clients like Nina

with strong countertransference reactions
and feelings of frustration, betrayal, anger,
and disgust. To work therapeutic with clients
who self -mutilate, it is MOST important for
nurses to:

A. Do - self disclosure and solicit

understanding from clients
B. Acknowledge and overcome strong
emotions = self-awareness
C. Suppress reactions to maintain
professionalism
D. Engage in constructive activities to dissipate
strong emotions.
30. The nurses involved in the care of Nina
feel caught in a bind because there is a need
to rescue in the event that she cuts herself
again and a need not to be manipulated by
her. It is MOST therapeutic for the nursing
team to recognize:
A. Being strict regarding imposition of external
controls

B. Writing a “no cutting on self” contract

C. Developing of a trust relationship
D. Taking self- responsibility by signing a
waiver
Situation: Children are unique requiring
specialize nursing care. To nurse a child,
health care professional need to be aware
that children are physically smaller and their
bones grow and mature at different rates.
31. A 10-month-old infant has developmental
dysplasia of the hip following confirmation of
the diagnosis by ultrasonography. She is
placed in Pavlik Harness. Which of the
following should you expect the infant to be
positioned?
A. Supine
B. Trendelenburg
C. Flexed abduction = Pavlik Harness (birth to
6 months of age; splinting of the hips with a
Palvik Harness to maintain and abduction
and external rotation
D. Flexed adduction
32. With the application of the harness, the
nurse should keep in mind the following
EXCEPT?
A. Assess skin daily.
B. The baby should wear the harness at all
times except while bathing
C. Harness should be worn above the clothing
continually = should be worn under
D. Instructing the parents on the practicalities
of daily care and continuous support
33. The infant did not respond to treatment
with Pavlik Harness. A surgical program is
undertaken. She was admitted into hospital
for a 1-week period of gallows traction. The
mother asks the nurse what Gallows traction
is. The nurse responds correctly if she states:
A. It is a skin traction applied to the legs which
are flexed at a 90-degree angle at the hips.
B. The child’s head provides counter traction =
Child’s trunk provides contraction
C. Type of traction with the legs in an
extended position = bucks traction, preop
mgt of child with dislocated hips
D. Uses skin traction on the lower leg and a
padded sling under the knee = Russel’s
34. The nurse should pay particular attention
to which part of the body of the infant in
gallows traction?
A. Back
B. Hips = elevation of extremities causes
blood to pool at the hips. Because of this, the
pressure caused by bandages increases the
risk of vasospasm and avascular hip necrosis
C. Lower extremities
D. Skin
35. The tractions is removed after 1 week and
the infant is bathed prior to surgery. Which
of the following constitute this intervention?
A. Bathing is necessary for hygienic measures
B. Cleanse the skin and allows for the gentle
removal of the adhesive traction
C. Allows for adequate physical preparation
D. A routine procedure prior to surgery to
prevent complications
Situation: Nurse Liza functions as a team 39. To make team nursing succeed, nurse Liza
leader and coordinates a small group of as coordinator of the team MUST possess
nurses in the psychiatric unit to provide care which of the following?
to a small group of patients. 1. Good communication skills
2. Delegation ability
36. As coordinator of the team her main
3. Strong clinical skills
function is to:
4. Create a cooperative working
A. Allow team members to practice high
A. 2,3,and 4
degree of authority
B. 1 and 3
B. Encourage the growth and training of each
member C. all except 4

C. Know the condition and needs of all the D. all

patients assigned to the team

D. Assume responsibility of the team for

40. Nurse Liza brings together the members
planning, directing and evaluating the
to work as a group. She has successfully
patient’s care
accomplished teamwork by means of:

A. Expertise of each member

37. As team leader, Nurse Liza assumes which
B. Well define goals and objectives of the
of the following duties?
team
A. Assessing patients and planning care
C. Clinical skills of team members
B. Directing and assisting team members
D. Adequate planning and control
C. Giving direct patient care

D. Coordinating patient activities

38. Nurse Liza’s team is using a team nursing
model. Weighing things, this model has
advantages and also disadvantages. Of the
following choices, which one is the
ADVANTAGE:
A. Use of each team member special expertise
in caring for patients
B. Direct patient care provided by a few nurses
Situation: Romina, age 19, was admitted with
acute pyelonephritis and has elevated
temperature. The nurse on duty reported
that she refused acetaminophen and has had
only sips of fluid to supplement her IV
therapy. The patient appears sad and has
remained in bed with the covers over her
head most of the day. Her history includes a
psychiatric hospitalization two years ago for
major depressive disorder. She was started
on antidepressant medication.

