1. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?

A. B. C. D. Within Within Within Within 4 days after discharge 24 hours after discharge 1 hour after discharge 1 week of discharge

2. Leah is developing constipation from being on bed rest. What measures would y ou suggest she take to help prevent this? A. B. C. D. Eat more frequent small meals instead of three large one daily Walk for at least half an hour daily to stimulate peristalsis Drink more milk, increased calcium intake prevents constipation 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 ne w mother is entering a postpartal taking-hold phase? A. B. C. D. She She She She urges the tells you says that sleeps as baby to stay awake so that she can breast-feed him or her she was in a lot of pain all during labor she has not selected a name for the baby as yet if exhausted from the effort of labor

4. At 6-week postpartum visit what should this postpartal mother s fundic height b e? A. B. C. D. Inverted and palpable at the cervix Six fingerbreadths below umbilicus No longer palpable on her abdomen 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. B. C. D. 350 kcal/day 500 kcal/day 200 kcal/day 1000 kcal/day

Situation 2 As the CPE is applicable for all professional nurse, the professiona l growth and development of Nurses with specialties shall be addressed by a Specialty Certifi cation 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 th e Board of Nursing to promulgate measures to effect the creation of a Specialty Certificati on Council and promulgate professional development programs for this group of nurse-profess ionals? A. B. C. D. R.A. P.D. R.A. R.A. 7610 223 9173 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. B. C. D. Quasi-Judicial Power Regulatory Power Quasi-Legislative Power Executive/Promulgating Power

8. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nurs ing

Specialty Certification Program and Council, which two (2) of the following serv es as the strongest for its enforcement? (a) Advances made in Science and Technology have provided the climate for specia lization in almost all aspects of human endeavor; and (b) As necessary consequence, there has emerged a new concept known as globaliza tion which seeks to remove barriers in trade, industry and services imposed by the na tional 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 Inter national 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 q uality of nursing care. A. B. C. D. b a a a & & & & c b c d are are are are strong strong strong strong justifications justifications justifications justifications

9. Which of the following IS NOT a correct statement as regards Specialty Certif ication? 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 or der to adopt the creation of the Nursing Specialty Certification Council and Program D. The Board of Nursing consulted nursing leaders of national nursing associatio ns 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 p olicy 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 CP E 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 at-

large; 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 follow ing conditions may be acceptable TRUTHS applied to Community Health Nursing Practice. 11. Which of the following is the primary focus of community health nursing prac tice? A. B. C. D. Cure of illnesses Prevention of illnesses Rehabilitation back to health Promotion of health

12. In community health nursing, which of the following is our unit of service a s nurses? A. B. C. D. The The The The community extended members of every family individual members of the Barangay Family

13. A very important part of the Community Health Nursing Assessment Process inc ludes: A. the application of professional judgment in facts to family and community B. evaluation structures and qualifications of C. coordination with other sectors in relation D. carrying out nursing procedures as per plan estimating importance of health center team to health concerns 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. B. C. D. evaluation assessment implementation planning

15. The initial step in PLANNING process in order to engage in any nursing proje ct or activities at the community level involves A. B. C. D. goal-setting monitoring evaluation of data provision of data

Situation 4 Please continue responding as a professional nurse in these other he alth situations through the following questions. 16. Transmission of HIV from an infected individual to another person occurs: A. B. C. D. Most frequently in nurses with needlesticks Only if there is a large viral load in the blood Most commonly as a result of sexual contact 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. B. C. D. Contracted pelvis Maternal disproportion Cervical insufficiency Fetopelvic disproportion

18. The nurse would anticipate a cesarean birth for a client who has which infec tion present

at the onset of labor?

A. B. C. D.

Herpes-simplex virus Human papilloma virus Hepatitis Toxoplasmosis

19. After a vaginal examination, the nurse determines that the client s fetus is i n an occiput posterior position. The nurse would anticipate that the client will have: A. B. C. D. A precipitous birth Intense back pain Frequent leg cramps Nausea and vomiting

20. The rationales for using a prostaglandin gel for a client prior to the induc tion of labor is to: A. B. C. D. Soften and efface the cervix Numb cervical pain receptors Prevent cervical lacerations Stimulate uterine contractions

Situation 5 Nurse Lorena is a Family Planning and Infertility Nurse Specialist a nd currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditio ns 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 s aid to exist when: A. B. C. D. a a a a woman has no uterus woman has no children couple has been trying to conceive for 1 year couple has wanted a child for 6 months

23. Another client named Lilia is diagnosed as having endometriosis. This condit ion interferes with fertility because: A. B. C. D. endometrial the uterine the ovaries pressure on implants can block the fallopian tubes cervix becomes inflamed and swollen stop producing adequate estrogen the pituitary leads to decreased FSH levels

24. Lilia is scheduled to have a hysterosalphingogram. Which of the following in structions

would you give her regarding this procedure?

A. B. C. D.

She will not be able to conceive for 3 months after the procedure The sonogram of the uterus will reveal any tumors present Many women experience mild bleeding as an after effect She may feel some cramping when the dye is inserted

25. Lilia s cousin on the other hand, knowing nurse Lorena s specialization asks wha t artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena? A. B. C. D. Donor sperm are introduced vaginally into the uterus or cervix Donor sperm are injected intra-abdominally into each ovary Artificial sperm are injected vaginally to test tubal patency 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. B. C. D. between between between between -4 deg C and +8 deg C 2 deg C and +8 deg C -8 deg C and 0 deg C -8 deg C and +4 deg C

27. Which of the following vaccines is not done by intramuscular (IM) injection? A. B. C. D. Measles vaccine DPT Hepa-B vaccine Tetanus toxoids

28. This vaccine content is derived from RNA recombinants. A. B. C. D. Measles Tetanus toxoids Hepatitis B vaccines 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. B. C. D. DPT Measles Hepatitis B BCG

30. Which of the following dose of tetanus toxoid is given to the mother to prot ect her infant from neonatal tetanus and likewise provide 10 years protection for the mother? A. B. C. D. Tetanus Tetanus Tetanus Tetanus toxoid toxoid toxoid toxoid 3 2 1 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 accountab ility in the care giving process. Nursing records normally differ from institution to ins titution 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 nurs e completes the information in this record particularly his/her basic personal data, current illness, previous health history, health history of the family, emotional profile, enviro nmental history as well as physical assessment together with nursing diagnosis on admiss ion. What do you call this record? A. B. C. D. Nursing Kardex Nursing Health History and Assessment Worksheet Medicine and Treatment Record Discharge Summary

32. These are sheets/forms which provide an efficient and time saving way to rec ord information that must be obtained repeatedly at regular and/or short intervals o f time. This does not replace the progress notes; instead this record of information on vital signs, intake and output, treatment, postoperative care, post partum care, and diabetic regime n, etc. This is used whenever specific measurements or observations are needed to be doc umented repeatedly. What is this? A. B. C. D. Nursing Kardex Graphic Flow Sheets Discharge Summary Medicine and Treatment Record

33. These records show all medications and treatment provided on a repeated basi s. What do you call this record? A. B. C. D. Nursing Health History and Assessment Worksheet Discharge Summary Nursing Kardex Medicine and Treatment Record

34. This flip-over card is usually kept in a portable file at the Nurse s Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the p hysician to be carried out by the nurse, written nursing care plan, nursing orders, schedule d tests and procedures, safety precautions in patient care and factors related to daily livi

ng activities. This record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. What record is this? A. B. C. D. Discharge Summary Medicine and Treatment Record Nursing Health History and Assessment Worksheet Nursing Kardex

35. Most nurses regard this conventional recording of the date, time, and mode b y which the patient leaves a healthcare unit but this record includes importantly, direc ts of planning for discharge that starts soon after the person is admitted to a healthcare inst itution. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. What do you call this? A. B. C. D. Discharge Summary Nursing Kardex Medicine and Treatment Record Nursing Health History and Assessment Worksheet

Situation 8 As Filipino Professional Nurses we must be knowledgeable about the C ode of Ethics for Filipino Nurse and practice these by heart. The next questions pertai n to this Code of Ethics. 36. Which of the following is TRUE about the Code of Ethics of Filipino Nurses? A. 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. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates C. The present code utilized the Code of Good Governance for the Professions in the Philippines D. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics. 37. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hal lmark of nursing responsibility and accountability? A. B. C. D. Human rights of clients, regardless of creed and gender The privilege of being a registered professional nurses Health, being a fundamental right of every individual Accurate documentation of actions and outcomes

38. Which of the following nurses behavior is regarded as a violation of the Cod e of Ethics of Filipino Nurses? A. A nurse withholding harmful information to the family members of a patient B. A nurse declining commission sent by a doctor for her referral C. A nurse endorsing a person running for congress. 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. 39. A nurse should be cognizant that professional programs for specialty certifi cation by the Board of Nursing accredited through the:

A. B. C. D.

Professional Regulation Commission Nursing Specialty Certification Council Association of Deans of Philippine Colleges of Nursing Philippine Nurse Association

40. Mr. Santos, R.N. works in a nursing home, and he knows that one of his dutie s is to be an advocate for his patients. Mr. Santos knows a primary duty of an advocate is to; A. B. C. D. act as the patient s legal representative complete all nursing responsibilities on time safeguard the well being of every patient maintain the patient s right to privacy

Situation 9 Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-R ISK PREGNANCIES: Particular women with preexisting or Newly Acquired illness. The fo llowing conditions apply 41. Bernadette is a 22-year old woman. Which condition would make her more prone than others to developing a Candida infection during pregnancy? A. B. C. D. Her She She She husband plays golf 6 days a week was over 35 when she became pregnant usually drinks tomato juice for breakfast has developed gestational diabetes

42. Bernadette develops a deep vein thrombosis following an auto accident and is prescribed heparin sub-Q. What should Joanna educate her about in regard to this ? A. B. C. D. Some infants will be born with allergic symptoms to heparin Her infant will be born with scattered petechiae on his trunk Heparin can cause darkened skin in newborns Heparin does not cross placenta and so does not affect a fetus

43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. What statement signifies this fact? A. B. C. D. I I I I ve stopped jogging so I don t risk becoming dehydrated. take an iron pill every day to help grow new red blood cells am careful to drink at least eight glasses of fluid every day understand why folic acid is important for red cell formation

44. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should she limit or discontinue this toward the end of pregnancy? A. B. C. D. Aspirin can lead to deep vein thrombosis following birth Newborns develop a red rash from salicylate toxicity Newbors develop withdrawal headaches from salicylates Salicylates can lead to increased maternal bleeding at childbirth

45. Bernadette received a laceration on her leg from her automobile accident. Wh y are

lacerations of lower extremities potentially more serious in pregnant women than others? A. B. C. D. . Lacerations can provoke allergic responses because of gonadothropic hormone Increased bleeding can occur from uterine pressure on leg veins A woman is less able to keep the laceration clean because of her fatigue Healing is limited during pregnancy, so these will not heal until after birth

Situation 10 Still in your self-managed Child Health Nursing Clinic, you encount er these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS. 46. Josie brought her 3 months old child to your clinic because of cough and col ds. Which of the following is your primary action? A. Give cotrimoxazole tablet or syrup B. Assess the patient using the chart on management of children with cough C. Refer to the doctor D. Teach the mother how to count her child s breathing 47. In responding to the care concerns of children with severe disease, referral to the hospital is of the essence especially if the child manifests which of the follow ing? A. B. C. D. Wheezing Stop feeding well Fast breathing Difficulty to awaken

48. Which of the following is the most important responsibility of a nurse in th e prevention of unnecessary deaths from pneumonia and other severe diseases? A. B. C. D. Giving antibiotics Taking of the temperature of the sick child Provision of Careful Assessment Weighing of the sick child

49. You were able to identify factors that lead to respiratory problems in the c ommunity where your health facility serve. Your primary role therefore in order to reduce morbidity due to pneumonia is to: A. B. C. D. Teach mothers how to recognize early signs and symptoms of pneumonia Make home visits to sick children Refer cases to hospitals Seek assistance and mobilize the BHWs to have a meeting with mothers

50. Which of the following is the principal focus of the CARI program of the Dep artment of Health? A. B. C. D. Enhancement of health team capabilities Teach mothers how to detect signs and where to refer Mortality reduction through early detection Teach other community health workers how to assess patients.

