NURSING PRACTICE II – Community Health Nursing and Care of the Mother and Child SITUATIONAL Situation 1 – Nurse Minette

is an Independent Nurse Practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTIAL MOTHER AND FAMILY focusing on HOME CARE. 1. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made? A. Within 4 days after discharge B. Within 24 hours after discharge C. Within 1 hour after discharge D. Within 1 week of discharge 2. Leah is developing constipation from being on bed rest. What measures would you suggest she take to help prevent this? A. Eat more frequent small meals instead of three large one daily B. Walk for at least half an hour daily to stimulate peristalsis C. Drink more milk, increased calcium intake prevents constipation D. Drink eight full glasses of fluid such as water daily 3. If you were Minette, which of the following actions would alert you that a new mother is entering a postpartal taking-hold phase? A. She urges the baby to stay awake so that she can breast-feed him or her B. She tells you she was in a lot of pain all during labor C. She says that she has not selected a name for the baby as yet D. She sleeps as if exhausted from the effort of labor 4. At 6-week postpartum visit what should this postpartal mother’s fundic height be? A. Inverted and palpable at the cervix B. Six fingerbreadths below umbilicus C. No longer palpable on her abdomen D. One centimeter above the symphysis pubis 5. This postpartal mother wants to loose the weight she gained in pregnancy, so she is reluctant to increase her caloric intake for breast-feeding. By how much should a lactating mother increase her caloric intake during the first 6 months after birth? A. 350 kcal/day B. 500 kcal/day C. 200 kcal/day D. 1000 kcal/day Situation 2 – As the CPE is applicable for all professional nurse, the professional growth and development of Nurses with specialties shall be addressed by a Specialty Certification Council. The following questions apply to these special groups of nurses. 6. Which of the following serves as the legal basis and statute authority for the Board of Nursing to promulgate measures to effect the creation of a Specialty Certification Council and promulgate professional development programs for this group of nurse-professionals? A. R.A. 7610 B. P.D. 223 C. R.A. 9173 D. R.A. 7164 7. By force of law, therefore, the PRC-Board of Nursing released Resolution No. 14 Series of 1999 entitled: “Adoption of a Nursing Specialty Certification Program and Creation of Nursing Specialty Certification Council.” This rule-making power is called: A. Quasi-Judicial Power B. Regulatory Power C. Quasi-Legislative Power D. Executive/Promulgating Power 8. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty Certification Program and Council, which two (2) of the following serves as the strongest for its enforcement? (a) Advances made in Science and Technology have provided the climate for specialization in almost all aspects of human endeavor; and (b) As necessary consequence, there has emerged a new concept known as globalization which seeks to remove barriers in trade, industry and services imposed by the national

laws of countries all over the world; and (c) Awareness of this development should impel the nursing sector to prepare our people in the services sector to meet the above challenge; and (d) Current trends of specialization in nursing practice recognized by the International Council of Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of deepening and refining nursing practice and enhancing the quality of nursing care. A. b & c are strong justifications B. a & b are strong justifications C. a & c are strong justifications D. a & d are strong justifications 9. Which of the following IS NOT a correct statement as regards Specialty Certification? A. The Board of Nursing intended to create the Nursing Specialty Certification Program as a means of perpetuating the creation of an elite force of Filipino Nurse Professionals. B. The Board of Nursing shall oversee the administration of the NSCP through the various Nursing Specialty Boards which will eventually be created C. The Board of Nursing at the time exercised their powers under R.A. 7164 in order to adopt the creation of the Nursing Specialty Certification Council and Program D. The Board of Nursing consulted nursing leaders of national nursing associations and other concerned nursing groups which later decided to ask a special group of nurses of the program for nursing specialty Certification. 10. The NSCC was created for the purpose of implementing the Nursing Specialty policy under the direct supervision and stewardship of the Board of Nursing. Who shall comprise the NSCC? A. A Chairperson who is the current President of the APO; a member from the Academe; and the last member coming from the Regulatory Board B. The chairperson and members of the Regulatory Board ipso facto acts as the CPE Council C. A Chairperson, chosen from among the Regulatory Board members; a Vice Chairperson appointed by the BON at-large; two other members also chosen atlarge; and one representing the consumer group; D. A Chairperson who is the President of the Association from the Academe; a member from the Regulatory Board; and the last member coming from the APO Situation 3 –Nurse Anna is a new BSN graduate and has just passed her Licensure Examination for Nurses in the Philippines. She has likewise been hired as a new Community Health Nurse in one of the Rural Health Units in their City, which of the following conditions may be acceptable TRUTHS applied to Community Health Nursing Practice. 11. Which of the following is the primary focus of community health nursing practice? A. Cure of illnesses B. Prevention of illnesses C. Rehabilitation back to health D. Promotion of health 12. In community health nursing, which of the following is our unit of service as nurses? A. The community B. The extended members of every family C. The individual members of the Barangay D. The Family 13. A very important part of the Community Health Nursing Assessment Process includes: A. the application of professional judgment in estimating importance of facts to family and community B. evaluation structures and qualifications of health center team C. coordination with other sectors in relation to health concerns D. carrying out nursing procedures as per plan of action 14. In community health nursing it is important to take into account the family health data coupled with an equally important need to perform ocular inspection of the area as activities which are powerful elements of: A. evaluation

B. assessment C. implementation D. planning 15. The initial step in PLANNING process in order to engage in any nursing project or activities at the community level involves A. goal-setting B. monitoring C. evaluation of data D. provision of data Situation 4 – Please continue responding as a professional nurse in these other health situations through the following questions. 16. Transmission of HIV from an infected individual to another person occurs: A. Most frequently in nurses with needlesticks B. Only if there is a large viral load in the blood C. Most commonly as a result of sexual contact D. In all infants born to women with HIV infection 17. The medical record of a client reveals a condition in which the fetus cannot pass through the maternal pelvis. The nurse interprets this as: A. Contracted pelvis B. Maternal disproportion C. Cervical insufficiency D. Fetopelvic disproportion 18. The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor? A. Herpes-simplex virus B. Human papilloma virus C. Hepatitis D. Toxoplasmosis 19. After a vaginal examination, the nurse determines that the client’s fetus is in an occiput posterior position. The nurse would anticipate that the client will have: A. A precipitous birth B. Intense back pain C. Frequent leg cramps D. Nausea and vomiting 20. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to: A. Soften and efface the cervix B. Numb cervical pain receptors C. Prevent cervical lacerations D. Stimulate uterine contractions Situation 5 – Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group. 21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer? A. Prostaglandins released from the cut fallopian tubes can kill sperm B. Sperm can not enter the uterus because the cervical entrance is blocked. C. Sperm can no longer reach the ova, because the fallopian tubes are blocked D. The ovary no longer releases ova as there is no where for them to go. 22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when: A. a woman has no uterus B. a woman has no children C. a couple has been trying to conceive for 1 year D. a couple has wanted a child for 6 months 23. Another client named Lilia is diagnosed as having endometriosis. This condition interferes with fertility because: A. endometrial implants can block the fallopian tubes

B. the uterine cervix becomes inflamed and swollen C. the ovaries stop producing adequate estrogen D. pressure on the pituitary leads to decreased FSH levels 24. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions would you give her regarding this procedure? A. She will not be able to conceive for 3 months after the procedure B. The sonogram of the uterus will reveal any tumors present C. Many women experience mild bleeding as an after effect D. She may feel some cramping when the dye is inserted 25. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena? A. Donor sperm are introduced vaginally into the uterus or cervix B. Donor sperm are injected intra-abdominally into each ovary C. Artificial sperm are injected vaginally to test tubal patency D. The husband’s sperm is administered intravenously weekly Situation 6 – There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION, these include: 26. The correct temperature to store vaccines in a refrigerator is: A. between -4 deg C and +8 deg C B. between 2 deg C and +8 deg C C. between -8 deg C and 0 deg C D. between -8 deg C and +4 deg C 27. Which of the following vaccines is not done by intramuscular (IM) injection? A. Measles vaccine B. DPT C. Hepa-B vaccine D. Tetanus toxoids 28. This vaccine content is derived from RNA recombinants. A. Measles B. Tetanus toxoids C. Hepatitis B vaccines D. DPT 29. This is the vaccine needed before a child reaches one (1) year in order for him/her to qualify as a :fully immunized child”. A. DPT B. Measles C. Hepatitis B D. BCG 30. Which of the following dose of tetanus toxoid is given to the mother to protect her infant from neonatal tetanus and likewise provide 10 years protection for the mother? A. Tetanus toxoid 3 B. Tetanus toxoid 2 C. Tetanus toxoid 1 D. Tetanus toxoid 4 Situation 7 – Records contain those comprehensive descriptions of patient’s health conditions and needs and at the same serve as evidences of every nurse’s accountability in the care giving process. Nursing records normally differ from institution to institution nonetheless they follow similar patterns of meeting needs for specific types of information. The following pertains to documentation/records management. 31. This special form is used when the patient is admitted to the unit. The nurse completes the information in this record particularly his/her basic personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record? A. Nursing Kardex B. Nursing Health History and Assessment Worksheet C. Medicine and Treatment Record D. Discharge Summary

The privilege of being a registered professional nurses C. 36. current orders of the physician to be carried out by the nurse. Human rights of clients.32. Discharge Summary B. The present code utilized the Code of Good Governance for the Professions in the Philippines D. treatment. Most nurses regard this conventional recording of the date. This carries information about basic demographic data. Based on the Code of Ethics for Filipino Nurses. directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. regardless of creed and gender B. What record is this? A. These records show all medications and treatment provided on a repeated basis. instead this record of information on vital signs. It has 2-parts: the activity and treatment section and a nursing care plan section. Nursing Kardex 35. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. Nursing Kardex B. etc. What do you call this? A. safety precautions in patient care and factors related to daily living activities. Medicine and Treatment Record C. Discharge Summary D. Graphic Flow Sheets C. Which of the following is TRUE about the Code of Ethics of Filipino Nurses? A. 37. Medicine and Treatment Record 34. The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics for Nurses which the Board of Nursing promulgated B. Nursing Kardex D. Nursing Health History and Assessment Worksheet Situation 8 – As Filipino Professional Nurses we must be knowledgeable about the Code of Ethics for Filipino Nurse and practice these by heart. A nurse withholding harmful information to the family members of a patient . This flip-over card is usually kept in a portable file at the Nurse’s Station. Which of the following nurses behavior is regarded as a violation of the Code of Ethics of Filipino Nurses? A. time. These are sheets/forms which provide an efficient and time saving way to record information that must be obtained repeatedly at regular and/or short intervals of time. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates C. This record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. what is regarded as the hallmark of nursing responsibility and accountability? A. This does not replace the progress notes. Nursing Health History and Assessment Worksheet B. post partum care. Medicine and Treatment Record 33. nursing orders. primary medical diagnosis. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. and diabetic regimen. Discharge Summary B. Health. Nursing Kardex C. Nursing Health History and Assessment Worksheet D. postoperative care. intake and output. This is used whenever specific measurements or observations are needed to be documented repeatedly. Accurate documentation of actions and outcomes 38. scheduled tests and procedures. Medicine and Treatment Record D. and mode by which the patient leaves a healthcare unit but this record includes importantly. being a fundamental right of every individual D. What is this? A. Discharge Summary C. What do you call this record? A. written nursing care plan. The next questions pertain to this Code of Ethics.

Philippine Nurse Association 40. Mr. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. act as the patient’s legal representative B. Bernadette develops a deep vein thrombosis following an auto accident and is prescribed heparin sub-Q. A. Which of the following is your primary action? A. 39. Santos knows a primary duty of an advocate is to. 46. Give cotrimoxazole tablet or syrup B. A nurse endorsing a person running for congress. Santos. Salicylates can lead to increased maternal bleeding at childbirth 45. The following conditions apply 41. Increased bleeding can occur from uterine pressure on leg veins C. maintain the patient’s right to privacy Situation 9 – Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particular women with preexisting or Newly Acquired illness. R. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. Professional Regulation Commission B. What should Joanna educate her about in regard to this? A. Her husband plays golf 6 days a week B. Bernadette is a 22-year old woman. safeguard the well being of every patient D. I am careful to drink at least eight glasses of fluid every day D. Healing is limited during pregnancy. complete all nursing responsibilities on time C. Why should she limit or discontinue this toward the end of pregnancy? A. Which condition would make her more prone than others to developing a Candida infection during pregnancy? A. Aspirin can lead to deep vein thrombosis following birth B. Lacerations can provoke allergic responses because of gonadothropic hormone B. Nursing Specialty Certification Council C. Josie brought her 3 months old child to your clinic because of cough and colds. and he knows that one of his duties is to be an advocate for his patients. Mr. I take an iron pill every day to help grow new red blood cells C. so these will not heal until after birth. A woman is less able to keep the laceration clean because of her fatigue D. Some infants will be born with allergic symptoms to heparin B. I understand why folic acid is important for red cell formation 44. Why are lacerations of lower extremities potentially more serious in pregnant women than others? A. She usually drinks tomato juice for breakfast D. Newbors develop withdrawal headaches from salicylates D. What statement signifies this fact? A.N. Situation 10 – Still in your self-managed Child Health Nursing Clinic. She has developed gestational diabetes 42. Refer to the doctor . you encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS. Assess the patient using the chart on management of children with cough C. Heparin does not cross placenta and so does not affect a fetus 43. I’ve stopped jogging so I don’t risk becoming dehydrated. A nurse should be cognizant that professional programs for specialty certification by the Board of Nursing accredited through the: A. A nurse declining commission sent by a doctor for her referral C. works in a nursing home. Association of Deans of Philippine Colleges of Nursing D. Her infant will be born with scattered petechiae on his trunk C.B. D. Bernadette received a laceration on her leg from her automobile accident. Heparin can cause darkened skin in newborns D. Nurse Reviewers and/or nurse review center managers who pays a considerable amount of cash for reviewees who would memorize items from the licensure exams and submit these to them after the examination. B. She was over 35 when she became pregnant C. Newborns develop a red rash from salicylate toxicity C.