C. Team leader direct the team for effective

care
41. Depressed mood or loss of interest in
D. Provide total patient care pleasure and activities in depressive disorder
is with duration of at least:

A. A month
B. Two weeks
C. 2-3 days
D. one week
42. Romina has been withdrawn and
appears sad. Which of the following
approaches validate your initial impression?
A. “I noticed that you've been withdrawn.
Describe your mood for me”
B. “what happened that brought your
sadness?”
C. “in a scale of 1 - 10, 10 being the highest,
what level is your feeling sad?”
D. “how long have you been feeling sad?”
43. Romina describes feeling like her body is
“numb” and feels “helpless to do anything to
feel better”. The nursing diagnosis is:
A. Anxiety
B. Risk for injury
C. Acute confusion
D. Powerlessness
44. Structuring a therapeutic environment
places urgency in providing:
A. Cheerful environment to counteract
depression
B. Access to security personnel
C. Adequate fluids and nutrition
D. Precautions regarding self-harm
45. Romina is being treated with SSRI;
/selective serotonin reuptake inhibitor. The
nurse watches for serotonin syndrome
characterized by:
A. Tremors, seizures, nausea, vomiting, and
confusion
B. Robot like inflexible movements
C. Bizarre behavior like hallucinations and
delusions
D. Agranulocytosis, jaundice, signs of infection
Situation: It is important for a psychiatric
nurse to be knowledgeable about the
different psychiatric medications
administered to patients. The following
questions will test you about
psychopharmacology:
46. Patient Santino is being treated for his
bipolar disorder. He is prescribed with
Eskalith. As a nurse, which of the following
should you exclude from your health
teachings?
A. Medication can be administered with food.
B. He is allowed to drink coffee every morning
= due to diuretic effect (fluid loss increase
serum lithium levels)
C. Notify the physician if fever occurs.
D. He can take the missed dose within 2 hours
of the scheduled time.
47. While reviewing about Eskalith, you know
that severe lithium toxicity is manifested by:
A. Anuria
B. Severe diarrhea
C. Apathy
D. Muscle twitching
48. Patient Cleo’s chart states that dystonia is
noted on her while taking antipsychotic
medications. Which manifestations do you
expect to see?
A. Dysphagia, facial grimacing
B. Oculogyric crisis, increased heart rate,
drooling
C. Twisting of the torso
D. Drowsiness, restlessness
49. Fluoxetine is prescribed to Patient Mark
Lee. How should it be administered?
A. On full stomach
B. On an empty stomach
C. At the same time each morning
D. At the same time each evening = due to
drowsiness
50. A mother of a child with ADHD asked you
the most effective medication in controlling
the disorder. Your answer would be:
A. CNS stimulants = in adults, they increase
agitation and activity; but calming effect on
children with ADHD and increase alertness
and sensitivity to stimuli
B. CNS depressants
C. Donepezil
D. Rivastigmine
Situation: A client is brought to the
Emergency Department complaining of
generalized weakness of all extremities and
facial muscles and drooping of the eyelids
since a week ago His condition fluctuates
from day to day. The examining physician
tested the client with an acetylcholinesterase
inhibitor test to diagnose myasthenia gravis.
51. Nurse Liza is assigned to care for the
client. Which of the following medications
prescribed by the physician should nurse Liza
prepare to diagnose myasthenia gravis?
A. Atropine sulfate
B. Tensilon
C. Mestinon = control MG symptoms
D. lsuprel
52. Thirty minutes after injection, nurse Liza
noted an immediate Improvement in the
muscle strength. This can be interpreted as a:
A. Autoimmune disorder
B. Positive test confirming the diagnosis
C. Negative failure
D. Negative for myasthenia gravis
53. The client asked if he will take Tensilon
for MG treatment. Nurse Liza answered “NO”
because:
A. It is toxic to the body
B. It is only short-acting
C. It causes adverse effects
D. It crosses the blood-brain barrier
54. Nurse Liza noticed the client suddenly
developed cramps and sweating. In a
situation like this, which of the following
drugs must be made available to control the
side effects of he tested drug?
A. Prednisone
B. Mestinon
C. Atropine sulfate
D. Potassium supplement
55. Nurse Liza is administering
pyridostigmine (Mestinon) orally to the
client. Which of the following nursing
intervention indicates safety measure before