Situation 11 You are working as a Pediatric Nurse in you own Child Health Nursin g Clinic. The following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK conditions. 51. Theresa, a mother with a 2 year old daughter asks, at what age can I be able

to take the blood pressure of my daughter as a routine procedure since hypertension is c ommon in the family? Your answer to this is:

A. B. C. D.

At 2 years you may As early as 1 year old When she s 3 years old When she s 6 years old

52. You typically gag children to inspect the back of their throat. When is it i mportant NOT to elicit a gag reflex? A. B. C. D. when When When When a girl has a geographic tongue a boy has a possible inguinal hernia a child has symptoms of epiglottitis children are under 5 years of age

53. Baby John was given a drug at birth to reverse the effects of a narcotic giv en to his mother in labor. What drug is commonly used for this: A. B. C. D. Naloxone (Narcan) Morphine Sulfate Sodium Chloride Penicillin G

54. Why are small-for-gestational-age newborns at risks for difficulty maintaini ng body temperature? A. B. C. D. They do not have as many fat stores as other infants They are more active than usual so throw off covers Their skin is more susceptible to conduction of cold They are preterm so are born relatively small in size

55. Baby John develops hyperbilirubinemia. What is a method used to treat hyperbilirubinemia in a newborn? A. B. C. D. Keeping infants in a warm and dark environment Administration of cardiovascular stimulant Gentle exercise to stop muscle breakdown Early feeding to speed passage of meconium

Situation 12 You are the nurse in the Out-Patient Department and during your shi ft you encountered multiple children s condition. The following questions apply. 56. You assessed a child with visible severe wasting, he has: A. B. C. D. edema LBM Kwashiorkor Marasmus

57. Which of the following conditions is NOT true about contraindication to immu nization? A. do not give DPT2 or DPT3 to a child who has had convulsions within 3 days of DPT1 B. do not give BCG if the child has known hepatitis C. do not give DPT to a child who has recurrent convulsion or active neurologic disease

D. do not give BCG if the child has known AIDS 58. Which of the following statements about immunization is NOT true: A. A child with diarrhea who is due for OPV should receive the OPV and make extr a dose on the next visit B. There is no contraindication to immunization if the child is well enough to g o home 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. A child should be immunized in the health center before referral 59. A child with visible severe wasting or severe palmar pallor may be classifie d as: A. B. C. D. moderate malnutrition/anemia severe malnutrition/anemia not very low weight no anemia anemia/very low weight

60. A child has some palmar pallor can be classified as: A. B. C. D. moderate anemia/normal weight severe malnutrition/anemia anemia/very low weight not very low weight no anemia

Situation 13 Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold s Maneuver is done. The obstetrician told that she appears to be 20 weeks pregnant. 61. Nette explains this because the fundus is: A. At the level of the umbilicus, and the fetal heart can be heard with a fetoscope B. 18 cm, and the baby is just about to move C. Is just over the symphisis, and fetal heart cannot be heard D. 28 cm, and fetal heart can be heard with a Doppler 62. In doing Leopold s Maneuver palpation which among the following IS NOT conside red a good preparation: A. The woman should lie in a supine position with her knees flexed slightly B. The hands of the nurse should be cold so that abdominal muscles would contract and tighten C. Be certain that your hands are warm (by washing them in warm water first if necessary) D. The woman empties her bladder before palpation 63. In her pregnancy, she experienced fatigue and drowsiness. This probably occu rs because:

A. of high blood pressure B. she is expressing pressure C. the fetus utilizes her glucose stores and leaves her with a low blood glucose D. of the rapid growth of the fetus 64. The nurse assesses the woman at 20 weeks gestation and expects the woman to report: A. B. C. D. Spotting related to fetal implantation Symptoms of diabetes as human placental lactogen is released Feeling fetal kicks Nausea and vomiting related HCG production

65. Mrs. Medina comes to you for check-up on June 2, her EDC is June 11, what do you expect during assessment? A. B. C. D. Fundic Cervix Cervix Fundic ht. 2 fingers below xyphoid process, engaged close, uneffaced, FH-midway between the umbilicus and symphysis pubis open, fundic ht. 2 fingers below xyphoid process, floating height at least at the level of the xyphoid process, engaged

Situation 14 Please continue responding as a professional nurse in theses varied health situations through the following questions. 66. Which of the following medications would the nurse expect the physician to o rder for recurrent convulsive seizures of a 10-year old child brought to your clinic? A. B. C. D. Phenobarbital Nifedipine Butorphanol Diazepam

67. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. The nurse is aware that in addition to pregnancy, Rh-negative women w ould also receive this medication after which of the following? A. B. C. D. Unsuccessful artificial insemination procedure Blood transfusion after hemorrhage Therapeutic or spontaneous abortion Head injury from a car accident

68. Which of the following would the nurse include when describing the pathophys iology of gestational diabetes? A. B. C. D. Glucose levels decrease to accommodate fetal growth Hypoinsulinemia develops early in the first trimester Pregnancy fosters the development of carbohydrate cravings There is progressive resistance to the effects of insulin

69. When providing prenatal education to a pregnant woman with asthma, which of the following would be important for the nurse to do?

A. B. C. D.

Demonstrate how to assess her blood glucose levels Teach correct administration of subcutaneous bronchodilators Ensure she seeks treatment for any acute exacerbation Explain that she should avoid steroids during her pregnancy

70. Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during her pregnancy? A. B. C. D. Rh incompatibility Placenta Previa Hyperemesis Gravidarum Abruprtion Placenta

Situation 15 One important tool a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice? 71. The community/Public Health Bag is: A. a requirement for home visits B. an essential and indispensable equipment of the community health nurse C. contains basic medications and articles used by the community health nurse D. a tool used by the Community health nurse is rendering effective nursing procedures during a home visit 72. What is the rationale in the use of bag technique during home visits? A. It helps render effective nursing care to clients or other members of the family B. It saves time and effort of the nurse in the performance of nursing procedure s C. It should minimize or prevent the spread of infection from individuals to fam ilies D. It should not overshadow concerns for the patient 73. Which among the following is important in the use of the bag technique durin g home visit? A. Arrangement of the bag s contents must be convenient to the nurse B. The bag should contain all necessary supplies and equipment ready for use C. Be sure to thoroughly clean your bag especially when exposed to communicable disease cases D. Minimize if not totally prevent the spread of infection 74. This is an important procedure of the nurse during home visits. A. B. C. D. protection of the CHN bag arrangement of the contents of the CHN bag cleaning of the CHN bag proper hand washing

75. In consideration of the steps in applying the bag technique, which side of t he paper lining of the CHN bag is considered clean to make a non-contaminated work area? A. The lower lip

B. The outer surface C. The upper tip D. The inside surface Situation 16 As a Community Health Nurse relating with people in different commu nities, 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 Lo cal Government/Municipal or City Level. 76. The following statements can correctly be made about Organization and manage ment: A. An organization (or company) is people. Values make people persons; values give vitality, meaning and direction to a company. As the people of an organization value, so the company becomes. B. Management is the process by which administration achieves its mission, goals , and objectives. C. 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. D. Management principles are universal therefore, one need not be concerned abou t peoples, culture, values, traditions and human relations. A. B. C. D. B and C only A,B and D only A and D only B, A and C only

77. Management by Filipino values advocate the consideration of the Filipino goa ls trilogy according to the Filipino priority-values which are: A. B. C. D. Family goals, national goals, organizational Organizational goals, national goals, family National goals, organizational goals, family Family goals, organizational goals, national goals goals goals goals

78. Since the advocacy for the utilization of Filipino value-system in managemen t has been encouraged, the Nursing sector is no except, management needs to examine Filipin o values and discover its positive potentials and harness them to achieve: A. Employee satisfaction B. Organizational commitments, organizational objectives and employee satisfacti on C. Employee objectives/satisfaction, commitments and organizational objectives D. Organizational objectives, commitments and employee objective/satisfaction/ 79. The following statements can correctly be made about an effective and effici ent community or even agency managerial-leader. A. Considers the achievement and advancement of the organization she/he

represents as well as his people B. Considers the recognition of individual efforts toward the realization of organizational goals as well as the welfare of his people C. Considers the welfare of the organization above all other consideration by hi gher administration D. Considers its own recognition by higher administration for purposes of promot ion and prestige.

A. Only C and are correct B. A, C and D are correct

C. B, C and D are correct D. Only A and B are correct

80. Whether management at the community or agency level, there are 3 essential t ypes of skills managers must have, these are: A. B. C. D. Human relation skills, technical skills, and cognitive skills Conceptual skills, human relation/behavioral skills, and technical skills Technical skills, budget and accounting skills, skills in fund-raising Manipulative skills, technical skill, resource management skills C. A is correct D. C and D are correct

A. A and D are correct B. B is correct

Situation 17 You are actively practicing nurse who just finished your Graduate S tudies. You learned the value of Research and would like to utilize the knowledge and sk ills gained in the application of research to Nursing service. The following questions apply to research. 81. Which type of research inquiry investigates the issues of human complexity ( e.g. understanding the human expertise)? A. B. C. D. Logical position Naturalistic inquiry Positivism Quantitative Research

82. Which of the following studies is based on quantitative research? A. A study examining the bereavement process in spouses of clients with terminal cancer B. A study exploring factors influencing weight control behavior. C. A study measuring the effects of sleep deprivation on wound healing D. A study examining client s feeling before, during and after a bone marrow aspiration 83. Which of the following studies is based on qualitative research? A. A study B. A study C. A study D. A study procedure examining measuring examining measuring clients reactions to stress after open heart surgery nutrition and weight loss/gain in clients with cancer oxygen levels after endotracheal suctioning differences in blood pressure before, during and after a

84. An 85 year old client in a nursing home tells a nurse, I signed the papers fo r that research study because the doctor was so insistent and I want him to continue ta king care of me . Which client right is being violated? A. B. C. D. Right Right Right Right of self determination to privacy and confidentiality to full disclosure not to be harmed

85. A supposition or system of ideas that is proposed to explain a given phenomen on , best defines: A. B. C. D. a a a a paradigm concept theory conceptual framework

Situation 18 Nurse Michelle works with a Family Nursing Team in Calbayog Provinc e specifically handling a UNICEF Project for Children. The following conditions pe rtain to CARE OF THE FAMILIES WITH PRESCHOOLERS. 86. Ronnie asks constant questions. How many does a typical 3-year-old ask in a day s time? A. B. C. D. 1,200 or more Less than 50 100-200 300-400

87. Ronnie will need to change to a new bed because his baby sister will need Ro nnie s old crib. What measure would you suggest that his parents take to help decrease sibl ing rivalry between Ronnie and his new sister? A. B. C. D. Move him to the new bed before the baby arrives Explain that new sisters grow up to become best friends Tell him he will have to share with the new baby Ask him to get his crib ready for the new baby

88. Ronnie s parents want to know how to react to him when he begins to masturbate while watching television. What would you suggest? A. B. C. D. They They They They refuse to allow him to watch television schedule a health check-up for sex-related disease remind him that some activities are private give her timeout when this begins