Seek assistance and mobilize the BHWs to have a meeting with mothers 50. When a boy has a possible inguinal hernia C. The following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK conditions. Morphine Sulfate C. Naloxone (Narcan) B. “at what age can I be able to take the blood pressure of my daughter as a routine procedure since hypertension is common in the family?” Your answer to this is: A. Sodium Chloride D. In responding to the care concerns of children with severe disease. Theresa. They do not have as many fat stores as other infants B. Your primary role therefore in order to reduce morbidity due to pneumonia is to: A. What is a method used to treat hyperbilirubinemia in a newborn? A. When is it important NOT to elicit a gag reflex? A. As early as 1 year old C. Gentle exercise to stop muscle breakdown . Penicillin G 54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature? A. Teach the mother how to count her child’s breathing 47. You were able to identify factors that lead to respiratory problems in the community where your health facility serve. They are preterm so are born relatively small in size 55.D. Fast breathing D. Mortality reduction through early detection D. Weighing of the sick child 49. when a girl has a geographic tongue B. Baby John develops hyperbilirubinemia. Difficulty to awaken 48. Taking of the temperature of the sick child C. Keeping infants in a warm and dark environment B. 51. Stop feeding well C. Teach mothers how to recognize early signs and symptoms of pneumonia B. When she’s 3 years old D. Which of the following is the principal focus of the CARI program of the Department of Health? A. referral to the hospital is of the essence especially if the child manifests which of the following? A. Make home visits to sick children C. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in labor. Which of the following is the most important responsibility of a nurse in the prevention of unnecessary deaths from pneumonia and other severe diseases? A. Teach other community health workers how to assess patients. Their skin is more susceptible to conduction of cold D. Provision of Careful Assessment D. When she’s 6 years old 52. At 2 years you may B. Administration of cardiovascular stimulant C. What drug is commonly used for this: A. Enhancement of health team capabilities B. Situation 11 – You are working as a Pediatric Nurse in you own Child Health Nursing Clinic. Teach mothers how to detect signs and where to refer C. They are more active than usual so throw off covers C. a mother with a 2 year old daughter asks. Wheezing B. You typically gag children to inspect the back of their throat. Giving antibiotics B. When a child has symptoms of epiglottitis D. Refer cases to hospitals D. When children are under 5 years of age 53.

A child should be immunized in the health center before referral 59. and fetal heart can be heard with a Doppler 62. severe malnutrition/anemia C. she experienced fatigue and drowsiness. Nette explains this because the fundus is: A. In doing Leopold’s Maneuver palpation which among the following IS NOT considered a good preparation: A. The hands of the nurse should be cold so that abdominal muscles would contract and tighten C. 61. moderate anemia/normal weight B. 56. Is just over the symphisis. The woman should lie in a supine position with her knees flexed slightly B. she is expressing pressure C. There is no contraindication to immunization if the child is well enough to go home and a child should be immunized in the health center before referral are both correct D. You assessed a child with visible severe wasting. not very low weight no anemia Situation 13 – Nette. The woman empties her bladder before palpation 63. and the fetal heart can be heard with a fetoscope B. the fetus utilizes her glucose stores and leaves her with a low blood glucose D. A child has some palmar pallor can be classified as: A. a nurse palpates the abdomen of Mrs. She is unsure of the date of her last menstrual period. The following questions apply. A child with visible severe wasting or severe palmar pallor may be classified as: A. The nurse assesses the woman at 20 weeks gestation and expects the woman to report: . Leopold’s Maneuver is done. LBM C. do not give DPT2 or DPT3 to a child who has had convulsions within 3 days of DPT1 B. moderate malnutrition/anemia B. of the rapid growth of the fetus 64. anemia/very low weight 60. Which of the following conditions is NOT true about contraindication to immunization? A. do not give DPT to a child who has recurrent convulsion or active neurologic disease D. Marasmus 57. of high blood pressure B. he has: A. 28 cm. At the level of the umbilicus. The obstetrician told that she appears to be 20 weeks pregnant. and the baby is just about to move C.D. There is no contraindication to immunization if the child is well enough to go home C. severe malnutrition/anemia C. edema B. Be certain that your hands are warm (by washing them in warm water first if necessary) D. a primigravida. Kwashiorkor D. 18 cm. In her pregnancy. do not give BCG if the child has known hepatitis C. Medina. do not give BCG if the child has known AIDS 58. and fetal heart cannot be heard D. Which of the following statements about immunization is NOT true: A. This probably occurs because: A. A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit B. not very low weight no anemia D. Early feeding to speed passage of meconium Situation 12 – You are the nurse in the Out-Patient Department and during your shift you encountered multiple children’s condition. anemia/very low weight D.

a requirement for home visits B. It should minimize or prevent the spread of infection from individuals to families D. Placenta Previa C. Cervix close. Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during her pregnancy? A. What is the rationale in the use of bag technique during home visits? A. Hyperemesis Gravidarum D. Unsuccessful artificial insemination procedure B. When providing prenatal education to a pregnant woman with asthma. Diazepam 67. The nurse is aware that in addition to pregnancy. Butorphanol D. Glucose levels decrease to accommodate fetal growth B. It saves time and effort of the nurse in the performance of nursing procedures C. 2 fingers below xyphoid process. Which of the following BEST DESCRIBES the use of this vital facility for our practice? 71. Phenobarbital B. what do you expect during assessment? A. Blood transfusion after hemorrhage C. Mrs. There is progressive resistance to the effects of insulin 69. Nifedipine C. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. Head injury from a car accident 68. Therapeutic or spontaneous abortion D. Which of the following would the nurse include when describing the pathophysiology of gestational diabetes? A. Pregnancy fosters the development of carbohydrate cravings D. Medina comes to you for check-up on June 2. Teach correct administration of subcutaneous bronchodilators C. Abruprtion Placenta Situation 15 – One important tool a community health nurse uses in the conduct of his/her activities is the CHN Bag. It helps render effective nursing care to clients or other members of the family B.A. her EDC is June 11. Demonstrate how to assess her blood glucose levels B. FH-midway between the umbilicus and symphysis pubis C. Which among the following is important in the use of the bag technique during home . Explain that she should avoid steroids during her pregnancy 70. 2 fingers below xyphoid process. Rh-negative women would also receive this medication after which of the following? A. floating D. engaged B. The community/Public Health Bag is: A. It should not overshadow concerns for the patient 73. a tool used by the Community health nurse is rendering effective nursing procedures during a home visit 72. Spotting related to fetal implantation B. Fundic ht. Hypoinsulinemia develops early in the first trimester C. which of the following would be important for the nurse to do? A. uneffaced. Symptoms of diabetes as human placental lactogen is released C. Rh incompatibility B. Feeling fetal kicks D. fundic ht. contains basic medications and articles used by the community health nurse D. engaged Situation 14 – Please continue responding as a professional nurse in theses varied health situations through the following questions. an essential and indispensable equipment of the community health nurse C. Nausea and vomiting related HCG production 65. Which of the following medications would the nurse expect the physiccian to order for recurrent convulsive seizures of a 10-year old child brought to your clinic? A. Cervix open. Fundic height at least at the level of the xyphoid process. Ensure she seeks treatment for any acute exacerbation D. 66.

The upper tip D. The following statements can correctly be made about Organization and management: A. Employee satisfaction B. D. Arrangement of the bag’s contents must be convenient to the nurse B. commitments and organizational objectives D. Organizational objectives. A and C only 77. As the people of an organization value. national goals. Considers the achievement and advancement of the organization she/he represents as well as his people B. protection of the CHN bag B. meaning and direction to a company. The following statements can correctly be made about an effective and efficient community or even agency managerial-leader. management needs to examine Filipino values and discover its positive potentials and harness them to achieve: A. This is an important procedure of the nurse during home visits. traditions and human relations. B. organizational objectives and employee satisfaction C. B and C only C. A. The bag should contain all necessary supplies and equipment ready for use C. B. Considers its own recognition by higher administration for purposes of promotion and prestige. commitments and employee objective/satisfaction/ 79. arrangement of the contents of the CHN bag C.visit? A. C. values. organizational goals B. organizational goals. B. values give vitality. National goals. culture. Management principles are universal therefore. Family goals. organizational goals. C and D are correct . family goals D. A and D only B. which side of the paper lining of the CHN bag is considered clean to make a non-contaminated work area? A. the Nursing sector is no except. Family goals. Only C and are correct C. The lower lip B. Minimize if not totally prevent the spread of infection 74. Organizational goals. and in the implementation of health programs and projects you experience vividly as well the varying forms of leadership and management from the Barangay Level to the Local Government/Municipal or City Level. Be sure to thoroughly clean your bag especially when exposed to communicable disease cases D. so the company becomes. Employee objectives/satisfaction. In consideration of the steps in applying the bag technique. national goals. one need not be concerned about peoples. Considers the welfare of the organization above all other consideration by higher administration D. Management effectiveness can be measured in terms of accomplishment of the purpose of the organization while management efficiency is measured in terms of the satisfaction of individual motives. A. proper hand washing 75. The outer surface C. family goals C. An organization (or company) is people. A. Management by Filipino values advocate the consideration of the Filipino goals trilogy according to the Filipino priority-values which are: A. Considers the recognition of individual efforts toward the realization of organizational goals as well as the welfare of his people C. national goals 78. Since the advocacy for the utilization of Filipino value-system in management has been encouraged. B and D only D. The inside surface Situation 16 – As a Community Health Nurse relating with people in different communities. Organizational commitments. and objectives. A. A. cleaning of the CHN bag D. goals. Values make people persons. Management is the process by which administration achieves its mission. 76.

Which type of research inquiry investigates the issues of human complexity (e. Right to full disclosure D. A study measuring the effects of sleep deprivation on wound healing D. 81. Less than 50 C. Positivism D. during and after a Procedure 84. Whether management at the community or agency level. Right not to be harmed 85. technical skills. What measure would you suggest that his parents take to help decrease sibling rivalry between Ronnie and his new sister? A. these are: A.g. understanding the human expertise)? A. Explain that new sisters grow up to become best friends . An 85 year old client in a nursing home tells a nurse. B is correct D. C and D are correct Situation 17 – You are actively practicing nurse who just finished your Graduate Studies. a theory D. Naturalistic inquiry C. How many does a typical 3-year-old ask in a day’s time? A. The following questions apply to research. C. budget and accounting skills. skills in fund-raising D. Logical position B. A study examining client’s feeling before. resource management skills A. “I signed the papers for that research study because the doctor was so insistent and I want him to continue taking care of me”. Which client right is being violated? A. A study measuring differences in blood pressure before. Technical skills. 1. a conceptual framework Situation 18 – Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF Project for Children. A study examining oxygen levels after endotracheal suctioning D. 100-200 D.B. during and after a bone marrow Aspiration 83.200 or more B. human relation/behavioral skills. and technical skills C. A is correct B. C and D are correct D. Ronnie asks constant questions. Manipulative skills. technical skill. Human relation skills. there are 3 essential types of skills managers must have. Conceptual skills. Quantitative Research 82. A study examining the bereavement process in spouses of clients with terminal cancer B. A. 86. Which of the following studies is based on quantitative research? A. and cognitive skills B. 300-400 87. best defines: A. You learned the value of Research and would like to utilize the knowledge and skills gained in the application of research to Nursing service. A study measuring nutrition and weight loss/gain in clients with cancer C. The following conditions pertain to CARE OF THE FAMILIES WITH PRESCHOOLERS. A study examining clients reactions to stress after open heart surgery B. Only A and B are correct 80. a concept C. “A supposition or system of ideas that is proposed to explain a given phenomenon”. Move him to the new bed before the baby arrives B. a paradigm B. A and D are correct C. Right of self determination B. A study exploring factors influencing weight control behavior. Ronnie will need to change to a new bed because his baby sister will need Ronnie’s old crib. Which of the following studies is based on qualitative research? A. Right to privacy and confidentiality C.