administering the medication?
A. Instructing the client to be in bed when
taking the medication
B. Determining client’s ability to swallow
C. Positioning the client to lie down on his left
side
D. Requiring the client to lei still in bed
Situation: Abbey is a 40-year-old wife who
was brought by neighbors to the emergency
room confused and crying with body bruises
and swollen eyes. She claimed that she was
physically abused by her husband who was
intoxicated with alcohol. She is admitted for
brief hospitalization for further observation
and crisis intervention.
56. The admitting nurse is aware that the
following should be carefully documented
EXCEPT:
A. Quote of Abbey’s account of the incident
that led to the injuries
B. Specific and factual assessment of physical
injuries incurred by Abbey
C. Photographs of Abbey’s physical injuries
D. Neighbors claim regarding estranged
relationship of Abbey and husband
57. The nurse did a process recording of an
interaction with Abbey. The following
descriptions about process recording are true
EXCEPT:
A. Recording of the verbatim account of the
entire interaction, including verbal and non-
verbal
B. Tool to improve interpersonal
communication techniques
C. A form of documentation for professional
development
D. Helps the nurse in analyzing content of
interaction
58. Which of the following information about
Abbey is LEAST ESSENTIAL FOR CRISIS
ITNERVENTION?
3 factors needed for Crisis Intervention
 Perception
 Support system
 Coping mechanism
A. Abbey perception of the event
B. Longitudinal life history
C. How Abbey is coping with the present
situation
D. Availability of friends or family for support
59. Abbey asked the nurse if she may have a
photocopy of her records. The nurse is aware
that client records belong to the:
A. Health facility
B. Health team members
C. Family of the client
D. Client
60. Potential benefits of the use of
computers in documentation have been
recognized, however clients are MOST
concerned about:
A. Validity
B. Accuracy
C. Reliability
D. Confidentiality
Situation: A 67 year old female client is
diagnosed with Senile Nuclear Cataract OU
(both eyes) H25.1; Dry Eye Syndrome.
61. The nurse is conducting nursing
assessment and preparing a nursing history.
Which of the following clinical manifestations
of the client gathered by the nurse is
characteristic of cataracts?
A. Narrow anterior chamber = glaucoma
B. Optic nerve damage = optic neuritis
C. Painless blurry vision
D. Age factor
62. Based from the information gathered the
nursing diagnosis is:
A. Self-care deficit related to impaired vision
B. Disturbed sensory perception related to
visual impairment
C. Acute pain related to eye dysfunction
D. Anxiety related to possible vision loss
63. The physician scheduled the client for
Phacoemulsification with intraocular lens
implantation surgery. The physician informed
the client of the nature of the procedure and
what to expect after surgery. The client
verbalized to the nurse,” I have never had
surgery before”. Given this situation, the
nurse appropriate expected outcome for the
client to:
A. Maintain asepsis aids in protecting the
surgical site form infection and complications
B. Know sign and symptoms of complications
that are to be reported to physician
immediately
C. Verbalize preoperative routine activities and
postoperative procedures and expectations
D. Understand handwashing and aseptic
technique for postoperative eyes care
64. The admitting order include:
Phacoemulsification with intraocular lens
implantation surgery right eye local
anesthesia 7:00AM OPD. Start Sanmyd – P
Ophthalmic Solution 1 drop every 5 minutes
to right eye once the client is admitted. The
client demonstrates understanding of the pre
– operative medication when she states that
the administration to eye drops:
A. Reduce intraocular pressure = mydriatics
can increase IOP
B. Minimize swelling
C. Dilate the pupils
D. Relieve pain
65. The client is given post – cataract surgery
instructions consisting of instillation of eye
meds, Tobrex, 1 drop every 3 hours (waking
hours), Pred Fortre – 1 drop every 3 hours
(waking hours): oral meds for pain including
health teaching and other instructions. Client
education guide should include the following
EXCEPT:
A. Not rubbing the right eye nor lifting objects
B. Placing plastic eye shield when sleeping.
Using eyeglasses while awake
C. Having regular baths and washing of face
but no swimming