89. How many words does a typical 12-month-old infant use? A. B. C. D. About 12 words Twenty or more words About 50 words Two, plus mama and

papa

90. As a nurse. You reviewed infant safety procedures with Bryan s mother. What ar e two of the most common types of accidents among infants? A. B. C. D. Aspiration and falls Falls and auto accidents Poisoning and burns Drowning and homicide

Situation 19 Among common conditions found in children especially among poor communities are ear infections/problems. The following questions apply. 91. A child with ear problem should be assessed for the following, EXCEPT: A. is there any fever? B. Ear discharge C. If discharge is present for how long? D. Ear pain 92. If the child does not have ear problem, using IMCI, what should you as the n urse do? A. B. C. D. Check Check Check Go to for for for the ear discharge tender swellings behind the ear ear pain next question, check for malnutrition

93. A ear discharge that has been present for more than 14 days can be classifie d as: A. B. C. D. mastoiditis chronic ear infection acute ear infection complicated ear infection

94. An ear discharge that has been present for less than 14 days can be classifi ed as: A. B. C. D. chronic ear infection mastoiditis acute ear infection complicate ear infection

95. If the child has severe classification because of ear problem, what would be the best thing that you as the nurse can do? A. B. C. D. instruct mother when to return immediately refer urgently give an antibiotic for 5 days dry the ear by wicking

Situation 20 If the child with diarrhea registers one sign in the pink row and o ne in the yellow row in the IMCI Chart 96. We can classify the patient as: A. B. C. D. moderate dehydration some dehydration no dehydration severe dehydration

97. The child with no dehydration needs home treatment. Which of the following i s not included in the rules for home treatment in this case: A. continue feeding the child B. gives oresol every 4 hours

C. know when to return to the health center D. give the child extra fluids 98. A child who has had diarrhea for 14 days but has no sign of dehydration is c lassified as: A. B. C. D. severe persistent diarrhea dysentery severe dysentery persistent diarrhea

99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back slowly, the classification would be: A. B. C. D. no dehydration moderate dehydration some dehydration severe dehydration

100. Carlo has had diarrhea for 5 days. There is no blood in the stool, he is ir ritable. His eyes are sunken, the nurse offers fluid to Carlo and he drinks eagerly. When the nurse pinched the abdomen, it goes back slowly. How will you classify Carlo s illness? A. B. C. D. severe dehydration no dehydration some dehydration moderate dehydration Care of Clients with Physiologic and Psychosocial Alteratio

NURSING PRACTICE III ns (Part A) SITUATIONAL

Situation 1 Concerted work efforts among members of the surgical team is essenti al to the success of the surgical procedure. 1. The sterile nurse or sterile personnel touch only sterile supplies and instru ments. When there is a need for sterile supply which is not in the sterile field, who hands out these items by opening its outer cover? A. B. C. D. Circulating Nurse Anaesthesiologist Surgeon Nursing Aide

2. The OR team performs distinct roles for one surgical procedure to be accompli shed within a prescribed time frame and deliver a standard patient outcome. While the surgeo n performs the surgical procedure, who monitors the status of the client like urin e output, blood loss?

A. B. C. D.

Scrub Nurse Surgeon Anaesthesiologist Circulating Nurse

3. Surgery schedules are communicated to the OR usually a day prior to the proce dure by the nurse of the floor or ward where the patient is confined. For orthopedic cas es, what department is usually informed to be present in the OR? A. B. C. D. Rehabilitation department Laboratory department Maintenance department Radiology department

4. Minimally invasive surgery is very much into technology. Aside from the usual surgical team, who else has to be present when a client undergoes laparoscopic surgery? A. B. C. D. Information technician Biomedical technician Electrician Laboratory technician

5. In massive blood loss, prompt replacement of compatible blood is crucial. Wha t department needs to be alerted to coordinate closely with the patient s family for immediate blood component therapy? A. B. C. D. Security Division Chaiplaincy Social Service Section Pathology department

Situation 2 You are assigned in the Orthopedic Ward where clients are complainin g of pain in varying degrees upon movement of body parts. 6. Troy is a one day post open reduction and internal fixation (ORIF) of the lef t hip and is in pain. Which of the following observation would prompt you to call the doctor? A. B. C. D. Dressing is intact but partially soiled Left foot is cold to touch and pedal pulse is absent Left leg in limited functional anatomic position BP 114/78, pulse of 82 beats/minute

7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You inje cted Demerol at 5 pm. The next dose of Demerol 50 mg I.M. is given: A. B. C. D. When the client asks for the next dose When the patient is in severe pain At11pm At12pm

8. You continuously evaluate the client s adaptation to pain. Which of the followi ng

behaviors indicate appropriate adaptation? A. B. C. D. The The The The client client client client reports pain reduction and decreased activity denies existence of pain can distract himself during pain episodes reports independence from watchers

9. Pain in ortho cases may not be mainly due to the surgery. There might be othe r factors such as cultural or psychological that influence pain. How can you alter these f actors as the nurse? A. B. C. D. to Explain all the possible interventions that may cause the client to worry Establish trusting relationship by giving his medication on time Stay with the client during pain episodes Promote client s sense of control and participation in control by listening his concerns

10. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case? A. B. C. D. Instruct client to observe strict bed rest Check for epidural catheter drainage Administer analgesia through epidural catheter as prescribed Assess respiratory rate carefully

Situation 3 Records are vital tools in any institution and should be properly ma intained for specific use and time. 11. The patient s medical record can work as a double edged sword. When can the me dical record become the doctor s/nurse s worst enemy? A. B. C. D. When When When When the record is voluminous a medical record is subpoenaed in court it is missing the medical record is inaccurate, incomplete, and inadequate

12. Disposal of medical records in government hospitals/institutions must be don e in close coordination with what agency? A. B. C. D. Department of Interior and Local Government (DILG) Metro Manila Development Authority (MMDA) Records Management Archives Office (RMAO) Department of Health (DOH)

13. In the hospital, when you need the medical record of a discharged patient fo r research you will request permission through: A. B. C. D. Doctor in charge The hospital director The nursing service Medical records section

14. You readmitted a client who was in another department a month ago. Since you

will need the previous chart, from whom do you request the old chart? A. B. C. D. Central supply section Previous doctor s clinic Department where the patient was previously admitted Medical records section

15. Records Management and Archives Office of the DOH is responsible for impleme nting its policies on record disposal. You know that your institution is covered by this p olicy if: A. B. C. D. Your hospital is considered tertiary Your hospital is in Metro Manila It obtained permit to operate from DOH Your hospital is PhilHealth accredited

Situation 4 In the OR, there are safety protocols that should be followed. The O R nurse should be well versed with all these to safeguard the safety and quality of pati ent delivery outcome. 16. Which of the following should be given highest priority when receiving patie nt in the OR? A. B. C. D. Assess level of consciousness Verify patient identification and informed consent Assess vital signs Check for jewelry, gown, manicure, and dentures

17. Surgeries like I and D (incision and drainage) and debridement are relativel y short procedures but considered dirty cases . When are these procedures best scheduled? A. B. C. D. Last case In between cases According to availability of anaesthesiologist According to the surgeon s preference

18. OR nurses should be aware that maintaining the client s safety is the overall goal of nursing care during the intraoperative phase. As the circulating nurse, you make certain that throughout the procedure A. the surgeon greets his client before induction of anesthesia B. the surgeon and anesthesiologist are in tandem 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. Client is monitored throughout the surgery by the assistant anesthesiologist 19. Another nursing check that should not be missed before the induction of gene ral anesthesia is: A. check for presence underwear

B. check for presence dentures C. check patient s ID D. check baseline vital signs 20. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate in creased risk for:

A. B. C. D.

perioperative anxiety and stress delayed coagulation time delayed wound healing postoperative respiratory function Nurses hold a variety of roles when providing care to a perioperativ

Situation 5 e patient.

21. Which of the following role would be the responsibility of the scrub nurse? A. Assess the readiness of the client prior to surgery B. Ensure that the airway is adequate C. Account for the number of sponges, needles, supplies, used during the surgical procedure. D. Evaluate the type of anesthesia appropriate for the surgical client 22. As a perioperative nurse, how can you best meet the safety need of the clien t after administering preoperative narcotic? A. B. C. D. Put side rails up and ask the client not to get out of bed Send the client to OR with the family Allow client to get up to go to the comfort room Obtain consent form

23. It is the responsibility of the pre-op nurse to do skin prep for patients un dergoing surgery. If hair at the operative site is not shaved, what should be done to mak e suturing easy and lessen chance of incision infection? A. B. C. D. Draped Pulled Clipped Shampooed

24. It is also the nurse s function to determine when infection is developing in t he surgical incision. The perioperative nurse should observe for what signs of impending inf ection? A. B. C. D. Localized heat and redness Serosanguinous exudates and skin blanching Separation of the incision Blood clots and scar tissue are visible

25. Which of the following nursing interventions is done when examining the inci sion wound and changing the dressing? A. B. C. D. Observe the dressing and type and odor of drainage if any Get patient s consent Wash hands Request the client to expose the incision wound

Situation 6 Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress.

26. Which of the following nursing actions should be initiated first?

A. B. C. D.

Promote emotional support Administer oxygen at 6L/min Suction the client every 30 min Administer bronchodilator by nebulizer

27. Aminophylline was ordered for acute asthmatic attack. The mother asked the n urse, what is its indication, the nurse will say: A. Relax smooth muscles of the bronchial airway B. Promote expectoration C. Prevent thickening of secretions D. Suppress cough 28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT: A. B. C. D. Avoid emotional stress and extreme temperature Avoid pollution like smoking Avoid pollens, dust, seafood Practice respiratory isolation

29. The asthmatic client asked you what breathing techniques he can best practic e when asthmatic attack starts. What will be the best position? A. B. C. D. Sit in high-Fowler s position with extended legs Sit-up with shoulders back Push on abdomen during exhalation Lean forward 30-40 degrees with each exhalation

30. As a nurse, you are always alerted to monitor status asthmaticus who will li kely and initially manifest symptoms of: A. B. C. D. metabolic alkalosis respiratory acidosis respiratory alkalosis metabolic acidosis

Situation 7 Joint Commission on Accreditation of Hospital Organization (JCAHO) p atient safety goals and requirements include the care and efficient use of technology i n the OR and elsewhere in the healthcare facility. 31. As the head nurse in the OR, how can you improve the effectiveness of clinic al alarm systems? A. B. C. D. Limit suppliers to a few so that quality is maintained Implement a regular inventory of supplies and equipment Adherence to manufacturer s recommendation Implement a regular maintenance and testing of alarm systems

32. Overdosage of medication or anesthetic can happen even with the aid of techn ology like infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how c an you

improve the safety of using infusion pumps?

A. B. C. D.

Check the functionality of the pump before use Select your brand of infusion pump like you do with your cellphone Allow the technician to set the infusion pump before use Verify the flow rate against your computation

33. JCAHOs universal protocol for surgical and invasive procedures to prevent wr ong site, wrong person, and wrong procedure/surgery includes the following, EXCEPT: A. B. C. D. Mark the operative site if possible Conduct pre-procedure verification process Take a video of the entire intra-operative procedure Conduct time out immediately before starting the procedure

34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following, EXCEPT: A. B. C. D. Assess potential risk of fall associated with the patient s medication regimen Take action to address any identified risks through Incident Report (IR) Allow client to walk with relative to the OR Assess and periodically reassess individual client s risk for falling

35. As a nurse, you know you can improve on accuracy of patient s identification b y 2 patient identifiers, EXCEPT: A. B. C. D. identify identify call the call the the client by his/her wrist tag and verify with family members client by his/her wrist tag and call his/her by name client by his/her case and bed number patient by his/her name and bed number Team efforts is best demonstrated in the OR.