Twenty or more words C. gives oresol every 4 hours C. A child with ear problem should be assessed for the following. Tell him he will have to share with the new baby D. instruct mother when to return immediately B. Ask him to get his crib ready for the new baby 88. About 12 words B. How many words does a typical 12-month-old infant use? A.C. give an antibiotic for 5 days D. check for malnutrition 93. If the child does not have ear problem. Check for ear pain D. is there any fever? B. complicated ear infection 94. They refuse to allow him to watch television B. Drowning and homicide Situation 19 – Among common conditions found in children especially among poor communities are ear infections/problems. What are two of the most common types of accidents among infants? A. They schedule a health check-up for sex-related disease C. mastoiditis B. You reviewed infant safety procedures with Bryan’s mother. dry the ear by wicking Situation 20 – If the child with diarrhea registers one sign in the pink row and one in the yellow row in the IMCI Chart – 96. no dehydration D. acute ear infection D. As a nurse. complicate ear infection 95. Check for tender swellings behind the ear C. using IMCI. plus “mama” and “papa” 90. Check for ear discharge B. An ear discharge that has been present for less than 14 days can be classified as: A. Aspiration and falls B. chronic ear infection B. acute ear infection D. continue feeding the child B. Two. what should you as the nurse do? A. Ear discharge C. know when to return to the health center . If the child has severe classification because of ear problem. refer urgently C. Ear pain 92. Which of the following is not included in the rules for home treatment in this case: A. We can classify the patient as: A. mastoiditis C. Go to the next question. what would be the best thing that you as the nurse can do? A. EXCEPT: A. If discharge is present for how long? D. chronic ear infection C. They remind him that some activities are private D. The child with no dehydration needs home treatment. What would you suggest? A. They give her “timeout” when this begins 89. moderate dehydration B. Falls and auto accidents C. The following questions apply. severe dehydration 97. 91. A ear discharge that has been present for more than 14 days can be classified as: A. Ronnie’s parents want to know how to react to him when he begins to masturbate while watching television. About 50 words D. some dehydration C. Poisoning and burns D.

give the child extra fluids 98. Biomedical technician C. When the nurse pinched the abdomen. Electrician D. Rehabilitation department B. Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. it goes back slowly. There is no blood in the stool. no dehydration C. blood loss? A. moderate dehydration NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part A) SITUATIONAL Situation 1 – Concerted work efforts among members of the surgical team is essential to the success of the surgical procedure. For orthopedic cases. prompt replacement of compatible blood is crucial. moderate dehydration C. The OR team performs distinct roles for one surgical procedure to be accomplished within a prescribed time frame and deliver a standard patient outcome. Information technician B. no dehydration B. 1. what department is usually informed to be present in the OR? A. The sterile nurse or sterile personnel touch only sterile supplies and instruments. How will you classify Carlo’s illness? A. Circulating Nurse 3. Anaesthesiologist C. the classification would be: A. Laboratory department C. Circulating Nurse B. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as: A. Scrub Nurse B. dysentery C.D. Chaiplaincy C. If the child has sunken eyes. When there is a need for sterile supply which is not in the sterile field. severe dysentery D. In massive blood loss. the nurse offers fluid to Carlo and he drinks eagerly. Nursing Aide 2. persistent diarrhea 99. thirsty and skin pinch goes back slowly. While the surgeon performs the surgical procedure. severe dehydration B. some dehydration D. What department needs to be alerted to coordinate closely with the patient’s family for immediate blood component therapy? A. who hands out these items by opening its outer cover? A. drinking eagerly. severe dehydration 100. Security Division B. His eyes are sunken. Social Service Section . Radiology department 4. who else has to be present when a client undergoes laparoscopic surgery? A. Surgeon C. Surgeon D. Minimally invasive surgery is very much into technology. some dehydration D. severe persistent diarrhea B. Laboratory technician 5. Carlo has had diarrhea for 5 days. he is irritable. who monitors the status of the client like urine output. Anaesthesiologist D. Maintenance department D. Aside from the usual surgical team.

Previous doctor’s clinic . Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in pain. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency? A. an epidural catheter for Fentanyl epidural analgesia is given. incomplete. Medical records section 14. Stay with the client during pain episodes D. At 11 pm D.D. now and every 6 hours p r n. Central supply section B. Doctor in charge B. and inadequate 12. There might be other factors such as cultural or psychological that influence pain. You injected Demerol at 5 pm. When the record is voluminous B. At 12 pm 8. The client can distract himself during pain episodes D. Pain in ortho cases may not be mainly due to the surgery. Left foot is cold to touch and pedal pulse is absent C. Records Management Archives Office (RMAO) D. Since you will need the previous chart. Which of the following observation would prompt you to call the doctor? A. Explain all the possible interventions that may cause the client to worry B. pulse of 82 beats/minute 7. You readmitted a client who was in another department a month ago. Left leg in limited functional anatomic position D. Department of Health (DOH) 13. How can you alter these factors as the nurse? A. is given: A. Which of the following behaviors indicate appropriate adaptation? A. 11. Metro Manila Development Authority (MMDA) C.M. Instruct client to observe strict bed rest B. The hospital director C. Pathology department Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. When the patient is in severe pain C. You continuously evaluate the client’s adaptation to pain. What is your nursing priority care in such a case? A. when you need the medical record of a discharged patient for research you will request permission through: A. There is an order of Demerol 50 mg I. The patient’s medical record can work as a double edged sword. from whom do you request the old chart? A. Administer analgesia through epidural catheter as prescribed D. The next dose of Demerol 50 mg I.M. When it is missing D. Dressing is intact but partially soiled B. Department of Interior and Local Government (DILG) B. Check for epidural catheter drainage C. 6. Promote client’s sense of control and participation in control by listening to his concerns 10. In the hospital. The client denies existence of pain C. The client reports independence from watchers 9. When can the medical record become the doctor’s/nurse’s worst enemy? A. Assess respiratory rate carefully Situation 3 – Records are vital tools in any institution and should be properly maintained for specific use and time. Establish trusting relationship by giving his medication on time C. When the medical record is inaccurate. The nursing service D. When a medical record is subpoenaed in court C. BP 114/78. When the client asks for the next dose B. In some hip surgeries. The client reports pain reduction and decreased activity B.

Your hospital is in Metro Manila C. the surgeon and anesthesiologist are in tandem C. Department where the patient was previously admitted D. needles. the surgeon greets his client before induction of anesthesia B. According to the surgeon’s preference 18. Obtain consent form 23. Last case B. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing . manicure. When are these procedures best scheduled? A. check patient’s ID D. perioperative anxiety and stress B. Your hospital is considered tertiary B. check baseline vital signs 20. As a perioperative nurse. Put side rails up and ask the client not to get out of bed B. In between cases C. Evaluate the type of anesthesia appropriate for the surgical client 22. Some lifetime habits and hobbies affect postoperative respiratory function. Records Management and Archives Office of the DOH is responsible for implementing its policies on record disposal. there are safety protocols that should be followed. delayed wound healing D. Account for the number of sponges. how can you best meet the safety need of the client after administering preoperative narcotic? A. postoperative respiratory function Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient. Check for jewelry. gown. 21. you will anticipate increased risk for: A. Which of the following role would be the responsibility of the scrub nurse? A. D. Assess level of consciousness B. 16. supplies. delayed coagulation time C. If your client smokes 3 packs of cigarettes a day for the past 10 years. According to availability of anaesthesiologist D. Surgeries like I and D (incision and drainage) and debridement are relatively short procedures but considered ‘dirty cases’. The OR nurse should be well versed with all these to safeguard the safety and quality of patient delivery outcome. Your hospital is PhilHealth accredited Situation 4 – In the OR. check for presence dentures C. It obtained permit to operate from DOH D. Assess vital signs D. Medical records section 15. Ensure that the airway is adequate C. strap made of strong non-abrasive materials are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board. D.C. Allow client to get up to go to the comfort room D. Send the client to OR with the family C. Assess the readiness of the client prior to surgery B. You know that your institution is covered by this policy if: A. check for presence underwear B. Another nursing check that should not be missed before the induction of general anesthesia is: A. and dentures 17. you make certain that throughout the procedure… A. used during the surgical procedure. Verify patient identification and informed consent C. As the circulating nurse. Client is monitored throughout the surgery by the assistant anesthesiologist 19. OR nurses should be aware that maintaining the client’s safety is the overall goal of nursing care during the intraoperative phase. Which of the following should be given highest priority when receiving patient in the OR? A.

you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of: A. Prevent thickening of secretions D. 16 years old. Push on abdomen during exhalation D. what should be done to make suturing easy and lessen chance of incision infection? A. Suppress cough 28. Lean forward 30-40 degrees with each exhalation 30. Get patient’s consent C. Sit in high-Fowler’s position with extended legs B. Implement a regular inventory of supplies and equipment C. It is also the nurse’s function to determine when infection is developing in the surgical incision. metabolic acidosis Situation 7 – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility. Serosanguinous exudates and skin blanching C. Shampooed 24. Administer oxygen at 6L/min C. respiratory acidosis C. Practice respiratory isolation 29. Which of the following nursing interventions is done when examining the incision wound and changing the dressing? A. Sit-up with shoulders back C. RR is 46/min and he appears to be in acute respiratory distress. Localized heat and redness B. Promote expectoration C. The health instruction will include the following. Draped B. Blood clots and scar tissue are visible 25. Relax smooth muscles of the bronchial airway B. a case of bronchial asthma. You will give health instructions to Carlo. As a nurse. If hair at the operative site is not shaved. comes to the ER with acute asthmatic attack. Observe the dressing and type and odor of drainage if any B. Overdosage of medication or anesthetic can happen even with the aid of technology like . the nurse will say: A. The mother asked the nurse. Promote emotional support B. metabolic alkalosis B. how can you improve the effectiveness of clinical alarm systems? A. 26. Adherence to manufacturer’s recommendation D. The asthmatic client asked you what breathing techniques he can best practice when asthmatic attack starts. EXCEPT: A. Separation of the incision D. Pulled C. Aminophylline was ordered for acute asthmatic attack. Wash hands D. What will be the best position? A. Avoid emotional stress and extreme temperature B. Request the client to expose the incision wound Situation 6 – Carlo. 31.surgery. Clipped D. seafood D. dust. respiratory alkalosis D. Avoid pollution like smoking C. Avoid pollens. Administer bronchodilator by nebulizer 27. Suction the client every 30 min D. Which of the following nursing actions should be initiated first? A. what is its indication. Implement a regular maintenance and testing of alarm systems 32. As the head nurse in the OR. The perioperative nurse should observe for what signs of impending infection? A. Limit suppliers to a few so that quality is maintained B.

Who is your assistant and anesthesiologist. Circulating Nurse D. what important information do you need to ask the surgeon? A. Who is your anesthesiologist 37. and instrument technician C. As a staff. Skin care around the stoma is critical. scrub nurse 39. Take action to address any identified risks through Incident Report (IR) C. and wrong procedure/surgery includes the following. Assess and periodically reassess individual client’s risk for falling 35. Allow the technician to set the infusion pump before use D. pathologist D. who coordinates the activities outside. wrong person. Conduct ‘time out’ immediately before starting the procedure 34. Allow client to walk with relative to the OR D. Take a video of the entire intra-operative procedure D. Conduct pre-procedure verification process C. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site. you know you can improve on accuracy of patient’s identification by 2 patient identifiers. To reduce the risk of patient harm resulting from fall. sphygmomanometer and similar devices/machines. how can you improve the safety of using infusion pumps? A. and assistant D. You identified a potential risk of pre-and postoperative clients. you can implement the following. call the client by his/her case and bed number D. Inadequate supply C. 36. While team effort is needed in the OR for efficient and quality patient care delivery. scrub nurse. EXCEPT: A. Nurse anesthetist. anesthesiologist. including the family? A. Mark the operative site if possible B. intern. identify the client by his/her wrist tag and verify with family members B. assistant surgeon. and what is your preferred time and type of surgery? C. Electricity B. 41. orderly B. circulating nurse. call the patient by his/her name and bed number Situation 8 – Team efforts is best demonstrated in the OR. Who are your anesthesiologist.infusion pumps. Check the functionality of the pump before use B. nurse assistant. Apply liberal amount of mineral oil to the area . Orderly/clerk B. we should limit the number of people in the room for infection control. anesthesiologist. Nurse Supervisor C. scrub nurse. assistants. depending on the disease condition. Who is your internist B. assistant surgeon. Who comprise this team? A. identify client by his/her wrist tag and call his/her by name C. Surgeon. Select your brand of infusion pump like you do with your cellphone C. Which of the following is not indicated as a skin care barriers? A. Scrub nurse and nurse anesthetist D. anesthesiologist. As a nurse. Surgeon. Communication Situation 9 – Colostomy is a surgically created anus. EXCEPT: A. Instrument technician and circulating nurse B. When surgery is on-going. The breakdown in teamwork is often times a failure in: A. internist. Scrub and circulating nurses 38. Assess potential risk of fall associated with the patient’s medication regimen B. Anesthesiologist 40. Surgeon. Surgeon. the nursing tandem for every surgery is: A. Verify the flow rate against your computation 33. In the OR. anesthesiologist C. If you are the nurse in charge for scheduling surgical cases. It can be temporary or permanent. scrub nurse. EXCEPT: A. radiologist. Leg work D.