D. Taking aspirin or drugs containing aspirin
Situation: Patient Fidel went to the ENT clinic
due to tender and enlarged postauricular
lymph nodes.
66. When doing an otoscopic examination,
the nurse should observe the following
EXCEPT:
A. Make sure the patient avoids moving the
head
B. Hold the handle of the otoscope in the
space between the thumb and index finger.
C. Make sure the radial side of the nurse’s
hand rests against the patient’s head
D. Insert the scope while pulling the auricle
upward and backward in the adult and older
child.
67. Upon examination of the ear, the nurse
agrees with the diagnosis of mastoiditis if the
tympanic membrane is:
A. Pink-colored
B. Grey-colored
C. Transparent and clear
D. Red and dull = thick and immobile
68. The following are correct statements
regarding mastoiditis EXCEPT:
A. Results from untreated chronic or acute
otitis media
B. Pain is relieved by myringotomy
C. Mastoidectomy with tympanoplasty is the
most common treatment
D. Abducens and facial cranial nerve damage
is a possible complication.
69. Vertigo occurs as a complication of
mastoiditis if:
A. Mastoiditis is untreated
B. Brain abscess occurs
C. The infection spreads into the labyrinth =
balancing center in the inner ear
Endolimpth = minniers disease
D. The infection spreads into the ear canal
70. After some clearance, Fidel underwent
mastoidectomy. Some postoperative
interventions include the following except:
A. Prepare for wound dressing change 1 day
postoperatively
B. Bed rest with bedside commode privileges
for 24 hours as prescribed
C. Monitor for signs of meningitis and for
other complications
D. Position the client prone for drainage. = flat
with operative side up
Situation: Virginia, 75 years, a retired nurse,
is a full caregiver for her husband who has
Alzheimer disease. She complains and
speaks. “My vision is getting worse. A lot of
time, my body aches. I’ve lost interest in
eating and I seem to have lost weight. What
if I can’t care for my husband anymore? I’m
reaching the end of my rope. Yet, when asked
by the nurse if she is depressed, her response
is an unqualified “NO.”
71. Depression is often overlooked especially
adults because of the belief that it is normal
for older adults to be less active, less
engaged and somatically preoccupied. Which
of the following repercussions of this belief
warrant the MOST urgency for health care
professionals to consider?
A. Older persons suffer in silence, remaining
either undiagnosed or misdiagnosed
B. Greater risk for developing heart disease
C. It can mean suicide
D. Longer hospital stays and decreased ability
to follow health regimens
72. Virginia is reluctant to be interviewed by
the nurse. In order to assess mental health
issues, it is MOST important for the nurse to
create an environment of:
A. Kind firmness and control
B. Respect, compassion and reassurance
C. Psychological safety and security
D. Privacy and confidence
73. Virginia’s verbalizations prompt the nurse
to assist her to become aware of the
existential aspects of depression such as:
A. Denial and cognitive dissonance
B. Little or no social support
C. Death, isolation and meaninglessness
D. Somatic complaints
74. Pharmacotherapy is the mainstay
treatment for older adults with moderate to
severe depression. Nurses should observe
caution in the administration of monoamine
oxidase inhibitors because of the risk of:
A. Orthostatic hypotension
B. Neuromalignant syndrome
C. Hypertensive crisis = occipital headeace
D. Serotonin syndrome
75. Older adults like Virginia respond slowly
to antidepressants, and clinicians should
assess for response at:
A. 8-12 weeks
B. 2-3 weeks
C. 4-6weeks
D. 12-16 weeks
Situation: Nurse Researcher Kai is planning to
create a phenomenological study. Before
starting, he wanted to review the methods
for descriptive phenomenology.
76. This method requires that intersubjective
agreement be reached with other expert
judges.
A. Colaizzi
B. Giorgi
C. Van Kaam
D. Warm and cool
77. This method calls for a validation of
results by returning to study participants.
A. Colaizzi
B. Giorgi
C. Van Kaam
D. Warm and cool
78. This method relies solely on researchers. Situation: A 56-year-old male client is
The proponent believes that it is admitted to the hospital and diagnosed with
inappropriate either to return to participants subarachnoid hemorrhage secondary to
to validate findings or to use external judges. ruptured cerebral aneurysm