Situation 8

36. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon? A. Who is your internist B. Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery? C. Who are your anesthesiologist, internist, and assistant D. Who is your anesthesiologist 37. In the OR, the nursing tandem for every surgery is: A. B. C. D. Instrument technician and circulating nurse Nurse anesthetist, nurse assistant, and instrument technician Scrub nurse and nurse anesthetist Scrub and circulating nurses

38. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who compris e this team? A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist

C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse 39. When surgery is on-going, who coordinates the activities outside, including the family? A. B. C. D. Orderly/clerk Nurse Supervisor Circulating Nurse Anesthesiologist

40. The breakdown in teamwork is often times a failure in: A. B. C. D. Electricity Inadequate supply Leg work Communication

Situation 9 Colostomy is a surgically created anus. It can be temporary or perma nent, depending on the disease condition. 41. Skin care around the stoma is critical. Which of the following is not indica ted as a skin care barriers? A. B. C. D. Apply liberal amount of mineral oil to the area Use karaya paste and rings around the stoma Clean the area daily with soap and water before applying bag Apply talcum powder twice a day

42. What health instruction will enhance regulation of a colostomy (defecation) of clients? A. B. C. D. Irrigate after lunch everyday Eat fruits and vegetables in all three meals Eat balanced meals at regular intervals Restrict exercise to walking only

43. After ileostomy, which of the following condition is NOT expected? A. B. C. D. Increased weight Irritation of skin around the stoma Liquid stool Establishment of regular bowel movement

44. The following are appropriate nursing interventions during colostomy irrigat ion, EXCEPT: A. B. C. D. Increase the irrigating solution flow rate when abdominal cramps is felt Insert 2-4 inches of an adequately lubricated catheter to the stoma Position client in semi-Fowler Hang the solution 18 inches above the stoma

45. What sensation is used as a gauge so that patients with ileostomy can determ ine how often their pouch should be drained?

A. B. C. D.

Sensation of taste Sensation of pressure Sensation of smell Urge to defecate

Situation 10 As a beginner in research, you are aware that sampling is an essent ial elements of the research process. 46. What does a sample group represent? A. B. C. D. Control group Study subjects General population Universe

47. What is the most important characteristic of a sample? A. B. C. D. Randomization Appropriate location Appropriate number Representativeness

48. Random sampling ensures that each subject has: A. Been selected systematically B. An equal chance of selection C. Been selected based on set criteria D. Characteristics that match other samples 49. Which of the following methods allows the use of any group of research subje ct? A. B. C. D. Purposive Convenience Snow-ball Quota

50. You decided to include 5 barangays in your municipality and chose a sampling method that would get representative samples from each barangay. What should be the app ropriate method ofor you to use in this care? A. B. C. D. Cluster sampling Random sampling Startified ampling Systematic sampling

Situation 11 After an abdominal surgery, the circulating and scrub nurses have c ritical responsibility about sponge and instrument count. 51. When is the first sponge/instrument count reported? A. B. C. D. Before Before Before Before closing the subcutaneous layer peritoneum is closed closing the skin the fascia is sutured

52. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture? A. B. C. D. Fascia Muscle Peritoneum Skin

53. Like sutures, needles also vary in shape and uses. If you are the scrub nurs e for a patient who is prone to keloid formation and has low threshold of pain, what nee dle would you prepare? A. B. C. D. Round needle Atraumatic needle Reverse cutting needle Tapered needle suture for skin closure is the use of ____________

54. Another alternative A. Staple B. Therapeutic glue C. Absorbent dressing D. Invisible suture

55. Like any nursing interventions, counts should be documented. To whom does th e scrub nurse report any discrepancy of counts so that immediate and appropriate action is instituted? A. B. C. D. Anesthesiologist Surgeon OR nurse supervisor Circulating nurse As a nurse, you should be aware and prepared of the different roles

Situation 12 you play.

56. What role do you play when you hold all client s information entrusted to you in the strictest confidence? A. B. C. D. Patient s advocate Educator Patient s Liaison Patient s arbiter

57. As a nurse, you can help improve the effectiveness of communication among he althcare givers by: A. B. C. D. Use of reminders of what to do Using standardized list of abbreviations, acronyms, and symbols One-on-one oral endorsement Text messaging and e-mail

58. As a nurse, your primary focus in the workplace is the client s safety. Howeve r, personal safety is also a concern. You can communicate hazards to your co-workers through the use of the following EXCEPT: A. B. C. D. Formal training Posters Posting IR in the bulletin board Use of labels and signs

59. As a nurse, what is one of the best way to reconcile medications across the continuum of care? A. Endorse on a case-to-case basis B. Communicate a complete list of the patient s medication to the next provider of service C. Endorse in writing D. Endorse the routine and stat

medications every shift

60. As a nurse, you protect yourself and co-workers from misinformation and misrepresentations through the following EXCEPT: A. Provide information to clients about a variety of services that can help alle viate the client s pain and other conditions B. Advising the client, by virtue of your expertise, that which can contribute t o the client s well-being C. Health education among clients and significant others regarding the use of chemical disinfectant D. Endorsement thru trimedia to advertise your favorite disinfectant solution Situation 13 You are assigned at the surgical ward and clients have been complai ning of post pain at varying degrees. Pain as you know, is very subjective. 61. A one-day postoperative abdominal surgery client has been complaining of sev ere throbbing abdominal pain described as 9 in a 1-10 pain rating. Your assessment r evelas bowel sounds on all quadrants and the dressing is dry and intact. What nursing i ntervention would you take A. B. C. D. Medicate client as prescribed Encourage client to do imagery Encourage deep breathing and turning Call surgeon stat

62. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. Wh ich will be your priority nursing action? A. Check abdominal dressing for possible swelling B. Explain the proper use of PCA to alleviate anxiety

C. Avoid overdosing to prevent dependence/tolerance D. Monitor VS, more importantly RR 63. The client complained of abdominal distention and pain. Your nursing interve ntion that can alleviate pain is:

A. B. C. D.

Instruct client to go to sleep and relax Advice the client to close the lips and avoid deep breathing and talking Offer hot and clear soup Turn to sides frequently and avoid too much talking

64. Surgical pain might be minimized by which nursing action in the O.R. A. B. C. D. Skill of surgical team and lesser manipulation Appropriate preparation for the scheduled procedure Use of modern technology in closing the wound Proper positioning and draping of clients

65. One very common cause of postoperative pain is: A. B. C. D. Forceful traction during surgery Prolonged surgery Break in aseptic technique Inadequate anesthetic

Situation 14 You were on duty at the medical ward when Zeny came in for admissio n for tiredness, cold intolerance, constipation, and weight gain. Upon examination, th e doctor s diagnosis was hypothyroidism. 66. Your independent nursing care for hypothyroidism includes: A. B. C. D. administer sedative round the clock administer thyroid hormone replacement providing a cool, quiet, and comfortable environment encourage to drink 6-8 glasses of water

67. As the nurse, you should anticipate to administer which of the following med ications to Zeny who is diagnosed to be suffering from hypothyroidism? A. B. C. D. Levothyroxine Lidocaine Lipitor Levophed

68. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroi dism would probably include which of the following? A. B. C. D. Activity intolerance related to tiredness associated with disorder Risk to injury related to incomplete eyelid closure Imbalance nutrition to hypermetabolism Deficient fluid volume related to diarrhea

69. Myxedema coma is a life threatening complication of long standing and untrea ted hypothyroidism with one of the following characteristics. A. B. C. D. Hyperglycemia Hypothermia Hyperthermia Hypoglycemia

70. As a nurse, you know that the most common type of goiter is related to a def iciency of: A. B. C. D. thyroxine thyrotropin iron iodine

Situation 15 Mrs. Pichay is admitted to your ward. The MD ordered Prepare for thoracentesis this pm to remove excess air from the pleural cavity. 71. Which of the following nursing responsibilities is essential in Mrs. Pichay who will undergo thoracentesis? A. Support and reassure client during the procedure B. Ensure that informed consent has been signed C. Determine if client has allergic reaction to local anesthesia D. Ascertain if chest x-rays and other tests have been prescribed and completed 72. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of th e following positions? A. B. C. D. Trendelenburg position Supine position Dorsal Recumbent position Orthopneic position

73. During thoracentesis, which of the following nursing intervention will be mo st crucial? A. Place patient in a quiet and cool room B. Maintain strict aseptic technique C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest D. Apply pressure over the puncture site as soon as the needle is withdrawn 74. To prevent leakage of fluid in the thoracic cavity, how will you position th e client after thoracentesis? A. B. C. D. Place flat in bed Turn on the unaffected side Turn on the affected side On bed rest

75. Chest x-ray was ordered after thoracentesis. When your client asks what is t he reason for another chest x-ray, you will explain: A. B. C. D. to to to to rule out pneumothorax rule out any possible perforation decongest rule out any foreign body

Situation 16 In the hospital, you are aware that we are helped by the use of a v ariety of equipment / devices to enhance quality patient care delivery. 76. You are to initiate an IV line to your patient, Kyle, 5, who is febrile. Wha t IV administration set will you prepare? A. B. C. D. Blood transfusion set Macroset Volumetric chamber Microset

77. Kyle is diagnosed to have measles. What will your protective personal attire include? A. B. C. D. Gown Eyewear Face mask Gloves

78. What will you do to ensure that Kyle, who is febrile, will have a liberal or al fluid intake? A. Provide a glass of fruit juice every meal B. Regulate his IV to 30 drops per minute C. Provide a calibrated pitcher of drinking water and juice at the bedside and monitor intake and output D. Provide a writing pad to record his intake 79. Before bedtime, you went to ensure Kyle s safety in bed. You will do which of the following: A. B. C. D. Put the lights on Put the side rails up Test the call system Lock the doors

80. Kyle s room is fully mechanized. What do you teach the watcher and Kyle to ale rt the nurses for help? A. B. C. D. How to lock side rails Number of the telephone operator Call system Remote control kissing tonsils and is scheduled for tonsille

Situation 17 Tony, 11 years old, has ctomy and adenoidectomy or T and A.