Startified ampling D. Been selected systematically B. Establishment of regular bowel movement 44. Quota 50. Sensation of taste B. You decided to include 5 barangays in your municipality and chose a sampling method that would get representative samples from each barangay. Randomization B. Irrigate after lunch everyday B. Apply talcum powder twice a day 42. Control group B. The following are appropriate nursing interventions during colostomy irrigation. What is the most important characteristic of a sample? A. Hang the solution 18 inches above the stoma 45. What health instruction will enhance regulation of a colostomy (defecation) of clients? A. Eat fruits and vegetables in all three meals C. Position client in semi-Fowler D. Before peritoneum is closed C. Universe 47. Before closing the skin . Been selected based on set criteria D. General population D. Systematic sampling Situation 11 – After an abdominal surgery. Sensation of pressure C. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained? A. When is the first sponge/instrument count reported? A. Sensation of smell D. Restrict exercise to walking only 43. Appropriate number D. Characteristics that match other samples 49. Study subjects C. Snow-ball D. which of the following condition is NOT expected? A. Random sampling C. Urge to defecate Situation 10 – As a beginner in research. Use karaya paste and rings around the stoma C. you are aware that sampling is an essential elements of the research process. Increase the irrigating solution flow rate when abdominal cramps is felt B. the circulating and scrub nurses have critical responsibility about sponge and instrument count. What does a sample group represent? A.B. An equal chance of selection C. Insert 2-4 inches of an adequately lubricated catheter to the stoma C. Increased weight B. Representativeness 48. Liquid stool D. Eat balanced meals at regular intervals D. EXCEPT: A. Before closing the subcutaneous layer B. Purposive B. Convenience C. Clean the area daily with soap and water before applying bag D. Which of the following methods allows the use of any group of research subject? A. 51. After ileostomy. Random sampling ensures that each subject has: A. Irritation of skin around the stoma C. Appropriate location C. Cluster sampling B. What should be the appropriate method ofor you to use in this care? A. 46.

Patient’s Liaison D. counts should be documented. Peritoneum D. personal safety is also a concern. Before the fascia is sutured 52. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted? A. Text messaging and e-mail 58. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture? A. Skin 53. by virtue of your expertise.D. Staple B. Surgeon C. OR nurse supervisor D. As a nurse. You can communicate hazards to your co-workers through the use of the following EXCEPT: A. you can help improve the effectiveness of communication among healthcare givers by: A. As a nurse. Another alternative “suture” for skin closure is the use of ____________ A. Fascia B. Endorse the routine and ‘stat’ medications every shift 60. Advising the client. Formal training B. Circulating nurse Situation 12 – As a nurse. What role do you play when you hold all client’s information entrusted to you in the strictest confidence? A. Anesthesiologist B. Provide information to clients about a variety of services that can help alleviate the client’s pain and other conditions B. Tapered needle 54. Use of reminders of ‘what to do’ B. Absorbent dressing D. Like any nursing interventions. Patient’s arbiter 57. you protect yourself and co-workers from misinformation and misrepresentations through the following EXCEPT: A. Patient’s advocate B. what needle would you prepare? A. Invisible suture 55. Use of labels and signs 59. acronyms. Round needle B. Therapeutic glue C. 56. However. that which can contribute to the client’s well-being . Using standardized list of abbreviations. what is one of the best way to reconcile medications across the continuum of care? A. Muscle C. Posting IR in the bulletin board D. Educator C. Endorse on a case-to-case basis B. Posters C. Communicate a complete list of the patient’s medication to the next provider of service C. and symbols C. As a nurse. Like sutures. If you are the scrub nurse for a patient who is prone to keloid formation and has low threshold of pain. needles also vary in shape and uses. you should be aware and prepared of the different roles you play. Reverse cutting needle D. Endorse in writing D. As a nurse. your primary focus in the workplace is the client’s safety. One-on-one oral endorsement D. Atraumatic needle C.

encourage to drink 6-8 glasses of water 67. Lidocaine C. A. Monitor VS. Endorsement thru trimedia to advertise your favorite disinfectant solution Situation 13 – You are assigned at the surgical ward and clients have been complaining of post pain at varying degrees. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. more importantly RR 63. Levophed 68. Deficient fluid volume related to diarrhea 69. Encourage deep breathing and turning D. Pain as you know. you should anticipate to administer which of the following medications to Zeny who is diagnosed to be suffering from hypothyroidism? A. The client complained of abdominal distention and pain. As the nurse. Appropriate preparation for the scheduled procedure C. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would probably include which of the following? A. Lipitor D. One very common cause of postoperative pain is: A. and comfortable environment D. Inadequate anesthetic Situation 14 – You were on duty at the medical ward when Zeny came in for admission for tiredness. administer sedative round the clock B. A one-day postoperative abdominal surgery client has been complaining of severe throbbing abdominal pain described as 9 in a 1-10 pain rating. Call surgeon stat 62. quiet. Health education among clients and significant others regarding the use of chemical disinfectant D. the doctor’s diagnosis was hypothyroidism. Prolonged surgery C. cold intolerance. Your independent nursing care for hypothyroidism includes: A. Skill of surgical team and lesser manipulation B. Imbalance nutrition to hypermetabolism D. Encourage client to do imagery C. and weight gain. Explain the proper use of PCA to alleviate anxiety C. Break in aseptic technique D. Your nursing intervention that can alleviate pain is: A. Hyperglycemia . Forceful traction during surgery B. Activity intolerance related to tiredness associated with disorder B. Check abdominal dressing for possible swelling B. A. Risk to injury related to incomplete eyelid closure C. Levothyroxine B. Upon examination. Turn to sides frequently and avoid too much talking 64. Surgical pain might be minimized by which nursing action in the O.C. Use of modern technology in closing the wound D. is very subjective. administer thyroid hormone replacement C. 66. Offer hot and clear soup D.R. Avoid overdosing to prevent dependence/tolerance D. What nursing intervention would you take A. Your assessment revelas bowel sounds on all quadrants and the dressing is dry and intact. Advice the client to close the lips and avoid deep breathing and talking C. Proper positioning and draping of clients 65. 61. Which will be your priority nursing action? A. Medicate client as prescribed B. Instruct client to go to sleep and relax B. providing a cool. constipation. Myxedema coma is a life threatening complication of long standing and untreated hypothyroidism with one of the following characteristics.

Supine position C. What will you do to ensure that Kyle. Microset 77. Ensure that informed consent has been signed C. thyrotropin C.” 71. thyroxine B. Blood transfusion set B. you know that the most common type of goiter is related to a deficiency of: A. Ascertain if chest x-rays and other tests have been prescribed and completed 72. What IV administration set will you prepare? A. which of the following nursing intervention will be most crucial? A. The MD ordered “Prepare for thoracentesis this pm to remove excess air from the pleural cavity. Place patient in a quiet and cool room B. 76. Place flat in bed B. iodine Situation 15 – Mrs. Provide a calibrated pitcher of drinking water and juice at the bedside and monitor intake and output . What will your protective personal attire include? A. Provide a glass of fruit juice every meal B. Kyle is diagnosed to have measles. to decongest D. When your client asks what is the reason for another chest x-ray. who is febrile. Turn on the unaffected side C. will have a liberal oral fluid intake? A. iron D. Mrs. 5. Orthopneic position 73.B. Pichay who is for thoracentesis is assigned by the nurse to which of the following positions? A. Dorsal Recumbent position D. Turn on the affected side D. To prevent leakage of fluid in the thoracic cavity. to rule out any foreign body Situation 16 – In the hospital. Kyle. Hyperthermia D. you will explain: A. Regulate his IV to 30 drops per minute C. who is febrile. Pichay who will undergo thoracentesis? A. Gloves 78. Hypoglycemia 70. to rule out any possible perforation C. Volumetric chamber D. Chest x-ray was ordered after thoracentesis. Maintain strict aseptic technique C. you are aware that we are helped by the use of a variety of equipment / devices to enhance quality patient care delivery. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest D. Gown B. You are to initiate an IV line to your patient. Apply pressure over the puncture site as soon as the needle is withdrawn 74. Eyewear C. Trendelenburg position B. On bed rest 75. Macroset C. As a nurse. During thoracentesis. Hypothermia C. Pichay is admitted to your ward. Face mask D. Support and reassure client during the procedure B. Determine if client has allergic reaction to local anesthesia D. Which of the following nursing responsibilities is essential in Mrs. how will you position the client after thoracentesis? A. to rule out pneumothorax B.

carrot. Avoid taking BP or blood sample from the arm with the shunt B. You as the nurse will say: A. endotracheal tube perforation C. and tomatoes C. low potassium and low sodium. Recommend protein of high biologic value like eggs. Bananas. Remote control Situation 17 – Tony. The PACU nurse will maintain postoperative T and A client in what position? A. Your teaching will focus on: A. The RR nurse should monitor for the most common postoperative complication of: A. orange and other fresh fruits can be included in the diet 88. poultry and lean meats B. Put the side rails up C. You will do which of the following: A. who has acute renal failure is low-protein. general anesthesia 82. 86. You as the RN will make sure that the family knows to: A. epiglottis 84. What do you teach the watcher and Kyle to alert the nurses for help? A. anesthesiologist’s preference C. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium . Encourage client to include raw cucumbers. Supine with neck hyperextended and supported with pillow B. Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. Heparinize the shunt daily D. Call system D. supplement his diet with Vitamin C rich juices to enhance healing D. soft diet when fully awake 83. hemorrhage B. offer clear liquid for 3 days to prevent irritation Situation 18 – Rudy was diagnosed to have chronic renal failure. Lock the doors 80. osopharyngeal edema D.D. Change dressing of the shunt daily 87. offer osterized feeding B. Prone with the head on pillow and turned to the side C. How to lock side rails B. Before bedtime. Which of the following action would be of highest priority with regards to the external shunt? A. 11 years old. local anesthesia D. ice cream when fully awake D. Semi-fowler’s with neck flexed D. Allowing the client cheese. Put the lights on B. Instruct the client not to exercise the arm with the shunt C. Test the call system D. offer soft foods for a week to minimize discomfort while swallowing C. you went to ensure Kyle’s safety in bed. hot soup when awake C. 81. Hemodialysis is ordered so that an A-V shunt was surgically created. Reverse trendelenburg with extended neck 85. Number of the telephone operator C. has ‘kissing tonsils’ and is scheduled for tonsillectomy and adenoidectomy or T and A. Diet therapy for Rudy. canned foods and other processed food D. balanced diet when fully awake B. cantaloupe. The nutrition instructions should include: A. Provide a writing pad to record his intake 79. cabbage. You are the nurse of Tony who will undergo T and A in the morning. spinal anesthesia B. His mother asked you if Tony will be put to sleep. Mothers of children undergoing tonsillectomy and adenoidectomy usually ask what food to prepare and give their children after surgery. Kyle’s room is fully mechanized.

You have a client with TPN. 24 hour urine specimen D. Colelithiasis B. No. incorporate insulin to present TPN. Will you follow the order? A. As the nurse you will collect… A. maintain a conducive comfortable and cool environment B. Which delegated function to the aide would you particularly check? A. first morning urine C. these should be no drug incorporation. You know that in TPN like blood transfusion. the nurse must also be concerned about drug interactions. Monitor intake and output 93. Report signs and symptoms for delayed allergic reaction B. Urolithiasis Situation 20 – At the medical-surgical ward. Nephrolithiasis C. Checking bowel movement C. 48 hour urine specimen B. You are assisted by a nursing aide with the care of the client with renal failure. What will the nurse monitor and instruct the client and significant others post IVP? A. Ureterolithiasis D. You instructed the family to include more vegetables in the diet and: A. random urine specimen Situation 19 – Fe is experiencing left sharp pain and occasional hematuria. Nursing health instruction will include: A. Fe was so anxious about the procedure and particularly expressed her low pain threshold. Bed rest 95. Fe should excrete the contrast medium. initial hemodialysis shall be done 30 minutes only so as not to rapidly remove the waste from the blood than from the brain D. No. assure the client that contrast medium will be given orally D. A renal failure patient was ordered for creatinine clearance. Monitoring diet 90. Ambulate more C. increase fluid intake B. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. assure the client that x-ray procedure like IVP is only done by experts 92. because insulin is not compatible with TPN . The presence of calculi in the urinary tract is called A. Increased fluid intake D. Obtaining vital signs D. because insulin is chemically stable with TPN and can enhance blood glucose level C.syndrome. Monitoring and recording I and O B. you instructed her to force fluids and do which of the following? A. 96. assure the client that the procedure painless C. Post IVP. Your response is: A. 91. maintain fluid and electrolyte balance C. Yes. Balanced diet B. However the MD’s order read. because insulin will induce hyperglycemia in patients with TPN B. Strain all urine D. cleansing enema D. assure the client that the pain is associated with the warm sensation during the administration of the Hypaque by IV B. maintain aseptic technique throughout the hemodialysis 89. She was advised to undergo IVP by her physician. To increase the chance of passing the stones. He asked you how this can be prevented. barium enema C. gastric lavage 94. Observe NPO for 6 hours C.