A. Colaizzi 81. The physician ordered aneurysm

precautions. Which of the following
B. Giorgi
measures should be instituted by the nurse
C. Van Kaam to prevent increased intracranial pressure?

D. Warm and cool A. Provide bright lights

B. Give enema as needed

79. As a nurse researcher, Kai understands C. Encourage entertainment using TV and

that according to Lincoln and Guba (1985), radio
_______ of qualitative research parallel the
D. Reduce environment stimuli
standards of reliability and validity in
quantitative research.

A. Dependability 82. A relative accompanying the client asks

the nurse if he can bring the client to the
B. Trustworthiness
cafeteria for a snack before going straight to
C. Complexity his room. Which of the following measures
should the nurse use why the client should
D. Triangulation directly get to his room?

A. Minimize environmental stimuli

80. According to Lincoln and Guba, this refers B. Client is anxious and needs rest
to the potential for congruence between two
or more independent people about the C. Require isolation precaution
data’s meaning.
D. Rest in a priority to promote healing
A. Credibility

B. Dependability
83. A Day after admission the client becomes
C. Confirmability restless and anxious. The nurse assesses
further the client and notices nuchal rigidity.
D. Transferability The nurse knows that nuchal rigidity is

A. Resistance to extension of the neck while

hip is flexed

B. Lockjaw

C. Neck stiffness = nuchal rigidity

D. Flexion of the neck and knees in response

to hip flexion
84. The client has a leaking cerebral
aneurysm. He is scheduled for surgery. Which
of the following should the nurse implement
prior to surgery?
A. Up in bed at least twice a day
B. Allow bathroom privileges
C. Offer bedside commode when needed
D. Strict bedrest
85. The client is recovering from surgery but
has become irritable and angry regarding
limitations. Which of the following is the
MOST appropriate approach to assist client
overcome limitations and succeed?
A. Secure trust and confidence of the client
B. Refer the client to physician psychiatrist
C. Support and praise client for
accomplishments
D. Accept the client’s behavior
Situation: Clients with psychosocial disorders
usually receive medications The nurse should
be able to inform the clients about the need
for medications in the course of their illness.
86. During discharge planning for Vilma,
a patient whose symptoms of manic disorder
are remitting, the patient asks, “do I have to
take lithium even though I’m high any
longer?”. The MOST appropriate response is:
A. “You can stop the medication 1 week after
discharge”
B. “Usually patients take medication for
6months after discharge”
C. “You will need to take medication for about
12 weeks”
D. “Taking the medication daily will help you
avoid relapses and recurrences”
87. Valium (Diazepam) is prescribed to
Rhodora, an extremely anxious client. She is
afraid to take this drug because she heard
that it is addicting. The nurse’s responses is
based on the knowledge that anti-anxiety
drugs:
A. May result in physical but not psychological
dependence
B. Rarely causes dependence
C. Can potentially cause both physical and
psychological dependence
D. May result in psychological but not physical
dependence
88. When taking care of a client anxiety drug
like Vallum (diazepam), the nurse’s concern
would be on:
A. Motor incoordination
B. Abrupt withdrawal = life threatening
C. Changes in bowel habits
D. Hypertension
89. Alvin, a client, is taking Lorazepam
(Ativan) for his anxiety. Since he goes to work
daily, special instructions are given to him for
his safety. The client understood the nurse’s
health instructions if while taking this
medication he:
A. Reduces her salt intake to protect her
kidney
B. Stays indoor
C. Takes over the counter cough syrup
D. Avoids driving a car while under medication
90. Ramon has been taking Vallum to help
him calm down when he experiences
nightmares and flashbacks after experience
of being robbed 3 weeks ago. While at the
doctor’s clinic, you observe the following
confusion, slurred speech, dizziness, ataxia.
What is the MOST appropriate nursing action
for you to take?
A. Teach the client how to relax using a tape
and breathing exercises
B. Recommend to the doctor the need to
increases dosage so he can sleep
C. Provide safety measures since he is having a
flashback
D. Inform his doctor about possible excessive
use of the medication
Situation: George, 25 years old, has been
diagnosed with undifferentiated
schizophrenia. He is the next to youngest of
eight children. According to him he has a