81. You are the nurse of Tony who will undergo T and A in the morning. His mothe r asked you if Tony will be put to sleep. Your teaching will focus on: A. spinal anesthesia B. anesthesiologist s preference C. local anesthesia

D. general anesthesia

82. Mothers of children undergoing tonsillectomy and adenoidectomy usually ask w hat food to prepare and give their children after surgery. You as the nurse will say: A. B. C. D. balanced diet when fully awake hot soup when awake ice cream when fully awake soft diet when fully awake

83. The RR nurse should monitor for the most common postoperative complication o f: A. B. C. D. hemorrhage endotracheal tube perforation osopharyngeal edema epiglottis

84. The PACU nurse will maintain postoperative T and A client in what position? A. B. C. D. Supine with neck hyperextended and supported with pillow Prone with the head on pillow and turned to the side Semi-fowler s with neck flexed Reverse trendelenburg with extended neck

85. Tony is to be discharged in the afternoon of the same day after tonsillectom y and adenoidectomy. You as the RN will make sure that the family knows to: A. offer osterized feeding B. offer soft foods for a week to minimize discomfort while swallowing C. supplement his diet with Vitamin C rich juices to enhance healing D. offer clear liquid for 3 days to prevent irritation Situation 18 Rudy was diagnosed to have chronic renal failure. Hemodialysis is o rdered so that an A-V shunt was surgically created. 86. Which of the following action would be of highest priority with regards to t he external shunt? A. B. C. D. Avoid taking BP or blood sample from the arm with the shunt Instruct the client not to exercise the arm with the shunt Heparinize the shunt daily Change dressing of the shunt daily

87. Diet therapy for Rudy, who has acute renal failure is low-protein, low potas sium and low sodium. The nutrition instructions should include: A. Recommend protein of high biologic value like eggs, poultry and lean meats B. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes C. Allowing the client cheese, canned foods and other processed food D. Bananas, cantaloupe, orange and other fresh fruits can be included in the die t

88. Rudy undergoes hemodialysis for the first time and was scared of disequilibr ium syndrome. He asked you how this can be prevented. Your response is:

A. maintain a conducive comfortable and cool environment B. maintain fluid and electrolyte balance C. initial hemodialysis shall be done 30 minutes only so as not to rapidly remove the waste from the blood than from the brain D. maintain aseptic technique throughout the hemodialysis 89. You are assisted by a nursing aide with the care of the client with renal fa ilure. Which delegated function to the aide would you particularly check? A. B. C. D. Monitoring and recording I and O Checking bowel movement Obtaining vital signs Monitoring diet

90. A renal failure patient was ordered for creatinine clearance. As the nurse y ou will collect A. B. C. D. 48 hour urine specimen first morning urine 24 hour urine specimen random urine specimen

Situation 19 Fe is experiencing left sharp pain and occasional hematuria. She wa s advised to undergo IVP by her physician. 91. Fe was so anxious about the procedure and particularly expressed her low pai n threshold. Nursing health instruction will include: A. assure the client that during the administration B. assure the client that C. assure the client that D. assure the client that the pain is associated with the warm sensation of the Hypaque by IV the procedure painless contrast medium will be given orally x-ray procedure like IVP is only done by experts

92. What will the nurse monitor and instruct the client and significant others p ost IVP? A. B. C. D. Report signs and symptoms for delayed allergic reaction Observe NPO for 6 hours Increased fluid intake Monitor intake and output

93. Post IVP, Fe should excrete the contrast medium. You instructed the family t o include more vegetables in the diet and: A. B. C. D. increase fluid intake barium enema cleansing enema gastric lavage

94. The IVP reveals that Fe has small renal calculus that can be passed out spon taneously. To increase the chance of passing the stones, you instructed her to force fluids and do

which of the following?

A. B. C. D.

Balanced diet Ambulate more Strain all urine Bed rest

95. The presence of calculi in the urinary tract is called A. B. C. D. Colelithiasis Nephrolithiasis Ureterolithiasis Urolithiasis

Situation 20 At the medical-surgical ward, the nurse must also be concerned abou t drug interactions. 96. You have a client with TPN. You know that in TPN like blood transfusion, the se should be no drug incorporation. However the MD s order read; incorporate insulin to present TPN. Will you follow the order? A. No, because insulin will induce hyperglycemia in patients with TPN B. Yes, because insulin is chemically stable with TPN and can enhance blood glucose level C. No, because insulin is not compatible with TPN D. Yes, because it was ordered by the MD 97. The RN should also know that some drugs have increased adsorption when infus ed in the PVC container. How will you administer drugs such as insulin, nitroglycerine hydralazine to promote better therapeutic drug effects? A. B. C. D. Administer by fast drip Inject the drugs as close to the IV injection site Incorporate to the IV solutions Use volumetric chamber

98. One patient had a runaway IV of 50% dextrose. To prevent temporary excess of i nsulin or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor s order? A. B. C. D. Any IV solution available to KVO Isotonic solution Hypertonic solution Hypotonic solution

99. How can nurses prevent drug interaction including adsorption? A. B. C. D. Always flush with NSS after IV administration Administering drugs with more diluents Improving on preparation techniques Referring to manufacturer s guidelines

100. In insulin administration, it should be understood that our body normally r eleases

insulin according to our blood glucose level. When is insulin and glucose level highest?

A. B. C. D.

After After After After

excitement a good night s rest an exercise ingestion of food SET B

NURSING PRACTICE IV

NURSING PRACTICE IV Care of Clients with Physiologic and Psychosocial Alterations (Part B) GENERAL INSTRUCTIONS 1. This test booklet contains 100 test questions 2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet. 3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. AVOID ERASURES. INSTRUCTIONS 1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 2. Write the subject title Nursing Practice IV on the box provided. 3. Shade Set Box A on your answer sheet if your test booklet is Set A; Set Box B if your test booklet is Set B. MULTIPLE CHOICE Situation 1 Because of the serious consequences of severe burns, management requ ires a multidisciplinary approach. You have important responsibilities as a nurse. 1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt bu rns into flames. The most effective way to extinguish the flames with as little further damage as possible is to: A. B. C. D. log roll on the grass/ground slap the flames with his hands remove the burning clothes pour cold liquid over the flames

2. Once the flames are extinguished, it is most important to: A. B. C. D. cover Sergio with a warm blanket give him sips of water calculate the extent of his burns assess the Sergio s breathing

3. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wif e asks what that means? Your most accurate response would be: A. B. C. D. Structures beneath the skin are damage Dermis is partially damaged Epidermis and dermis are both damaged Epidermis is damaged

4. During the first 24 hours after the thermal injury, you should asses Sergio f or: A. B. C. D. hypokalemia and hypernatremia hypokalemia and hyponatremia hyperkalemia and hyponatremia hyperkalemia and hypernatremia

5. Teddy, who sustained deep partial thickness and full thickness burns of the f ace, whole anterior chest and both upper extremities two days ago begins to exhibit extreme restlessness. You recognize that this most likely indicates that Teddy i s developing: A. C. B. D. Cerebral hypoxia metabolic acidosis Hypervolemia Renal failure

Situation 2 You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legal and moral implifications. 6. You are in night duty in surgical ward. One of your patients Martin is a pris oner who sustained an abdominal gunshot wound. He is being guarded by policeman from the local police unit. During your rounds you heard a commotion. You saw the policeman trying to hit Martin. You asked why he was trying to hit Martin. H e denied the matter. Which among the following activities will you do first? A. B. C. D. Write an accident report Call security officer and report the incident Call your nurse supervisor and report the incident Call the physician on duty

7. You are on morning duty in the medical ward. You have 10 patients assigned to you. During your endorsement rounds, you found out that one of your patients was not in bed. The patient next to him informed you that he went home without notifying the nurses. Which among the following will you do first? A. Make an incident report B. Call security to report the incident

C. Wait for 2 hours before reporting D. Report the incident to your supervisor 8. You are on duty in the medical ward. You were asked to check the narcotics ca binet. You found out that what is on record does not tally with the drugs used. Which among the following will you do first? A. B. C. D. Write an incident report and refer the matter to the nursing director Keep your findings to yourself Report the matter to your supervisor Find out from the endorsement any patient who might have been given narcotics

9. You are on duty in the medical ward. The mother of your patient who is also a nurse, came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest. A. B. C. D. Start basic life support measures Call for the Code Bring the crush cart to the room Go to see Fiolo and assess for airway patency and breathing problems

10. You are admitting Jorge to the ward and you found out that he is positive fo r HIV. Which among the following will you do first? A. B. C. D. Take note of it and plan to endorse this to next shift Keep this matter to yourself Write an incident report Report the matter to your head nurse

Situation 3 -Colorectal cancer can affect old and younger people. Surgical proce dures and other modes of treatment are done to ensure quality of life. You are assigned in the cancer institute to care of patients with this type of cancer. 11. Larry, 55 years old, who is suspected of having colorectal cancer, is admitt ed to the CI. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer. A. B. C. D. Barium enema Carcinoembryonic antigen Annual digital rectal examination Proctosigmoidoscopy

12. To confirm his impression of colorectal cancer, Larry will require which dia gnostic study? A. B. C. D. Carcinoembryonic antigen Proctosigmoidoscopy Stool hematologic test Abdominal computed tomography (CT) test

13. The following are risk factors for colorectal cancer, EXCEPT:

A. B. C. D.

Inflammatory bowels High fat, high fiber diet Smoking Genetic factors-familial adenomatous polyposis

14. Symptoms associated with cancer of the colon include: A. B. C. D. constipation, ascites and mucus in the stool diarrhea, heart burn and eructation blood in the stools, anemia, and pencil shaped stools anorexia, hematemesis, and increased peristalasis

15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to: A. B. C. D. promote rest of the bowel by minimizing peristalsis reduce the bacterial content of the colon empty the bowel of solid waste soften the stool by retaining water in the colon

Situation 4 ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. 16. You plan to teach Fermin how to irrigate the colostomy when: A. B. C. D. The perineal wound heals And Fermin can sit comfortably on the commode Fermin can lie on the side comfortably, about the 3rd postoperative day The abdominal incision is closed and contamination is no longer a danger The stools starts to become formed, around the 7th postoperative day

17. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure: A. B. C. D. When Fermin would have normal bowel movement At least 2 hours before visiting hours Prior to breakfast and morning care After Fermin accepts alteration in body image

18. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin: A. Lubricates the tip of the catheter prior to inserting into the stoma B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion C. Discontinues the insertion of fluid after only 500 ml of fluid has been insti lled D. Clamps of the flow of fluid when felling uncomfortable 19. You are aware that teaching about colostomy care is understood when Fermin states, I will contact my physician and report: A. B. C. D. If I have any difficulty inserting the irrigating tub into the stoma. If I noticed a loss of sensation to touch in the stoma tissue. The expulsion of flatus while the irrigating fluid is running out. When mucus is passed from the stoma between the irrigations.

20. You would know after teaching Fermin that dietary instruction for him is effective when he states, It is important that I eat:

A. Soft food that are easily digested and absorbed by my large intestines. B. Bland food so that my intestines do not become irritated. C. Food low in fiber so that there is less stool. D. Everything that I ate before the operation, while avoiding foods that cause gas. Situation 5 Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications. 21. Randy has chest tubes attached to a pleural drainage system. When caring for him you should: A. B. C. D. empty the drainage system at the end of the shift clamp the chest tube when suctioning palpate the surrounding areas for crepitus change the dressing daily using aseptic techniques

22. Fanny, came in from PACU after pelvic surgery. As Fanny s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be: A. a tender, painful area on the leg B. a pitting edema of the ankle C. a reddened area at the ankle D. pruritus on the calf and ankle 23. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to: A. seek early treatment for respiratory infections B. take showers instead of tub bath C. continue to take the same restrictions on fluid intake D. avoid situations that involve physical activity 24. Herbert had a laryngectomy and he is now for discharge. He verbalized his

concern regarding his laryngectomy tube being dislodged. What should you teach him first? A. B. C. D. Recognize that prompt closure of the tracheal opening may occur Keep calm because there is no immediate emergency Reinsert another tubing immediately Notify the physician at once

25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain: A. B. C. D. supplementary oxygen ventilation exchange chest tube drainage blood replacement

Situation 6 Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care. 26. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for herself and her household help. Your most appropriate response would be: A. Don t worry your husband s type of hepatitis is no longer communicable B. Gamma globulin provides passive immunity for hepatitis B C. You should contact your physician immediately about getting gammaglobulin. D. A vaccine has been developed for this type of hepatitis 27. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your best response would be: A. You acquired the infection after you have been admitted to the hospital. B. This is a highly contagious infection requiring complete isolation. C. The infection you had prior to hospitalization flared up. D. As a result of medical treatment, you have acquired a secondary infection. 28. 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. B. C. D. stomatitis hepatitis dysrhythmia infection

29. A solution used to treat Pseudomonas wound infection is: A. B. C. D. Dakin s solution Half-strength hydrogen peroxide Acetic acid Betadine

30. Which of the following is the most reliable in diagnosing a wound infection?

A. B. C. D.

Culture and sensitivity Purulent drainage from a wound WBC count of 20,000/L 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. 31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on admission. A central venous catheter was inserted an I.V. infusion was started. As a nurse assigned to Wendy what will be your priority goal? A. B. C. D. Prevent skin breakdown Preserve muscle function Promote urinary elimination Maintain a patent airway

32. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy s nurse, what should you do? A. B. C. D. Tell her family that probably she can t hear them Talk loudly so that Wendy can hear you Tell her family who are in the room not to talk Speak softly then hold her hands gently

33. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke? A. B. C. D. Place June on an upright lateral position Perform range of motion exercises Apply antiembolic stockings Use hand rolls or pillows for support

34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can provide a therapeutic environment by doing which of the following? A. honoring her request for a television B. placing her bed near the window C. dimming the light in her room D. allowing the family unrestricted visiting privileges

35. When performing a neurologic assessment on Walter, you find that his pupils are fixed and dilated. This indicated that he: A. B. C. D. probably has meningitis is going to be blind because of trauma is permanently paralyzed 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. There are frequently encountered situations and issues relevant to the older patients. 36. Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging. A. B. C. D. Ineffective airway clearance Decreased alveolar surfaced area Decreased anterior-posterior chest diameter Hyperventilation

37. The older patient is at higher risk for incontinence because of: A. B. C. D. dilated urethra increased glomerular filtration rate diuretic use decreased bladder capacity

38. Merle, age 86, is complaining of dizziness when she stands up. This may indicate: A. B. C. D. dementia a visual problem functional decline drug toxicity

39. Cardiac ischemia in an older patient usually produces: A. B. C. D. ST-T wave changes Very high creatinine kinase level Chest pain radiating to the left arm Acute confusion

40. The most dependable sign of infection in the older patient is: A. B. C. D. change in mental status fever pain 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. Disaster preparedness is crucial and is everybody s business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector. 41. 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. ? A. B. C. D. Recovery Mitigation Response Preparedness

42. 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. Finding safe housing for survivors, organizing support for the family, organizing counseling debriefing sessions and securing physical care are the services you are involved with. To which type of prevention are these activities included: A. B. C. D. Tertiary prevention Primary prevention Aggregate care prevention Secondary prevention

43. During the disaster you see a victim with a green tag, you know that the person: A. has injuries that are significant and require medical care but can wait hours with threat to life or limb B. has injuries that are life threatening but survival is good with minimal intervention C. indicates injuries that are extensive and chances of survival are unlikely ev en with definitive care D. has injuries that are minor and treatment can be delayed from hours to days 44. The term given to a category of triage that refers to life threatening or potentially life threatening injury or illness requiring immediate treatment: A. B. C. D. Immediate Emergent Non-acute Urgent

45. 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. B. C. D. Clinical incident stress management Follow-up Debfriefing 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. 46. While eating his meal, Matthew accidentally dislodges his IV lines and bleed s. Blood oozes on the surface of the over-bed table. It is most appropriate that you instruct the housekeeper to clean the table with: A. B. C. D. Acetone Alcohol Ammonia Bleach

47. You are a member of the infection control team of the hospital. 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). What is your priority activity? A. Establish policies for surveillance and monitoring B. Do data gathering about the possible sources of infection (observation, chart review, interview). C. Assign point persons who can implement policies. D. Meet with the nursing group working in the burn unit and discuss problem with them. 48. 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. Prior to discharge today, 4 patients are referred to you. How would you start prioritizing your activities? A. Bring your diabetes teaching kit and start your session taking into considera tion their distance from your office B. Contact the nurse in-charge and find out from her the reason for the referral C. Determine their learning needs then prioritize D. Involve the whole family in the teaching class 49. You have been designated as a member of the task force to plan activities fo r the Cancer Consciousness Week. Your committee has 4 months to plan and implement the plan. You are assigned to contact the various cancer support groups in your hospital. What will be your priority activity? A. Find out if there is a budget for this activity B. Clarify objectives of the activity with the task force before contacting the support groups

C. Determine the VIPs and Celebrities who will be invited D. Find out how many support groups there are in the hospital and get the contac t number of their president 50. You are invited to participate in the medical mission activity of your alumn i association. In the planning stage everybody is expected to identify what they can do during the medical mission and what resources are needed. You thought it is also your chance to share what you can do for others. What will be your most important role where you can demonstrate the impact of nursing in health? A. B. C. D. Conduct health education on healthy life style Be a triage nurse Take the initial history and document findings Act as a coordinator

Situation 11 One of the realities that we are confronted with is our mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying. 51. Irma is terminally ill, she speaks to you in confidence. You now feel that Irma s family could be helpful if they knew what Irma has told to you. What should you do first? A. B. C. D. Tell the physician who in turn could tell the family Obtain Irma s permission to share the information in the family Tell Irma that she has to tell her family what she told you Make an appointment to discuss the situation with the family

52. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can best help her by: A. Coming back periodically and indicating your availability if she would like you to sit with her B. Insisting that Ruby should talk with you because it is not good to keep everything inside C. Leaving her alone because she is uncooperative and unpleasant to be with D. Encouraging her to be physically active as possible

53. Leo, who is terminally ill and recognizes that he is in the process of losin g everything and everybody he loves, is depressed. Which of the following would best help him during his depression? A. B. C. D. Arrange for visitors who might cheer him Sit down and talk with him for a while Encourage him to look at the brighter side of things Sit silently with him

54. Which of the following statements would best indicate that Ruffy, who is dying, has accepted his impending death? A. B. C. D. I m ready to go. I have resigned myself to dying. What s the use? I m giving up

55. Marla, 90 years old has planned ahead for her death-philosophically, sociall y, financially and emotionally. This is recognized as: A. B. C. D. Acceptance that death is inevitable Avoidance of the true situation Denial with planning for continued life Awareness that death will soon occur

Situation 12 Brain tumor, whether malignant or benign, has serious management implications. As a nurse, you should be able to understand the consequences of the disease and the treatment. 56. You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP? A. B. C. D. Administer bowel softener Position Conrad with his head turned toward the side of the tumor Provide sensory stimulation Encourage coughing and deep breathing

57. Keeping Conrad s head and neck alignment results in: A. B. C. D. increased increased decreased increased inthrathoracic pressure venous outflow venous outflow intrabdominal pressure

58. Which of the following activities may increase intracranial pressure (ICP)?

A. B. C. D.

Raising the head of the bed Manual hyperventilation Use of osmotic diuretics Valsalva s maneuver

59. After you asses Conrad, you suspected increased ICP. Your most appropriate respiratory goal is to: A. B. C. D. maintain partial pressure of arterial O2 (PaO2) above 80 mmHg lower arterial pH prevent respiratory alkalosis promote CO2 elimination

60. Conrad underwent craniotomy. As his nurse, you know that drainage on a craniotomy dressing must be measured and marked. Which findings should you report immediately to the surgeon? A. Foul-smelling drainage B. Yellowish drainage Situation 13 C. Greenish drainage D. Bloody drainage

As a Nurse, you have specific responsibilities as professional. You

have to demonstrate specific competencies. 61. The essential components of professional nursing practice are all the follow ing EXCEPT: A. C. B. D. Culture Cure Care Coordination

62. You are assigned to care for four (4) patients. Which of the following patie nts should you give first priority? A. B. C. D. Grace, who is terminally ill with breast cancer. Emy, who was previously lucid but is now unarousable. Aris, who is newly admitted and is scheduled for an executive check-up. Claire, who has cholelithiasis and is for operation on call.

63. Brenda, the Nursing Supervisor of the intensive care unit (ICU) is not on du ty when a staff nurse committed a serious medication error. Which statement accurately reflects the accountability of the nursing supervisor? A. Brenda should be informed when she goes back on duty B. Although Brenda is not on duty, the nursing supervisor on duty decides to cal l her if time permits C. The nursing supervisor on duty will notify Brenda at home D. Brenda is not duty therefore it is not necessary to inform her. 64. Which barrier should you avoid, to manage time wisely?

A. B. C. D.

Practical planning Procrastination Setting limits Realistic personal expectation

65. You are caring for Vincent who has just been transferred to the private room . He is anxious because he fears he won t be monitored as closely as he was in the Coronary Care Unit. How can you allay his fear? A. B. C. D. Move his bed to a room far from nurse s station to reduce Assign the same nurse to him when possible Allow Vincent uninterrupted period of time Limit Vincent s visitors to coincide with CCU policies

Situation 14 As a nurse in the Oncology Unit, you have to be prepared to provide safe, efficient and effective care to your patients. 66. Which one of the following nursing interventions would be most helpful in preparing the patient for radiation therapy? A. B. C. D. Offer tranquilizers and antiemetics Instruct the patient of the possibility of radiation burn Emphasis on the therapeutic value of the treatment Map out the precise course of treatment

67. What side effects are most apt to occur the patient during radiation therapy to the pelvis? A. B. C. D. Urinary retention Abnormal vaginal or perineal discharge Paresthesia of the lower extremities Nausea and vomiting and diarrhea

68. Which of the following can be used on the irradiated skin during a course of radiation therapy? A. B. C. D. Adhesive tape Mineral oil Talcum powder Zinc oxide ointment

69. Earliest sign of skin reaction to radiation therapy is: A. desquamation B. erythema C. atrophy D. pigmentation

70. What is the purpose of wearing a film badge while caring for the patient who is radioactive? A. B. C. D. Identify the nurse who is assigned to care for such a patient Prevent radiation-induced sterility Protect the nurse from radiation effects 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. Within the health care group there are pre-assigned roles based on education, experience and training on disaster. 71. As a nurse to which of the following groups are you best prepared to join? A. Treatment group C. Morgue management B. Triage group D. Transport group 72. 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. The following principles should be observed in disaster triage, EXCEPT: A. any disaster plan should have resources available to triage at each facility and at the disaster site if possible B. make the most efficient use of available resources C. 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. do the greatest good for the greatest number of casualties 73. Which of the following categories of conditions should be considered first priority in a disaster? A. B. C. D. Intracranial pressure and mental status Lower gastrointestinal problems Respiratory infections Trauma

74. A guideline that is utilized in determining priorities is to asses the statu s of the following, EXCEPT: A. C. B. D. perfusion respiration locomotion mentation

75. The most important component of neurologic assessment is: A. B. C. D. pupil reactivity vital sign assessment cranial nerve assessment level of consciousness/responsiveness

Situation 16 You are going to participate in a Cancer Consciousness Week. You are assigned to take charge of the women to make them aware of cervical cancer. You reviewed its manifestations and

management, 76. The following are risk factors for cervical cancer EXCEPT: A. immunosuppressive therapy B. sex at an early age, multiple partners, exposure to socially transmitted dise ase, male partner s sexual habits C. viral agents like the Human Papilloma Virus D. smoking 77. Late signs and symptoms of cervical cancer include the following EXCEPT: A. B. C. D. urinary/bowel changes pain in pelvis, leg or flank uterine bleeding lymph edema of lower extremities

78. When a panhysterectomy is performed due to cancer of the cervix, which of the following organs are removed? A. B. C. D. the the the the uterus, cervix, and one ovary uterus, cervix, and two-thirds of the vagina uterus, cervix, tubes and ovaries uterus and cervix

79. The primary modalities of treatment for Stage 1 and IIA cervical cancer include the following: A. B. C. D. surgery, radiation therapy and hormone therapy surgery radiation therapy surgery and radiation therapy

80. A common complication of hysterectomy is A. B. C. D. thrombophelbitis of the pelvic and thigh vessels diarrhea due to over stimulation atelectasis wound dehiscence

Situation 17 The body has regulatory mechanism to maintain the needed electrolytes. However there are conditions/surgical interventions that could compromise life. You have to understand how management of these conditions are done. 81. You are caring for Leda who is scheduled to undergo total thyroidectomy beca use of a diagnosis of thyroid cancer. Prior to total thyroidectomy, you should instruct Leda to: A. B. C. D. Perform range and motion exercise on the head and neck Apply gentle pressure against the incision when swallowing Cough and deep breath every 2 hours Support head with the hands when changing position

82. As Leda s nurse, you plan to set up an emergency equipment at her beside following thyroidectomy. You should include: A. An airway and rebreathing tube

B. A tracheostomy set and oxygen C. A crush cart with bed board D. Two ampules of sodium bicarbonate 83. Which of the following nursing interventions is appropriate after a total thyroidectomy? A. B. C. D. Place pillows under your patient s shoulders. Raise the knee-gatch to 30 degrees Keep you patient in a high-fowler s position. Support the patient s head and neck with pillows and sandbags.