2. How can nurses prevent drug interaction including adsorption? A. Sergio is brought to Emergency Room after the barbecue grill accident. it should be understood that our body normally releases insulin according to our blood glucose level. The most effective way to extinguish the flames with as little further damage as possible is to: A. One patient had a ‘runaway’ IV of 50% dextrose. management requires a multidisciplinary approach. his shirt burns into flames. In insulin administration. Administer by fast drip B. log roll on the grass/ground B. it is most important to: A. Referring to manufacturer’s guidelines 100. Any IV solution available to KVO B. cover Sergio with a warm blanket B. Set Box “B” if your test booklet is Set B. assess the Sergio’s breathing 3. After ingestion of food NURSING PRACTICE IV – SET B NURSING PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations (Part B) GENERAL INSTRUCTIONS 1. give him sips of water C. While Sergio was lighting a barbecue grill with a lighter fluid. 3. After a good night’s rest C. Hypotonic solution 99. Based on . Improving on preparation techniques D. To prevent temporary excess of insulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s order? A. Always flush with NSS after IV administration B. calculate the extent of his burns D. Shade only one (1) box for each question on your answer sheets. When is insulin and glucose level highest? A. Once the flames are extinguished. After excitement B. 1. AVOID ERASURES. How will you administer drugs such as insulin. pour cold liquid over the flames 2. Hypertonic solution D. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. The RN should also know that some drugs have increased adsorption when infused in the PVC container. because it was ordered by the MD 97. nitroglycerine hydralazine to promote better therapeutic drug effects? A. INSTRUCTIONS 1. Incorporate to the IV solutions D. You have important responsibilities as a nurse. remove the burning clothes D. slap the flames with his hands C. MULTIPLE CHOICE Situation 1 – Because of the serious consequences of severe burns. Two or more boxes shaded will invalidate your answer. After an exercise D. 3.D. This test booklet contains 100 test questions 2. Isotonic solution C. Write the subject title “Nursing Practice IV” on the box provided. 4. Yes. Shade Set Box A on your answer sheet if your test booklet is Set A. Use volumetric chamber 98. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. Inject the drugs as close to the IV injection site C. Administering drugs with more diluents C.

Which among the following will you do first? A. You are admitting Jorge to the ward and you found out that he is positive for HIV. Sergio sustained superficial partial thickness burns on his trunk. Write an incident report and refer the matter to the nursing director B. hyperkalemia and hyponatremia D. hypokalemia and hypernatremia B. Report the matter to your supervisor D. Write an incident report D. Start basic life support measures B. Call security to report the incident C. you should asses Sergio for: A. Report the incident to your supervisor 8. hyperkalemia and hypernatremia 5. Make an incident report B. You were asked to check the narcotics cabinet. Bring the crush cart to the room D. Renal failure Situation 2 – You are now working as a staff nurse in a general hospital. Keep this matter to yourself C. You are on duty in the medical ward. Call your nurse supervisor and report the incident D. You saw the policeman trying to hit Martin. Epidermis is damaged 4. Which among the following will you do first? A. Take note of it and plan to endorse this to next shift B. You are on morning duty in the medical ward. You have to be prepared to handle situations with ethico-legal and moral implifications. Which among the following activities will you do first? A. Call the physician on duty 7.Colorectal cancer can affect old and younger people. You have 10 patients assigned to you.the assessment of the physician. Which among the following will you do first? A. You asked why he was trying to hit Martin. whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness. Hypervolemia D. Go to see Fiolo and assess for airway patency and breathing problems 10. His wife asks what that means? Your most accurate response would be: A. Surgical procedures . During the first 24 hours after the thermal injury. you found out that one of your patients was not in bed. You are in night duty in surgical ward. He is being guarded by policeman from the local police unit. He denied the matter. Call security officer and report the incident C. Dermis is partially damaged C. hypokalemia and hyponatremia C. came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest. metabolic acidosis B. You are on duty in the medical ward. You recognize that this most likely indicates that Teddy is developing: A. who sustained deep partial thickness and full thickness burns of the face. Epidermis and dermis are both damaged D. Teddy. Write an accident report B. A. During your rounds you heard a commotion. During your endorsement rounds. 6. Find out from the endorsement any patient who might have been given narcotics 9. The mother of your patient who is also a nurse. Report the matter to your head nurse Situation 3 . Call for the Code C. Wait for 2 hours before reporting D. One of your patients Martin is a prisoner who sustained an abdominal gunshot wound. Cerebral hypoxia C. The patient next to him informed you that he went home without notifying the nurses. Structures beneath the skin are damage B. Keep your findings to yourself C. You found out that what is on record does not tally with the drugs used. right upper extremities and right lower extremities.

The following are risk factors for colorectal cancer. around the 7th postoperative day 17. soften the stool by retaining water in the colon Situation 4 – ENTEROSTOMAL THERAPY is now considered a specialty in nursing. empty the bowel of solid waste D. You are aware that teaching about colostomy care is understood when Fermin states. High fat.” D.and other modes of treatment are done to ensure quality of life. anorexia. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer. Symptoms associated with cancer of the colon include: A. When mucus is passed from the stoma between the irrigations. Larry. and “pencil shaped” stools D. EXCEPT: A. Carcinoembryonic antigen C. When preparing to teach Fermin how to irrigate colostomy. “I will contact my physician and report: A. Larry may be given sulfasuxidine and neomycin primarily to: A. Inflammatory bowels B. The stools starts to become formed. you should plan to do the procedure: A. anemia. Abdominal computed tomography (CT) test 13. When observing a return demonstration of a colostomy irrigation. 16. about the 3rd postoperative day C. When Fermin would have normal bowel movement B. Several days prior to bowel surgery. The perineal wound heals And Fermin can sit comfortably on the commode B. You would know after teaching Fermin that dietary instruction for him is . Barium enema B. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled D. If I have any difficulty inserting the irrigating tub into the stoma. heart burn and eructation C. The expulsion of flatus while the irrigating fluid is running out. you know that more teaching is required if Fermin: A. Proctosigmoidoscopy 12. You are assigned in the cancer institute to care of patients with this type of cancer. Smoking D. Prior to breakfast and morning care D. diarrhea. After Fermin accepts alteration in body image 18. Proctosigmoidoscopy C. Fermin can lie on the side comfortably. Lubricates the tip of the catheter prior to inserting into the stoma B. is admitted to the CI. Larry will require which diagnostic study? A. Annual digital rectal examination D. Stool hematologic test D. promote rest of the bowel by minimizing peristalsis B. hematemesis. Genetic factors-familial adenomatous polyposis 14. A. The abdominal incision is closed and contamination is no longer a danger D.” 20.” C. and increased peristalasis 15. 11. You are participating in the OSTOMY CARE CLASS. To confirm his impression of colorectal cancer. reduce the bacterial content of the colon C. At least 2 hours before visiting hours C. ascites and mucus in the stool B. If I noticed a loss of sensation to touch in the stoma tissue. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion C. Clamps of the flow of fluid when felling uncomfortable 19. high fiber diet C. who is suspected of having colorectal cancer. You plan to teach Fermin how to irrigate the colostomy when: A.” B. constipation. Carcinoembryonic antigen B. blood in the stools. 55 years old.

You will need to provide instructions and information to your clients to prevent complications. supplementary oxygen B. ventilation exchange C. Fanny. change the dressing daily using aseptic techniques 22. He verbalized his concern regarding his laryngectomy tube being dislodged. empty the drainage system at the end of the shift B. Randy has chest tubes attached to a pleural drainage system.” B. 21. blood replacement Situation 6 – Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable.” B. “It is important that I eat: A. while avoiding foods that cause gas. Reinsert another tubing immediately D. take showers instead of tub bath C. seek early treatment for respiratory infections B. Your most appropriate response would be: A. Recognize that prompt closure of the tracheal opening may occur B.effective when he states. He ask you what that means? Your best response would be: A. What should you teach him first? A. When caring for him you should: A.” D. clamp the chest tube when suctioning C. “Don’t worry your husband’s type of hepatitis is no longer communicable” B. 26. “Gamma globulin provides passive immunity for hepatitis B” C. palpate the surrounding areas for crepitus D. painful area on the leg B. When caring for Larry after an exploratory chest surgery and pneumonectomy. Infection control is one important responsibility of the nurse to ensure quality of care. “You acquired the infection after you have been admitted to the hospital. avoid situations that involve physical activity 24. continue to take the same restrictions on fluid intake D. Voltaire develops a nosocomial respiratory tract infection. your priority would be to maintain: A. Everything that I ate before the operation. Herbert had a laryngectomy and he is now for discharge. his wife asks you about gamma globulin for herself and her household help.” Situation 5 – Ensuring safety is one of your most important responsibilities. pruritus on the calf and ankle 23. a pitting edema of the ankle C. after a workup he is diagnosed of having Hepatitis A. Bland food so that my intestines do not become irritated. “A vaccine has been developed for this type of hepatitis” 27. you should instruct her to: A. To prevent recurrent attacks on Terry who has acute glumerulonephritis. Keep calm because there is no immediate emergency C. develops jaundice. a reddened area at the ankle D. who has been complaining of anorexia and feeling tired. As Fanny’s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be: A.” C. a tender. Honrad.” D. chest tube drainage D.” . Food low in fiber so that there is less stool. Soft food that are easily digested and absorbed by my large intestines. “You should contact your physician immediately about getting gammaglobulin. “This is a highly contagious infection requiring complete isolation. came in from PACU after pelvic surgery. Notify the physician at once 25.

Tell her family who are in the room not to talk D. Knowing that for a comatose patient hearing is the last sense to be lost. infection 29. has received a significant brain injury Situation 8 – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. As a nurse assigned to Wendy what will be your priority goal? A. Gram stain testing Situation 7 – As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke? A. Hypoxia may occur in the older patients because of which of the following . as Judy’s nurse. Promote urinary elimination D. stomatitis B. A central venous catheter was inserted an I. Prevent skin breakdown B.’ 28. Preserve muscle function C. Purulent drainage from a wound C. Betadine 30. age 40. Maintain a patent airway 32.V. Half-strength hydrogen peroxide C. “As a result of medical treatment. allowing the family unrestricted visiting privileges 35. Use hand rolls or pillows for support 34. Her Glasgow Coma Scale is 6 on admission. placing her bed near the window C. you have acquired a secondary infection. infusion was started. is permanently paralyzed D. When performing a neurologic assessment on Walter. 36.000/μL D. Place June on an upright lateral position B. Talk loudly so that Wendy can hear you C. Which of the following is the most reliable in diagnosing a wound infection? A. There are frequently encountered situations and issues relevant to the older patients. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. Acetic acid D. Tell her family that probably she can’t hear them B. “The infection you had prior to hospitalization flared up. you find that his pupils are fixed and dilated. Wendy is admitted to the hospital with signs and symptoms of stroke. what should you do? A. you can provide a therapeutic environment by doing which of the following? A. dimming the light in her room D. Culture and sensitivity B. Perform range of motion exercises C. dysrhythmia D. This indicated that he: A. is going to be blind because of trauma C. As a nurse you know that one of the complications that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is: A. WBC count of 20. stiff neck and photophobia. While waiting for surgery. honoring her request for a television B. hepatitis C. was admitted to the hospital with a severe headache.C. 31. Speak softly then hold her hands gently 33. probably has meningitis B.” D. Ivy. Dakin’s solution B. Apply antiembolic stockings D. A solution used to treat Pseudomonas wound infection is: A.

Cardiac ischemia in an older patient usually produces: A. functional decline D. During the disaster you see a victim with a green tag. Hyperventilation 37. Response D. Tertiary prevention B. ST-T wave changes B. pain D.”? A. increased glomerular filtration rate C. age 86. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergency phases (mitigation. preparedness. Ineffective airway clearance B. dilated urethra B. Secondary prevention 43. indicates injuries that are extensive and chances of survival are unlikely even . organizing counseling debriefing sessions and securing physical care are the services you are involved with. you know that the person: A. Recovery B. and attack) and for all levels of government and the private sector. Decreased alveolar surfaced area C. fever C. a visual problem C. Which of the four phases of emergency management is defined as “sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects. Decreased anterior-posterior chest diameter D. Aggregate care prevention D.physiologic changes associated with aging. dementia B. Preparedness 42. 41. To which type of prevention are these activities included: A. There are agencies that are in charge of ensuring prompt response. Merle. has injuries that are life threatening but survival is good with minimal intervention C. You are a community health nurse collaborating with the Red Cross and working with disaster relief following a typhoon which flooded and devastated the whole province. decreased bladder capacity 38. response. Mitigation C. decreased breath sounds with crackles Situation 9 – A “disaster” is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster. has injuries that are significant and require medical care but can wait hours with threat to life or limb B. and recovery). Primary prevention C. Disaster preparedness is crucial and is everybody’s business. Acute confusion 40. A. The most dependable sign of infection in the older patient is: A. drug toxicity 39. Very high creatinine kinase level C. Finding safe housing for survivors. diuretic use D. for all types of emergencies and disasters (natural. is complaining of dizziness when she stands up. man-made. Chest pain radiating to the left arm D. This may indicate: A. The older patient is at higher risk for incontinence because of: A. change in mental status B. organizing support for the family.