twin brother who has also major mental
illness. In an interview with George, he
stated, “my mama had schizophrenia for 10
years then God saved her”. George recalled
that his father used to beat his mother and
the children. He described a beating he
received from his father that left him
bleeding. When asked why his father beat
him, he responded, “he got mad a lot. I
forgot to wash the car like he asked me to.”
He thinks back to his past and remembers
molestation, cruelty and punishment.
91. George was observed to be
extremely withdrawn. What is the
appropriate nursing diagnosis for the
patient?
A. Disturbed thought process
B. Complicated grieving
C. Impaired social interaction
D. Self-care deficit
92. When asked about his relationship with
his mother, he said that she left the rest of
the family after his father died. A therapeutic
response would be to:
A. Confront him his evasive response
B. Remain quiet
C. Change the subject
D. Assist him to focus
93. George talks about his experiences of
molestation, cruelty and punishment from
his father and also from his peers. The nurse
is using therapeutic communication if she
says:
A. “Let’s look at that a little closer.” =
exploring while still giving chance to the
client to pick a topic
B. “Everything will fall into places.”
C. “That’s good. I am glad that you are telling
me this.”
D. “Tell me how your father abused you when
you were a child.”
94. George verbalized, “when I was little, I
started hearing voices after those boys did
awful things to me. I was fixing my bicycle
and I heard the devil talk to me over and
over. The nurse notes this as:
A. Hallucination
B. Illusion
C. Delusion
D. Obsession
95. Twin studies have repeatedly
demonstrated high concordancy rates (50%).
The fact that there is not 100% concordancy
(probability that a pair of individuals will
both have a certain characteristics) suggest:
A. Maternal exposure to great stress
B. Nongenetic variables in
schizophrenogenesis
C. Infection during pregnancy
D. Exposure to toxins prenatally
Situation: A substance abuse research
established a relationship between trauma
and addiction. Community health nurse are
getting involved in community-based
intervention units. Nurses are becoming to
be an integral part of the emergency centers
and are facing challenges to effectively
interact those in need.
96. Nurses need to be diligent in their
observations of those possibly experiencing
post-incident stress especially in which of the
following client situations?
A. Young adult with history of rejection in love
affairs
B. Teen age girl who has been gang-raped
C. Young boy with early exposures to illicit
drugs
D. Child with a history of conflicted family life
97. Among helping professionals and first
responders to stressful and traumatic
incidents, like calamities, fires, typhoons and
crime scenes, the individuals who are MOST
likely to fall to substance abuse are those
who:
A. Have history of trauma in the past
B. Tell their stories to friends and relative
C. Rely on self-help to cope with their
experiences
D. Ignore signs and symptoms of traumatic
exposure = denial of he stressor is a
maladaptive behavior
98. The community nurse led a monthly
informal discussion group among police
officers in the local government police
headquarters. The theme of the group
sharing was on the use of alcohol to cope
with the emotional impact of their job.
Which of the following police’s responses
need crucial individual follow-up?
A. “Sometimes I cannot avoid the invitation of
my team and I choose what I drink”
B. “I must admit I drink sporadically just to
relax a little bit”
C. “Occasionally I need to unwind while we
share our personal experiences.”
D. “I drink alone and a shot of wine in my
coffee perks me up every morning.”
99. Nurses can do the following EXCEPT:
A. Establish a peer support group in the
community.
B. Provide alternative methods to handle
stresses inherent in trauma work
C. Conduct debriefing or incident stress
management
D. Provide detoxification Intervention for
alcohol and substance abuse
100. Nursing in community-based trauma
health intervention facilities daily encounter
clients who need to be helped with
emotional stress of being too overwhelmed
to cope with the realities of life they
witnessed. As a self-management
intervention, it is therapeutic that the nurses
must:
A. Be constantly aware of the effects of
compassion fatigue leading to burnout.
B. Have a personal value system anchored on
the family system
C. Clearly define role in addressing the
confounded effects of trauma and addiction

D. Provide stress management guideline