84. If there is an accidental injury to the parathyroid gland during a thyroidec tomy which of the following might Leda develop postoperatively? A. Cardiac arrest B. Dyspnea C. Respiratory failure D. Tetany

85. After surgery Leda develops peripheral numbness, tingling and muscle twitching and spasm. What would you anticipate to administer? A. Magnesium sulfate B. Calcium gluconate C. Potassium iodide D. Potassium chloride

Situation 18 NURSES are involved in maintaining a safe and healthy environment. This is part of quality care management. 86. The first step in decontamination is: A. to immediately apply a chemical decontamination foam to the area of contamination B. a through soap and water wash and rinse of the patient C. to immediately apply personal protective equipment D. removal of the patients clothing and jewelry and then rinsing the patient with water 87. For a patient experiencing pruritus, you recommend which type of bath. A. C. B. D. water saline colloidal (oatmeal sodium bicarbonate

88. Induction of vomiting is indicated for the accidental poisoning patient who has ingested. A. C. B. D. rust remover toilet bowl cleaner gasoline aspirin

89. 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. Secondary blood stream infections

B. Nosocomial infection C. Emerging infectious disease D. Primary blood stream infection 90. Which of the following guidelines is not appropriate to helping family members cope with sudden death? A. Obtain orders for sedation of family members B. Provide details of the factors attendant to the sudden death C. Show acceptance of the body by touching it and giving the family permission to touch D. 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. You have to be updated on the latest trends and issues affecting profession and the best practices arrived at by the profession. 91. You are interested to study the effects of meditation and relaxation on the pain experienced by cancer patients. What type of variable is pain? A. Dependent B. Correlational C. Independent D. Demographic

92. You would like to compare the support system of patients with chronic illnes s to those with acute illness. How will you best state your problem? A. 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. B. The Effect Of The Type Of Support System of Patients With Chronic Illness And Those With Acute Illness. C. A Comparative Analysis Of The Support System Of Patients With Chronic Illness And Those With Acute Illness. D. A Study To Compare The Support System Of Patients With Chronic Illness And Those With Acute Illness. 93. You would like to compare the support system of patients with chronic illnes s to those with acute illness. What type of research it this? A. B. C. D. Correlational Descriptive Experimental Quasi-experimental

94. You are shown a Likert Scale that will be used in evaluating your performanc e in the clinical area. Which of the following questions will you not use in critiquing the Likert Scale? A. Are the techniques to complete and score the scale provided? B. Are the reliability and validity information on the scale described? C. If the Likert scale is to be used for a study, was the development process described? D. Is the instrument clearly described? 95. In any research study where individual persons are involved, it is important

that an informed consent for the study is obtained. The following are essential information about the consent that you should disclose to the prospective subjects EXCEPT: A. B. C. D. Consent to incomplete disclosure Descriptions of benefits, risks and discomforts Explanation of procedure 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. You also have to understand the rationale of the treatment. 96. What type of debridement involves proteolytic enzymes? A. C. B. D. Interventional Surgical Mechanical Chemical

97. Which topical antimicrobial is most frequently used in burn wound care? A. B. C. D. Neosporin Silver nitrate Silver sulfadiazine Sulfamylon

98. Hypertrophic burn scars are caused by: A. B. C. D. exaggerated contraction random layering of collagen wound ischemia delayed epithelialization

99. The major disadvantage of whirlpool cleansing of burn wound is: A. B. C. D. patient hypothermia cross contamination of wound patient discomfort excessive manpower requirement

100. Oral analgesics are most frequently used to control burn injury pain: A. upon patient request B. during the emergent phase C. after hospital discharge D. during the acute phase *** END *** SUBMIT THIS TEST BOOKLET TOGETHER WITH THE ANSWER SHEET TO YOUR WATCHERS. BRINGING THE TEST BOOKLET OUT OF THE ROOM WILL BE A GROUND FOR CANCELLATION OF YOUR EXAMINATION. NURSING PRACTICE V-Care of Clients with physiologic and Psychosocial Alterations (Part C). SITUATIONAL

Situation 1 Jimmy developed this goal for hospitalization. To get a handle on my nervousness. The nurse is going to collaborate with him to reach his goal. 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. He realized he needed help. 1. The nurse recognized that Jimmy had conceptualized his problem and the next p riority goal in the care plan is: A. B. C. D. help help help help the the the the client client client client find meaning in his experience to plan alternatives cope with the present problem to communicate whe

2. The nurse is guided that Jimmy is aware of his concerns of the here and now n he crossed out which item from this list of what to know . A. B. C. D. anxiety laden unconscious conflicts subjective idea of the range of mild to severe anxiety early signs of anxiety physiologic indices of anxiety

3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that complete disruption of the ability to perceive occurs in: A. B. C. D. panic state of anxiety severe anxiety moderate anxiety mild anxiety

4. Jimmy initiates independence and takes an active part in his self care with t he following EXCEPT: A. B. C. D. agreeing to contact the staff when he is anxious becoming aware of the conscious feeling assessing need for medication and medicating himself writing out a list of behaviors that he identified as anxious

5. The nurse notes effectiveness of interventions in using subjective and object ive data in the: A. initial plans or orders B. database C. problem list D. progress notes Situation 2 A research study was undertaken in order to identify and analyze a d isabled boy s coping reaction pattern during stress. 6. This study which is an in depth study of one boy is a: A. B. C. D. case study longitudinal study cross-sectional study evaluative study

7. The process recording was the principal tool for data collection. Which of th e following is NOT a part of a process recording? A. B. C. D. Non verbal narrative account Analysis and interpretation Audio-visual recording Verbal narrative account

8. Which of these does NOT happen in a descriptive study? A. B. C. D. Exploration of relationship between two or more phenomena. Explanation of relationship between two or more phenomena. Investigation of a phenomenon in real life context. Manipulation of variable

9. The investigator also provided the nursing care of the subject. The investiga tor is referred to as a/an:

A. B. C. D.

Participant-observer Observer researcher Caregiver Advocate

10. To ensure reliability of the study, the investigator s analysis and interpreta tions were: A. B. C. D. subjected to statistical treatment correlated with a list of coping behaviors subjected to an inter-observer agreement scored and compared standard criteria

Situation 3 During the morning endorsement, the outgoing nurse informed the nurs ing staff that Regina, 35 years old, was given Flurazepam (Dalmane) 15mg at 10:00pm because she had trouble going to sleep. Before approaching Regina, the nurse read the observation of the night nurse. 11. Which of the following approaches of the nurse validates the data gathered? A. I learned that you were up till ten last night, tell me what happened before you were finally able to sleep and how was your sleep? B. Hmm.. You look like you had a very sound sleep. That pill you were given last night is effective isn t it? C. Regina, did you sleep well? D. Regina, how are you? 12. Regina is a high school teacher. Which of these information LEAST communicat e attention and care for her needs for information about her medicine? A. Guided by a medication teaching plan, go over with her the purpose, indicatio ns and special instructions, about the medication and provide her a checklist B. Provide a drug literature. C. Have an informal conversation about the medication and its effects D. Ask her what time she would like to watch the informative video about the med ication. 13. The nurse engages Regina in the process of mutual inquiry to provide an oppo rtunity for Regina to: A. B. C. D. face emerging problems realistically conceptualize her problem cope with her present problem perceive her participation in an experience

14. Which of these responses indicate that Regina needs further discussion regar ding special instructions? A. B. r me C. D. I have to take this medicine judiciously I know I will stop taking the medicine when there is advice from the doctor fo to discontinue. I will inform you and the doctor any untoward reactions I have. I like taking this sleeping pill. It solves my problem of insomnia. I wish

I can take it for life. 15. Regina commits to herself that she understood and will observe all the medic ine precautions by: A. affixing her signature to the teaching plan that she has understood the nurse B. committing what she learned to her memory C. verbally agreeing with the nurse 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. 16. The nurse s most unique tool in working with the emotionally ill client is his /her A. B. C. D. theoretical knowledge personality make up emotional reactions communication skills

17. The psychiatric nurse who is alert to both the physical and emotional needs of clients is working from the philosophical framework that states: A. All behavior is meaningful, communicating a message or a need. B. Human beings are systems of interdependent and interrelated parts. C. Each individual has the potential for growth and change in the direction of positive mental health. D. There is a basic similarity among all human beings. 18. One way to increase objectivity in dealing with one s fears and anxieties is t hrough the process of: A. B. C. D. observation intervention validation collaboration

19. All of the following responses are non therapeutic. Which is the MOST direct violation of the concept, congruence of behavior? A. B. C. D. Responding in a punitive manner to the client. Rejecting the client as a unique human being Tolerating all behavior in the client. Communicating ambivalent messages to the client.

20. The mentally ill person responds positively to the nurse who is warm and car ing. This is a demonstration of the nurse s role as: A. B. C. D. counselor mother surrogate therapist socializing agent

Situation 5

The nurse engages the client in a nurse-patient interaction.

21. The best time to inform the client about terminating the nurse-patient relat ionship is: A. B. C. D. when the client asks how long the relationship would be during the working phase towards the end of the relationship at the start of the relationship

22. The client says, I want to tell you something but can you promise that you wi ll keep this a secret? A therapeutic response of the nurse is: A. is B. C. D. Yes, our interaction is confidential provided the information you tell me not detrimental to your safety. Of course yes, this is just between you and me. Promise! Yes, it is my principle to uphold my client s rights. Yes, you have the right to invoke confidentiality of our interaction.

23. When the nurse respects the client s self-disclosure, this is a gauge for the nurse s: A. B. C. D. trustworthiness loyalty integrity professionalism

24. Rapport has been established in the nurse-client relationship. The client as ks to visit the nurse after his discharge. The appropriate response of the nurse would be: A. The best time to talk is during the nurse-client interaction time. I am committed to have this time available for us while you are at the hospital and ends after your discharge. B. Yes, If you keep it confidential, this is part of privileged communication. C. I am committed for your care. D. I am sorry, though I would want to, it is against hospital policy. 25. The client has not been visited by relatives for months. He gives a telephon e number and requests the nurse to call. An appropriate action of the nurse would be: A. Inform the attending physician about the request of the client. B. Assist the client to bring his concern to the attention of the social worker. C. Here (gives her mobile phone). You may call this number now . D. Ask the client what is the purpose of contacting his relatives. Situation 6 Camila, 25 years old, was reported to be gradually withdrawing and i solating herself from friends and family members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently. She was diagnosed as schizophrenia disorder. 26. The past history of Camila would most probably reveal that her premorbid per sonality is:

A. B. C. D.

schizoid extrovert ambivert cycloid

27. Camila refuses to relate with to others because she: A. B. C. D. is irritable feels superior of others anticipates rejection is depressed

28. Which of the following disturbances in interpersonal relationships MOST ofte n predispose to the development of schizophrenia? A. B. C. D. Lack of participation in peer groups Faulty family atmosphere and interaction Extreme rebellion towards authority figures Solo parenting

29. Camila s indifference toward the environment is a compensatory behavior to ove rcome: A. B. C. D. Guilt feelings Ambivalence Narcissistic behavior Insecurity feelings