Matthew accidentally dislodges his IV lines and bleeds. C. Immediate B. Determine their learning needs then prioritize D. Bring your diabetes teaching kit and start your session taking into consideration their distance from your office B. Acetone B. Debfriefing D. Clarify objectives of the activity with the task force before contacting the support groups C. Meet with the nursing group working in the burn unit and discuss problem with them. Find out how many support groups there are in the hospital and get the contact number of their president 50. Based on a feedback during the meeting of the committee there is an increased incidence of pseudomonas infection in the Burn Unit (3 out of 10 patients had positive blood and wound culture). Prior to discharge today. You are assigned to contact the various cancer support groups in your hospital. Determine the VIPs and Celebrities who will be invited D. You are a member of the infection control team of the hospital. It is most appropriate that you instruct the housekeeper to clean the table with: A. Assign point persons who can implement policies. Defusion Situation 10 – As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon. 4 patients are referred to you. You thought it is also your chance to share what you can do for others. Clinical incident stress management B. interview). 46. Ammonia D. Contact the nurse in-charge and find out from her the reason for the referral C.with definitive care D. Involve the whole family in the teaching class 49. 48. What will . While eating his meal. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness requiring immediate treatment: A. How would you start prioritizing your activities? A. What is your priority activity? A. In the planning stage everybody is expected to identify what they can do during the medical mission and what resources are needed. Blood oozes on the surface of the over-bed table. Bleach 47. Find out if there is a budget for this activity B. D. Non-acute D. Part of your responsibility as a member of the diabetes core group is to get referrals from the various wards regarding diabetic patients needing diabetes education. Establish policies for surveillance and monitoring B. has injuries that are minor and treatment can be delayed from hours to days 44. Do data gathering about the possible sources of infection (observation. Alcohol C. Your committee has 4 months to plan and implement the plan. Follow-up C. Which of the following terms refer to a process by which the individual receives education about recognition of stress reaction and management strategies for handling stress which may be instituted after a disaster? A. chart review. Urgent 45. You have been designated as a member of the task force to plan activities for the Cancer Consciousness Week. What will be your priority activity? A. You are invited to participate in the medical mission activity of your alumni association. Emergent C.

pain. Provide sensory stimulation D. is depressed. Sit silently with him 54. turns away and refuses to respond to you. Encourage coughing and deep breathing 57. What should you do first? A. Acceptance that death is inevitable B. Insisting that Ruby should talk with you because it is not good to keep everything inside C. Irma is terminally ill. “I’m ready to go. Arrange for visitors who might cheer him B. 56. Awareness that death will soon occur Situation 12 – Brain tumor. has serious management implications.” C. “I have resigned myself to dying. whether malignant or benign. Be a triage nurse C. Sit down and talk with him for a while C. Coming back periodically and indicating your availability if she would like you to sit with her B. “What’s the use?” D. Take the initial history and document findings D. you should be able to understand the consequences of the disease and the treatment. This is recognized as: A. she speaks to you in confidence. 51. Obtain Irma’s permission to share the information in the family C. increased venous outflow . Leo. Avoidance of the true situation C.be your most important role where you can demonstrate the impact of nursing in health? A. Conduct health education on healthy life style B. socially. You now feel that Irma’s family could be helpful if they knew what Irma has told to you. Which intervention should you include in your plan to reduce ICP? A. That way we can help our patients cope with death and dying. As a nurse. financially and emotionally. Leaving her alone because she is uncooperative and unpleasant to be with D. Tell the physician who in turn could tell the family B. Encourage him to look at the brighter side of things D. has accepted his impending death? A. Which of the following statements would best indicate that Ruffy. who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves. Which of the following would best help him during his depression? A. It is important for us nurses to be aware of how we view suffering. and even our death as well as its meaning. Marla. increased inthrathoracic pressure B. Tell Irma that she has to tell her family what she told you D.” B. Administer bowel softener B. Ruby who has been told she has terminal cancer. You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP). Make an appointment to discuss the situation with the family 52. 90 years old has planned ahead for her death-philosophically. “I’m giving up” 55. Denial with planning for continued life D. Position Conrad with his head turned toward the side of the tumor C. Act as a coordinator Situation 11 – One of the realities that we are confronted with is our mortality. who is dying. illness. Keeping Conrad’s head and neck alignment results in: A. Encouraging her to be physically active as possible 53. You can best help her by: A.

The nursing supervisor on duty will notify Brenda at home D. Raising the head of the bed B. D. Practical planning B. After you asses Conrad. What side effects are most apt to occur the patient during radiation therapy . you suspected increased ICP. lower arterial pH C. As his nurse. 61. Greenish drainage B. decreased venous outflow D. Assign the same nurse to him when possible C. the nursing supervisor on duty decides to call her if time permits C. You are assigned to care for four (4) patients. the Nursing Supervisor of the intensive care unit (ICU) is not on duty when a staff nurse committed a serious medication error. maintain partial pressure of arterial O2 (PaO2) above 80 mmHg B. you have to be prepared to provide safe. Which statement accurately reflects the accountability of the nursing supervisor? A. Culture C. Manual hyperventilation C. Claire. He is anxious because he fears he won’t be monitored as closely as he was in the Coronary Care Unit. Allow Vincent uninterrupted period of time D. Setting limits D. who was previously lucid but is now unarousable. Yellowish drainage D. Move his bed to a room far from nurse’s station to reduce B. Bloody drainage Situation 13 – As a Nurse. 63. who is newly admitted and is scheduled for an executive check-up. Procrastination C. Emy. Cure B. C. to manage time wisely? A. Emphasis on the therapeutic value of the treatment D. Which of the following activities may increase intracranial pressure (ICP)? A. Which one of the following nursing interventions would be most helpful in preparing the patient for radiation therapy? A. efficient and effective care to your patients. Brenda is not duty therefore it is not necessary to inform her. Aris. Valsalva’s maneuver 59. prevent respiratory alkalosis D. promote CO2 elimination 60. you know that drainage on a craniotomy dressing must be measured and marked. Realistic personal expectation 65. Which findings should you report immediately to the surgeon? A. Brenda. Instruct the patient of the possibility of radiation burn C. How can you allay his fear? A. You have to demonstrate specific competencies. Map out the precise course of treatment 67. You are caring for Vincent who has just been transferred to the private room. who has cholelithiasis and is for operation on call. Brenda should be informed when she goes back on duty B. Your most appropriate respiratory goal is to: A. Care D. Coordination 62. Foul-smelling drainage C. Grace. who is terminally ill with breast cancer. The essential components of professional nursing practice are all the following EXCEPT: A. B. increased intrabdominal pressure 58.C. Offer tranquilizers and antiemetics B. 66. Although Brenda is not on duty. Limit Vincent’s visitors to coincide with CCU policies Situation 14 – As a nurse in the Oncology Unit. you have specific responsibilities as professional. Which of the following patients should you give first priority? A. Use of osmotic diuretics D. 64. Conrad underwent craniotomy. Which barrier should you avoid.

mentation 75. The following principles should be observed in disaster triage. 71. Talcum powder D. Abnormal vaginal or perineal discharge C. The most important component of neurologic assessment is: A. Identify the nurse who is assigned to care for such a patient B. Which of the following categories of conditions should be considered first priority in a disaster? A. EXCEPT: A. What is the purpose of wearing a film badge while caring for the patient who is radioactive? A. Transport group 72. any disaster plan should have resources available to triage at each facility and at the disaster site if possible B. training on the disaster is not important to the response in the event of a real disaster because each disaster is unique in itself D. pupil reactivity B. Within the health care group there are pre-assigned roles based on education. A guideline that is utilized in determining priorities is to asses the status of the following. EXCEPT: A. Zinc oxide ointment 69. The following are risk factors for cervical cancer EXCEPT: . You are assigned to take charge of the women to make them aware of cervical cancer. Urinary retention B. do the greatest good for the greatest number of casualties 73. desquamation B. You reviewed its manifestations and management. Which of the following can be used on the irradiated skin during a course of radiation therapy? A. Lower gastrointestinal problems C. perfusion C. There are important principles that should guide the triage team in disaster management that you have to know if you were to volunteer as part of the triage team. As a nurse to which of the following groups are you best prepared to join? A. Treatment group C. Paresthesia of the lower extremities D. Intracranial pressure and mental status B. Trauma 74. locomotion D. Triage group D. Nausea and vomiting and diarrhea 68. respiration B. vital sign assessment C. Prevent radiation-induced sterility C.to the pelvis? A. Respiratory infections D. erythema C. Mineral oil C. Measure the amount of exposure to radiation Situation 15 – In a disaster there must be a chain of command in place that defined the roles of each member of the response team. make the most efficient use of available resources C. Morgue management B. experience and training on disaster. Adhesive tape B. Earliest sign of skin reaction to radiation therapy is: A. pigmentation 70. 76. cranial nerve assessment D. Protect the nurse from radiation effects D. atrophy D. level of consciousness/responsiveness Situation 16 – You are going to participate in a Cancer Consciousness Week.

Cardiac arrest C. As Leda’s nurse. and one ovary B. smoking 77. You have to understand how management of these conditions are done. Apply gentle pressure against the incision when swallowing C. Cough and deep breath every 2 hours D. B. When a panhysterectomy is performed due to cancer of the cervix. radiation therapy and hormone therapy B. you should instruct Leda to: A. tubes and ovaries D. pain in pelvis. Magnesium sulfate C. You should include: A. What would you anticipate to administer? A. diarrhea due to over stimulation C. You are caring for Leda who is scheduled to undergo total thyroidectomy because of a diagnosis of thyroid cancer. Support head with the hands when changing position 82. Potassium iodide B. leg or flank C. viral agents like the Human Papilloma Virus D. An airway and rebreathing tube B. which of the following organs are removed? A. male partner’s sexual habits C. the uterus. the uterus. Perform range and motion exercise on the head and neck B. 81. surgery and radiation therapy 80. exposure to socially transmitted disease. A common complication of hysterectomy is A. radiation therapy D. cervix. the uterus. Support the patient’s head and neck with pillows and sandbags. and two-thirds of the vagina C. However there are conditions/surgical interventions that could compromise life. A crush cart with bed board D. Tetany 85. lymph edema of lower extremities 78. cervix. Which of the following nursing interventions is appropriate after a total thyroidectomy? A. Prior to total thyroidectomy. wound dehiscence Situation 17 – The body has regulatory mechanism to maintain the needed electrolytes. D. A tracheostomy set and oxygen C. sex at an early age. Dyspnea D. Place pillows under your patient’s shoulders.A. multiple partners. 84. Calcium gluconate D. surgery C. tingling and muscle twitching and spasm. Two ampules of sodium bicarbonate 83. the uterus and cervix 79. Potassium chloride Situation 18 – NURSES are involved in maintaining a safe and healthy . urinary/bowel changes B. The primary modalities of treatment for Stage 1 and IIA cervical cancer include the following: A. Raise the knee-gatch to 30 degrees C. cervix. you plan to set up an emergency equipment at her beside following thyroidectomy. Late signs and symptoms of cervical cancer include the following EXCEPT: A. surgery. Respiratory failure B. If there is an accidental injury to the parathyroid gland during a thyroidectomy which of the following might Leda develop postoperatively? A. thrombophelbitis of the pelvic and thigh vessels B. atelectasis D. Keep you patient in a high-fowler’s position. immunosuppressive therapy B. After surgery Leda develops peripheral numbness. uterine bleeding D.

A. sodium bicarbonate 88. You have to be updated on the latest trends and issues affecting profession and the best practices arrived at by the profession. Obtain orders for sedation of family members B. A Comparative Analysis Of The Support System Of Patients With Chronic Illness And Those With Acute Illness. Which of the following questions will you not use in critiquing the Likert Scale? A. aspirin 89. 91. You would like to compare the support system of patients with chronic illness to those with acute illness. How will you best state your problem? A. Descriptive C. Correlational D. Which of the following term most precisely refer to an infection acquired in the hospital that was not present or incubating at the same time of hospital admission? A. a through soap and water wash and rinse of the patient C. What type of research it this? A. 93. You are interested to study the effects of meditation and relaxation on the pain experienced by cancer patients. For a patient experiencing pruritus. to immediately apply personal protective equipment D. Correlational B. Independent B. What type of variable is pain? A. toilet bowl cleaner B. D. You would like to compare the support system of patients with chronic illness to those with acute illness. Dependent C. C. Nosocomial infection C. Primary blood stream infection 90. You are shown a Likert Scale that will be used in evaluating your performance in the clinical area.environment. A Study To Compare The Support System Of Patients With Chronic Illness And Those With Acute Illness. removal of the patients clothing and jewelry and then rinsing the patient with water 87. Provide details of the factors attendant to the sudden death C. 86. B. Demographic 92. Induction of vomiting is indicated for the accidental poisoning patient who has ingested. you recommend which type of bath. to immediately apply a chemical decontamination foam to the area of contamination B. Emerging infectious disease D. A Descriptive Study To Compare The Support System Of Patients With Chronic Illness And Those With Acute Illness In Terms Of Demographic Data And Knowledge About Interventions. rust remover C. gasoline D. Show acceptance of the body by touching it and giving the family permission to touch D. colloidal (oatmeal D. water C. Are the techniques to complete and score the scale provided? . A. Quasi-experimental 94. Experimental D. The Effect Of The Type Of Support System of Patients With Chronic Illness And Those With Acute Illness. Secondary blood stream infections B. This is part of quality care management. Inform the family that the patient has passed on Situation 19 – As a nurse you are expected to participate in initiating or participating in the conduct of research studies to improve nursing practice. The first step in decontamination is: A. Which of the following guidelines is not appropriate to helping family members cope with sudden death? A. saline B.

was the development process described? D. help the client to communicate 2. Are the reliability and validity information on the scale described? C. exaggerated contraction B. Mechanical D. If the Likert scale is to be used for a study. 1. Sulfamylon 98. cross contamination of wound C. Is the instrument clearly described? 95. SITUATIONAL Situation 1 – Jimmy developed this goal for hospitalization. Assurance of anonymity and confidentiality Situation 20 – Because severe burn can affect the person’s totality it is important that-you apply interventions focusing on the various dimensions of man. random layering of collagen C. Interventional C. after hospital discharge D. anxiety laden unconscious conflicts . The following are essential information about the consent that you should disclose to the prospective subjects EXCEPT: A. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is: A. Oral analgesics are most frequently used to control burn injury pain: A. He realized he needed help. wound ischemia D. patient discomfort D. What type of debridement involves proteolytic enzymes? A.” The nurse is going to collaborate with him to reach his goal. In any research study where individual persons are involved.Care of Clients with physiologic and Psychosocial Alterations (Part C). Consent to incomplete disclosure B. it is important that an informed consent for the study is obtained. Neosporin B. Silver nitrate C. A. Hypertrophic burn scars are caused by: A. Descriptions of benefits. 96. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. Which topical antimicrobial is most frequently used in burn wound care? A. help the client find meaning in his experience B. The major disadvantage of whirlpool cleansing of burn wound is: A. upon patient request B. patient hypothermia B. Surgical B. risks and discomforts C. The nurse is guided that Jimmy is aware of his concerns of the “here and now” when he crossed out which item from this “list of what to know”. during the acute phase NURSING PRACTICE V. “To get a handle on my nervousness. excessive manpower requirement 100. You also have to understand the rationale of the treatment. Silver sulfadiazine D.B. Explanation of procedure D. Chemical 97. during the emergent phase C. delayed epithelialization 99. help the client cope with the present problem D. help the client to plan alternatives C.

The investigator is referred to as a/an: A. the investigator’s analysis and interpretations were: A. 6.B. Participant-observer B.. Verbal narrative account 8. database C. becoming aware of the conscious feeling C. The process recording was the principal tool for data collection. You look like you had a very sound sleep. This study which is an in depth study of one boy is a: A. agreeing to contact the staff when he is anxious B. subjective idea of the range of mild to severe anxiety C. D. tell me what happened before you were finally able to sleep and how was your sleep?” B. moderate anxiety D. Observer researcher C. 11. “I learned that you were up till ten last night. evaluative study 7. “Hmm. B. assessing need for medication and medicating himself D. panic state of anxiety B. was given Flurazepam (Dalmane) 15mg at 10:00pm because she had trouble going to sleep. the nurse read the observation of the night nurse. physiologic indices of anxiety 3. Non verbal narrative account B. case study B. While Jimmy was discussing the signs and symptoms of anxiety with his nurse. Audio-visual recording D. The nurse notes effectiveness of interventions in using subjective and objective data in the: A. severe anxiety C. Exploration of relationship between two or more phenomena. Investigation of a phenomenon in real life context. 35 years old. early signs of anxiety D. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT: A. Analysis and interpretation C. Which of these does NOT happen in a descriptive study? A. To ensure reliability of the study. he recognized that complete disruption of the ability to perceive occurs in: A. Explanation of relationship between two or more phenomena. the outgoing nurse informed the nursing staff that Regina. The investigator also provided the nursing care of the subject. That pill you were given last night is effective isn’t it?” . writing out a list of behaviors that he identified as anxious 5. mild anxiety 4. Advocate 10. Manipulation of variable 9. correlated with a list of coping behaviors C. scored and compared standard criteria Situation 3 – During the morning endorsement. subjected to statistical treatment B. C. progress notes Situation 2 – A research study was undertaken in order to identify and analyze a disabled boy’s coping reaction pattern during stress. cross-sectional study D. Caregiver D. Before approaching Regina. problem list D. initial plans or orders B. subjected to an inter-observer agreement D. Which of the following is NOT a part of a process recording? A. Which of the following approaches of the nurse validates the data gathered? A. longitudinal study C.

Tolerating all behavior in the client.” D. affixing her signature to the teaching plan that she has understood the nurse B. Regina commits to herself that she understood and will observe all the medicine precautions by: A. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to: A. committing what she learned to her memory C. verbally agreeing with the nurse D. personality make up C. communicating a message or a need. C. “I have to take this medicine judiciously” B. cope with her present problem D. “Regina. D. Each individual has the potential for growth and change in the direction of positive mental health. Ask her what time she would like to watch the informative video about the medication. 16. go over with her the purpose. intervention C. communication skills 17. emotional reactions D. relying on her husband to remember the precautions Situation 4 – The nurse-patient relationship is a modality through which the nurse meets the client’s needs. “I like taking this sleeping pill. Which of these information LEAST communicate attention and care for her needs for information about her medicine? A. C. There is a basic similarity among all human beings. “Regina. This is a demonstration of the nurse’s role as: A. The nurse’s most unique tool in working with the emotionally ill client is his/her A. counselor . Guided by a medication teaching plan. theoretical knowledge B. 18. collaboration 19. Regina is a high school teacher. 20. “I will inform you and the doctor any untoward reactions I have. The psychiatric nurse who is alert to both the physical and emotional needs of clients is working from the philosophical framework that states: A. One way to increase objectivity in dealing with one’s fears and anxieties is through the process of: A. perceive her participation in an experience !4. 13. did you sleep well?” D. conceptualize her problem C. “I know I will stop taking the medicine when there is advice from the doctor for me to discontinue.” 15.” C. Human beings are systems of interdependent and interrelated parts. I wish I can take it for life. observation B. congruence of behavior? A.C. about the medication and provide her a checklist B. All of the following responses are non therapeutic. face emerging problems realistically B. B. indications and special instructions. B. validation D. D. Have an informal conversation about the medication and its effects D. Responding in a punitive manner to the client. Which is the MOST direct violation of the concept. It solves my problem of insomnia. Communicating ambivalent messages to the client. Provide a drug literature. The mentally ill person responds positively to the nurse who is warm and caring. Rejecting the client as a unique human being C. Which of these responses indicate that Regina needs further discussion regarding special instructions? A. how are you?” 12. All behavior is meaningful.

this is part of privileged communication. “Yes. Ask the client what is the purpose of contacting his relatives. trustworthiness B. Rapport has been established in the nurse-client relationship. Lack of participation in peer groups B.” B. at the start of the relationship 22. is depressed 28. She was observed to be talking irrelevantly and incoherently. Situation 6 – Camila. our interaction is confidential provided the information you tell me is not detrimental to your safety. Guilt feelings B.” C. The best time to inform the client about terminating the nurse-patient relationship is: A.B. 25 years old. professionalism 24. Faulty family atmosphere and interaction C.” B. feels superior of others C. “Of course yes. it is against hospital policy. If you keep it confidential. The past history of Camila would most probably reveal that her premorbid personality is: A. Extreme rebellion towards authority figures D. “Yes. mother surrogate C. B. When the nurse respects the client’s self-disclosure. D. 26. during the working phase C. Promise!” C. ambivert D. is irritable B. it is my principle to uphold my client’s rights. “I am committed for your care. The client has not been visited by relatives for months.” D. The client says. Assist the client to bring his concern to the attention of the social worker. He gives a telephone number and requests the nurse to call. was reported to be gradually withdrawing and isolating herself from friends and family members. though I would want to. 21.” D. “Here (gives her mobile phone). socializing agent Situation 5 – The nurse engages the client in a nurse-patient interaction. therapist D. She became neglectful of her personal hygiene. C. Camila refuses to relate with to others because she: A. You may call this number now”. cycloid 27. Which of the following disturbances in interpersonal relationships MOST often predispose to the development of schizophrenia? A. “Yes. this is just between you and me.” 25. Solo parenting 29. extrovert C. “I want to tell you something but can you promise that you will keep this a secret?” A therapeutic response of the nurse is: A. anticipates rejection D. An appropriate action of the nurse would be: A. this is a gauge for the nurse’s: A. “The best time to talk is during the nurse-client interaction time. when the client asks how long the relationship would be B. “Yes. Ambivalence .” 23. I am committed to have this time available for us while you are at the hospital and ends after your discharge. Inform the attending physician about the request of the client. you have the right to invoke confidentiality of our interaction. “I am sorry. The client asks to visit the nurse after his discharge. The appropriate response of the nurse would be: A. towards the end of the relationship D. loyalty C. schizoid B. Camila’s indifference toward the environment is a compensatory behavior to overcome: A. integrity D. She was diagnosed as schizophrenia disorder.

beginning indifference to the world around her B. has been observed to be irritable. agoraphobia D. psychosis D. behavior indicative of unresolved repressed conflict of the past 32. Speaking at eye level and having the client’s attention D. prescribed level D. adjust to the loss of sensory and perceptual function B. sensory deprivation B. cognitive impairment D. Allowing her to take her meals alone 35. therapeutic level B. social isolation C. psychotic D. increase her self-esteem to maintain her authoritative role 34. Cecilia is persistently feeling restless. She would prefer to be alone and take her meals by herself. A nursing diagnosis for Salome is: A. 31. Using short simple sentences B. audible level Situation 8 – For more than a month now. accept the steady loss of hearing that occurs with aging D. the device is turned on and adjusted to a: A. demanding and speaking louder than usual. The nurse counsels Salome’s daughter that Salome’s becoming very loud and tendency to become aggressive is a/an: A.C. organic B. ego despair 33. She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her. Phobia is a symptom described as: A. psychosomatic C. neurotic 38. worried and feeling as if something dreadful is going to happen. Narcissistic behavior D. comfortable level C. overcompensation for hearing loss D. minimize receiving visitors at home and no longer bothers to answer telephone calls because of deterioration of hearing. personality disorder Situation 7 – Salome. claustrophobia C. Cecilia’s problem is that she always sees and thinks negative things hence she is always fearful. acrophobia B. participate in conversation and other social situations C. communication B. cognition . Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her: A. Schizophrenia is a/an: A. The nurse will assist Salome and her daughter to plan a goal which is for Salome to: A. anxiety disorder B. Cecilia is demonstrating: A. xenophobia 37. 36. attempt to maintain authoritative role C. neurosis C. 80 year old widow. Salome was fitted a hearing aid. Insecurity feelings 30. the following ways to assist Salome meet her needs and avoiding which of the following: A. She was brought by her daughter to the Geriatric clinic for assessment and treatment. She understood the proper use and wear of this device when she says that the battery should be functional. The daughter understood. Speaking distinctly and slowly C.

C. the nurse emphasizes that the team members including nursing students are legally responsible to safeguard patient’s records from loss or destruction or from people not authorized to read it. Social worker C. After discharge. Doctor B. During the orientation. Identification of patient’s responses to medical diagnoses and treatment C. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the: A. The following are SOAP (Subjective – Objective – Analysis – Plan) statements on a problem: Anxiety about diagnosis. Parents or legal guardian D. perception 39. 48 hours D. B. Civil liberty 42. Informed consent B. provide positive reinforcement for acceptable behavior D. Confidentiality C. “I’m so worried about what else they’ll find wrong with me. Summary of chronological notations made by individual health team members B. infections D. She drives alone along the long expressway. Which of the following should the nurse implement? A. 46. Which of the following is the MOST common physiological cause of night bed wetting? A. help find meaning in her behavior C. She watches television with the family in the recreation room D. continue to make necessary explanations regarding diagnostic tests. the order has to be correctly written and signed by the physician within: A.” 45. Administer anxiolytic drug 40. initiate and encourage her to verbalize her fears. 41. deep sleep factors B. Law enforcement authorities 43. She joins an art therapy group Situation 9 – It is the first day of clinical experience of nursing students at the Psychiatry Ward. observation D. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. 36 hours C. frequently verbalizes fear of what diagnostic tests will reveal C. abnormal bladder development C. Anxiety due to unknown D.C. 24 hours B. 12 hours 44. assist her in recognizing irrational beliefs and thoughts B. The nurse must see to it that the written consent of mentally ill patients must be taken from: A. What is the objective data? A. Patient’s responses to health and illness as a total person in interaction with the environment D. Step by step procedures for the management of common problems Situation 10 – Marie is 5½ years old and described by the mother as bedwetting at night. In an extreme situation and when no other resident or intern is available. give emotional support by spending more time with patient. which of these behaviors indicate a positive result of being able to overcome her phobia? A. Relate patient’s feelings to physician. should a nurse receive telephone orders. It is unethical to tell one’s friends and family members data about patients because doing so is a violation of patients’ rights to: A. Least restrictive environment D. She reads a book in the public library B. Has periods of crying. familial and genetic factors .

The next time you bed wet. I’ll tell your friends and hang your sheets out the window for them to see. To help Marie who bed wets at night practice acceptable and appropriate behavior. discipline with a kind attitude B. A therapeutic verbal approach that communicates strong disapproval is: A. sympathize for the child D.” C. e. “Stop! The security will be here in a minute. What situations provoke you to be angry?” 55. Give praise and hugs occasionally.g. Hands by sides but palms turned outwards 52.” B. A. I’d be upset and disappointed.” B.” 50. keep an eye contact while staring at the client B. it is important for the parents to be consistent with the following approaches EXCEPT: A. “If you bed wet. client clenched his jaw/teeth.” Situation 12 – Nursing care for the elderly . his anger was suppressed” 54. A. fold his/her arms across his/her chest D. During the pre-interaction phase of the N-P relationship. “When asked about his relationship with his father. Which of the following is an accurate way of reporting and recording an incident? A. Situation 11 – The nurse is often met with the following situations when clients become angry and hostile. made a fist and turned away from the nurse. “When asked about his relationship with his father. the nurse recognizes this normal INITIAL reaction to an assaultive or potentially assaultive person. EXCEPT one compromise the concepts of behavior therapy program. Tokens make her materialistic at an early age. “When asked about his relationship with his father. I expect you to from now on without fail.47. A. you will change your bed linen and wash the sheets. To stay and fight or run away 53.” C. C. Give a star each time she wakes up dry and every set of five stars. “Calm down. the parent inquires how to motivate Marie to be dry in the morning. extinction C. To call for help from other members of the team D. “If you don’t make an effort to control your bedwetting. 51. “You are supposed to get up and go in the toilet when you feel you have to go and did not. Promise him/her a long awaited vacation after school is over. Display empathy towards the patient C. “How do you usually express anger?” D.” B. reward and punishment B. “Don’t be silly. placebo as a form of treatment 48. To encourage thought. During your conference. keep an “open” posture. The nurse best responds saying. give a prize. which of the following approaches is NOT therapeutic? A. To remain and cope with the incident B. Your response which is an immediate intervention would be: A. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual. learning D. “When do you usually feel angry?” C. All of the following. the nurse should: A. client became anxious.” D. A patient grabs and about to throw it. client was resistant to respond” D. B. “When asked about his relationship with his father. matter of fact in handling the behavior C. What does your child want that you can give every time he/she wakes up dry in the morning? D. “Why do you feel angry?” B. keep his/her hands behind his/her back or in one’s pockets C. be loving yet firm 49. “Stop! Put that chair down. “You are supposed to get up and go in the toilet when you feel you have to go and did not.” D.” C.

She will be observed for signs of increased intracranial pressure which include: A. B. The nurse is unable to insert a finger under the edge of Graciela’s cast on her left foot. Loss D. An elderly who has lots of regrets. In planning care for a patient with Parkinson’s disease. Grief D. Personality development in his life span 58. Crisis B. Despair C. Remind client to call the nurse when she wants to get up D. Put side rails on the bed 60. I will use white shoe polish to keep the cast neat. Graciela’s buttocks are resting on the bed. While on Bryant’s traction. I will use cool water to wash the cast. Graciela is placed on Bryant’s traction. C. Confusion 59. which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction? A. Graciela’s cast is still damp. D. The Bryant’s traction is removed. Number of accomplishments B. Loneliness B. B. unhappy and miserable is experiencing: A. Physical health throughout life D. An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another bed when she returns. A positive Kernig’s sign 63. Which of these statements indicate that the mother understood an important aspect of cast care? A. The traction weights are hanging 10 inches above the floor. The nurse notes that the fall might also cause a possible head injury. Suspicion C. Ambivalence Situation 13 – Graciela 1½ year old is admitted to the hospital from the emergency room with a fracture of the left femur due to a fall down a flight of stairs. Graciela is scratching the cast over her abdomen. 64. C. Assign client to a single room B. Periorbital edema D. A healthy adaptation to aging is primarily related to an individual’s… A. potential for injury B. .56. 62. altered nutritional state C. 61. A plaster of Paris hip spica is applied. The MOST appropriate action the nurse would take is to: A. Which of these finding is a concern of immediate attention that must be reported to the physician immediately? A. Part of discharge plan is for the nurse to give instructions about the care of Graciela’s cast to the mother. The frequent use of the older client’s name by the nurse is MOST effective in alleviating which of the following responses to old age? A. D. The traction ropes move freely through the pulley. ineffective coping D. I will reinforce cracked areas on the cast with adhesive tape. Graciela is assessed to have no head injury. D. C. altered mood state 57. Leave a light on all night C. Narrowing of the pulse pressure B. Vomiting C. which of these nursing diagnoses should have priority? A. The toes of Graciela’s left foot blanch when the nurse applies pressure on them. Ability to avoid interpersonal conflict C. Graciela’s legs are suspended at a 90 degree angle to her trunk. I will place plastic sheeting around the perineal area of the cast. B.

Discovers that his feelings are shared by the group members C. Sertraline (Zoloft) D. Experiences feelings of frustration in the group D. The nurse counsels Graciela’s mother ways to safeguard safety while providing opportunities for Graciela to develop a sense of: A. Insight B. Make some decisions about her future C. Jolina is put on antidepressant drugs. She is not mixing well with other clients. Autonomy Situation 14 – Jolina is an 18 year old beginning college student. Encourage her to join group therapy with other patients. Productivity C. Realistically assess her assets and limitations D. Unusual because action of antidepressant drug is immediate. Flouxetine (Prozac) C. Why haven’t we heard from you? 73. 70. Formulate a structured schedule so she is able to channel her energies externally B. She has lost insight. the nurse suggests vocational guidance because it should help Jolina to: A. Socialization D. Jolina still manifests depression. Unexpected because therapeutic effectiveness takes within a few days. 66. endogenous depression D. Her mother observed that she is having problems relating with her friends. Venlafaxine (Effexor) B. The treatment of the family as a unit is based on the belief that the family: A. Where do you go from here? D. What were you saying? B. Which of the following questions illustrates the group role of encourager? A. After one week of antidepressant medication. Discusses personal concerns with group members 72. Industry D. B. Who wants to respond next? C. Imipramine (Tofranil) 68. therefore they would be useful in which type of depression? A. The goal of remotivation therapy is to facilitate: A. psychotic depression 67. 69. is a social system and all the members are interrelated components of that system . Let her alone until she feels like mingling with others. B. D. D. Trust B. Find a good job. lost interest in anything and complained of constant tiredness. This is a tricyclic antidepressant drug: A. C. These drugs act on the brain chemistry. The nurse evaluates this as: A. During the predischarge conference. Expected because therapeutic effectiveness takes 2-4 weeks. C. Encourage her to join socialization hour so she will start to relate with others. Ineffective result because perhaps the drug’s dosage is inadequate. Solve her own problems Situation 15 – Group Approach in Nursing 71. Intimacy 74. One of the nurse’s important considerations for Jolina INITIALLY is: A. neurotic depression C. Jolina continues to verbalize feeling sad and hopeless. She is undecided about her future. Accomplishes his goal in joining the group B. Initiative C. exogenous depression B. Membership dropout generally occurs in group therapy after a member: A.65.

Sex education Situation 17 – Nurses in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse. due to biochemical factors 82. 76. Recreational therapy B. ego C. The parents of special children who are behaviorally disturbed need mental health education. Cohesiveness C. cut out fabric and use a sewing machine to make simple outfits that will help her earn in the future. Art therapy C. relaxation music C. Drug education B. free clinics and more hospitals 77. caused by multiplicity of factors C. aggressive family planning methods B. social action D. Poverty as reflected in prevalence of communicable diseases. conscience B. rock music 80. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is: A. 81. To deescalate possible anger and aggression among the clients it is BEST to play: A. In a residential treatment home for adolescent girls. a common problem brought about by socioeconomic deprivation B. the clients were becoming increasingly tense and upset because of shortening of their recreation time. A community approach to cope with this problem is for the nurse to support: A. Child abuse C. Lorelie upon discharge was referred to a volunteer group where she has learned to read patterns. Caution B. What type of therapy is this? A. id D. Effective parenting D. provision of social welfare benefits for the poor C. dance music D. Competition Situation 16 – The mental health – psychiatric nurse functions in a variety of setting with different types of clients. rehabilitation D. is “contaminated” by the presence of deviant member and all members need treatment. 75. Educational therapy 79. religious music B.B. prevention C. homeless and prostitution is a predisposing factor to mental illness. who has therapy together will tend to remain together D. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses D. treatment B. Confusion D. research 78. super ego . The MOST cost effective way to meet the mental health needs of the public is through programs with a priority goal of: A. Which of these topics would the school nurse consider as priority for their parent’s class? A. Being in contact with reality and the environment is a function of the: A. as a unit of society needs the opportunity to change its own destiny C. Vocational therapy D. malnutrition and social ills such as street children. The working phase in a therapy group is usually characterized by which of the following? A.

what are your thoughts about it?” D. Methamphetamine hydrochloride Situation 18 – It is common that clients ask the nurse personal questions. “Are you getting bored?” B. Commonly known as “shabu” is: A.83. he is slim and walks sluggishly with a limp. The nurse considers as priority. B. Working phase C. When the client asks about the family of the nurse. She asked. produces less severe symptoms than that of abuse D. substance dependence: A. It is 10 o’clock on your watch. His/Her right to privacy is being intruded. 86. Need for self esteem C. which of these reactions indicates a need for her to introspect? A. “It is confidential I just don’t give it to anyone. He wears a neck brace as a support for his neck. When the nurse is asked a personal question. “Why do you ask?” D. C. “Are you asking for an official number of the hospital/clinic for your reference?” 88. Ricky’s mother visited the school nurse. teach skills to recognize and respond to health threatening situations B. Give a brief and simple response and focus on the client. The classroom teacher consults the school nurse for guidance on how to take care of Ricky while inside of the classroom. includes characteristics of adverse consequences and repeated use B. The client is simply curious. X-ray of cervical spine showed “subluxation of C1 in relation to C2 with cord compression”. increase the client’s awareness of unsatisfactory protective behaviors C. Needs for safety and security D. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship? A. C. “What time is it?” The nurse’s appropriate is: A. Physiological needs B. If the client asks for the nurse’s telephone number. includes characteristics of tolerance and withdrawal 84. “Guess. “If I say No to your request. 90. Avoid the situation and redirect the client’s attention B. promote homeostasis and minimize the client’s withdrawal symptoms 85.” B. Some patients are like children in seeking recognition from the nurse. D. Lysergic acid diethylamide C. 91. Termination phase 87. Ricky’s: A. “It is 10 o’clock. the MOST appropriate response is: A. During the detoxification stage. implement behavior modification D. what time is it?” Situation 19 – Ricky is a 12 year old boy with Down’s syndrome. “Why don’t we talk about your family instead?” D. it is a priority for the nurse to: A. He attends a school for a special education. Substance abuse is different from substance dependence in that. Orientation phase B. The client asks. Methylenedioxy methamphetamine D. “What should I do when Ricky . Introduce another topic like the client’s interests 89. The client knows no other way to begin a conversation.” C. Cannabis Sativa B. He stands 5’ ½” and weighs 100 lbs. “What would you do with my number if I give it to you?” C. Needs for belonging 92. Pre-interaction phase D. which of these responses is NOT appropriate? A. requires long term treatment in a hospital based program C.

Divert Ricky’s attention and engage him in satisfying activities B. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son might just become worse while relating with other drug users. Psychological dependence after prolonged use 100. he can be expected to: A. Danger of acquiring hepatitis or AIDS C. Supportive ***END*** . The mother’s behavior can be described as: A. flight of ideas. The nurse evaluates that her health teaching to a group of high school boys is effective if these students recognize which of the following dangers of inhalant abuse. and “bloodshot eyes” due to dilated pupils. Marijuana D. distance and time.fondles his genitalia?” An appropriate response of the nurse is for the mother to: A. socialize with people B. Competitive sport C. projection D. select and prepare his own food D. Heroin 99. A. The nurse had one on one health education sessions with Ricky’s mother. This drug produces mirthfulness. Live successfully in the community C. The nurse should recognize that the unit primarily responsible for education and awareness of the members of the family on the ill effects of dangerous drugs is the: A. repression B. school C. do activities of daily living 94. Tell Ricky that it is wrong to keep fondling his genitalia C. Unhelpful B. Acquire academic skills of 6th grade level Situation 20 – The abuse of dangerous drugs is a serious public health concern that nurses need to address. A. law enforcement agencies B. family 97. eventually go to school alone C. LSD C. Sudden death from cardiac or respiratory depression B. Engage him in computer TV games that engage his hands 93. Perform simple tasks in closely supervised settings D. church D. Codependent C. Preparing and cooking simple menu D. The mother understood that for her son to learn to cope and be independent. Ignore Ricky’s behavior because he will outgrow it later D. A. All of the following activities are appropriate for Ricky EXCEPT: A. Opiates B. Ricky’s IQ falls within the range of 50-55. Card and table games 95. fantasies. she should constantly provide activities for Ricky to be able to: A. Profit from vocational training with moderate supervision B. Working with clay B. loss of train of thought. Experience of “blackout” D. 96. rationalization C. sublimation 98. A drug dependent utilizes this defense mechanism and enables him to forget shame and pain. distortion of size. Caretaking D.