30. Schizophrenia is a/an: A. B. C. D. anxiety disorder neurosis psychosis personality disorder

Situation 7 Salome, 80 year old widow, has been observed to be irritable, demand ing and speaking louder than usual. She would prefer to be alone and take her meals by herself, minimize receiving visitors at home and no longer bothers to answer telephone calls because of deterioration of hearing. She was brought by her daughter to the Geriatric clinic for assessment and treatment. 31. The nurse counsels Salome s daughter that Salome s becoming very loud and tenden cy to become aggressive is a/an: A. B. C. D. beginning indifference to the world around her attempt to maintain authoritative role overcompensation for hearing loss behavior indicative of unresolved repressed conflict of the past

32. A nursing diagnosis for Salome is: A. B. C. D. sensory deprivation social isolation cognitive impairment ego despair

33. The nurse will assist Salome and her daughter to plan a goal which is for Sa lome to: A. B. C. D. adjust to the loss of sensory and perceptual function participate in conversation and other social situations accept the steady loss of hearing that occurs with aging increase her self-esteem to maintain her authoritative role

34. The daughter understood, the following ways to assist Salome meet her needs and avoiding which of the following: A. B. C. D. Using short simple sentences Speaking distinctly and slowly Speaking at eye level and having the client s attention Allowing her to take her meals alone

35. Salome was fitted a hearing aid. She understood the proper use and wear of t his device when she says that the battery should be functional, the device is turned on and adjusted to a: A. B. C. D. therapeutic level comfortable level prescribed level audible level

Situation 8 For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if something dreadful is going to happen. 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. 36. Cecilia is demonstrating: A. B. C. D. acrophobia claustrophobia agoraphobia xenophobia

37. Cecilia s problem is that she always sees and thinks negative things hence she is always fearful. Phobia is a symptom described as: A. B. C. D. organic psychosomatic psychotic neurotic

38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify h er: A. B. C. D. communication cognition observation perception

39. Cognitive therapy is indicated for Cecilia when she is already able to handl

e anxiety reactions. Which of the following should the nurse implement?

A. B. C. D.

assist her in recognizing irrational beliefs and thoughts help find meaning in her behavior provide positive reinforcement for acceptable behavior Administer anxiolytic drug

40. After discharge, which of these behaviors indicate a positive result of bein g able to overcome her phobia? A. B. C. D. She She She She reads a book in the public library drives alone along the long expressway. watches television with the family in the recreation room joins an art therapy group

Situation 9 It is the first day of clinical experience of nursing students at th e Psychiatry Ward. During the orientation, 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. 41. It is unethical to tell one s friends and family members data about patients b ecause doing so is a violation of patients rights to: A. B. C. D. Informed consent Confidentiality Least restrictive environment Civil liberty

42. The nurse must see to it that the written consent of mentally ill patients m ust be taken from: A. B. C. D. Doctor Social worker Parents or legal guardian Law enforcement authorities

43. In an extreme situation and when no other resident or intern is available, s hould a nurse receive telephone orders, the order has to be correctly written and signed by the physician within: A. B. C. D. 24 36 48 12 hours hours hours hours Plan) statements on a

44. The following are SOAP (Subjective Objective Analysis problem: Anxiety about diagnosis. What is the objective data?

A. Relate patient s feelings to physician; initiate and encourage her to verbalize her fears; give emotional support by spending more time with patient; continue to make necessary explanations regarding diagnostic tests. B. Has periods of crying; frequently verbalizes fear of what diagnostic tests will reveal C. Anxiety due to unknown

D.

I m so worried about what else they ll find wrong with me.

45. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the: A. Summary of chronological notations made by individual health team members B. Identification of patient s responses to medical diagnoses and treatment C. 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 ght. Marie is 5 years old and described by the mother as bedwetting at ni

46. Which of the following is the MOST common physiological cause of night bed w etting? A. B. C. D. deep sleep factors abnormal bladder development infections familial and genetic factors

47. All of the following, EXCEPT one compromise the concepts of behavior therapy program. A. B. C. D. reward and punishment extinction learning placebo as a form of treatment

48. To help Marie who bed wets at night practice acceptable and appropriate beha vior, it is important for the parents to be consistent with the following approaches EXCEPT: A. B. C. D. discipline with a kind attitude matter of fact in handling the behavior sympathize for the child be loving yet firm

49. A therapeutic verbal approach that communicates strong disapproval is: A. You are supposed to get up and go in the toilet when you feel you have to go and did not. The next time you bed wet, I ll tell your friends and hang your sheets out the window for them to see. B. You are supposed to get up and go in the toilet when you feel you have to go and did not. I expect you to from now on without fail. C. If you bed wet, you will change your bed linen and wash the sheets. D. If you don t make an effort to control your bedwetting, I d be upset and disappointed. 50. During your conference, the parent inquires how to motivate Marie to be dry in the morning. Your response which is an immediate intervention would be: A. Give a star each time she wakes up dry and every set of five stars, give a pr ize. B. Tokens make her materialistic at an early age. Give praise and hugs occasiona lly.

C. What does your child want that you can give every time he/she wakes up dry in the morning? D. Promise him/her a long awaited vacation after school is over. Situation 11 The nurse is often met with the following situations when clients b ecome angry and hostile. 51. To maintain a therapeutic eye contact and body posture while interacting wit h angry and aggressive individual, the nurse should: A. B. C. D. keep keep fold keep an eye contact while staring at the client his/her hands behind his/her back or in one s pockets his/her arms across his/her chest an open posture, e.g. Hands by sides but palms turned outwards

52. During the pre-interaction phase of the N-P relationship, the nurse recogniz es this normal INITIAL reaction to an assaultive or potentially assaultive person. A. B. C. D. To remain and cope with the incident Display empathy towards the patient To call for help from other members of the team To stay and fight or run away

53. Which of the following is an accurate way of reporting and recording an inci dent? A. When asked about his relationship with his father, B. When asked about his relationship with his father, jaw/teeth, made a fist and turned away from the nurse. C. When asked about his relationship with his father, respond D. When asked about his relationship with his father, client became anxious. client clenched his client was resistant to his anger was suppressed

54. To encourage thought, which of the following approaches is NOT therapeutic? A. B. C. D. Why do you feel angry? When do you usually feel angry? How do you usually express anger? What situations provoke you to be angry?

55. A patient grabs and about to throw it. The nurse best responds saying. A. B. C. D. Stop! Put that chair down. Don t be silly. Stop! The security will be here in a minute. Calm down. Nursing care for the elderly

Situation 12

56. In planning care for a patient with Parkinson s disease, which of these nursin g diagnoses should have priority? A. B. C. D. potential for injury altered nutritional state ineffective coping altered mood state

57. A healthy adaptation to aging is primarily related to an individual s A. B. C. D. Number of accomplishments Ability to avoid interpersonal conflict Physical health throughout life Personality development in his life span

58. 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. B. C. D. Loneliness Suspicion Grief Confusion

59. An elderly confused client gets out of bed at night to go to the bathroom an d tries to go to another bed when she returns. The MOST appropriate action the nurse would tak e is to: A. B. C. D. Assign client to a single room Leave a light on all night Remind client to call the nurse when she wants to get up Put side rails on the bed

60. An elderly who has lots of regrets, unhappy and miserable is experiencing: A. B. C. D. Crisis Despair Loss Ambivalence

Situation 13 Graciela 1 year old is admitted to the hospital from the emergency r oom with a fracture of the left femur due to a fall down a flight of stairs. Graciel a is placed on Bryant s traction. 61. While on Bryant s traction, which of these observations of Graciela and her tr action apparatus would indicate a decrease in the effectiveness of her traction? A. B. C. D. Graciela s buttocks are resting on the bed. The traction weights are hanging 10 inches above the floor. Graciela s legs are suspended at a 90 degree angle to her trunk. The traction ropes move freely through the pulley.

62. The nurse notes that the fall might also cause a possible head injury. She w ill be observed for signs of increased intracranial pressure which include: A. B. C. D. Narrowing of the pulse pressure Vomiting Periorbital edema A positive Kernig s sign

63. Graciela is assessed to have no head injury. The Bryant s traction is removed.

A plaster of Paris hip spica is applied. Which of these finding is a concern of immediate attention that must be reported to the physician immediately? A. Graciela is scratching the cast over her abdomen. B. The toes of Graciela s left foot blanch when the nurse applies pressure on them . C. Graciela s cast is still damp. D. The nurse is unable to insert a finger under the edge of Graciela s cast on her left foot. 64. Part of discharge plan is for the nurse to give instructions about the care of Graciela s cast to the mother. Which of these statements indicate that the mother understoo d an important aspect of cast care? A. B. C. D. I I I I will will will will use white shoe polish to keep the cast neat. place plastic sheeting around the perineal area of the cast. use cool water to wash the cast. reinforce cracked areas on the cast with adhesive tape.

65. The nurse counsels Graciela s mother ways to safeguard safety while providing opportunities for Graciela to develop a sense of: A. B. C. D. Trust Initiative Industry Autonomy

Situation 14 Jolina is an 18 year old beginning college student. Her mother obse rved that she is having problems relating with her friends. She is undecided about her future. She has lost insight, lost interest in anything and complained of constant tiredness. 66. Jolina is put on antidepressant drugs. These drugs act on the brain chemistr y, therefore they would be useful in which type of depression? A. B. C. D. exogenous depression neurotic depression endogenous depression psychotic depression

67. This is a tricyclic antidepressant drug: A. B. C. D. Venlafaxine (Effexor) Flouxetine (Prozac) Sertraline (Zoloft) Imipramine (Tofranil)

68. After one week of antidepressant medication, Jolina still manifests depressi on. The nurse evaluates this as: A. Unusual because action of antidepressant drug is immediate. B. Unexpected because therapeutic effectiveness takes within a few days. C. Expected because therapeutic effectiveness takes 2-4 weeks.

D. Ineffective result because perhaps the drug s dosage is inadequate.

69. Jolina continues to verbalize feeling sad and hopeless. She is not mixing we ll with other clients. One of the nurse s important considerations for Jolina INITIALLY is: A. Formulate a structured schedule so she is able to channel her energies externally B. Let her alone until she feels like mingling with others. C. Encourage her to join socialization hour so she will start to relate with oth ers. D. Encourage her to join group therapy with other patients. 70. During the predischarge conference, the nurse suggests vocational guidance b ecause it should help Jolina to: A. B. C. D. Find a good job. Make some decisions about her future Realistically assess her assets and limitations Solve her own problems Group Approach in Nursing

Situation 15

71. Membership dropout generally occurs in group therapy after a member: A. B. C. D. Accomplishes his goal in joining the group Discovers that his feelings are shared by the group members Experiences feelings of frustration in the group Discusses personal concerns with group members

72. Which of the following questions illustrates the group role of encourager? A. B. C. D. What were you saying? Who wants to respond next? Where do you go from here? Why haven t we heard from you?

73. The goal of remotivation therapy is to facilitate: A. B. C. D. Insight Productivity Socialization Intimacy

74. The treatment of the family as a unit is based on the belief that the family : A. is a social system and all the members are interrelated components of that system B. as a unit of society needs the opportunity to change its own destiny C. who has therapy together will tend to remain together D. is contaminated by the presence of deviant member and all members need treatment. 75. The working phase in a therapy group is usually characterized by which of th e following? A. Caution B. Cohesiveness C. Confusion

D. Competition Situation 16 The mental health ng with different types of clients. psychiatric nurse functions in a variety of setti

76. Poverty as reflected in prevalence of communicable diseases, malnutrition an d social ills such as street children, homeless and prostitution is a predisposing factor to m ental illness. A community approach to cope with this problem is for the nurse to supp ort: A. B. C. D. aggressive family planning methods provision of social welfare benefits for the poor social action free clinics and more hospitals

77. The MOST cost effective way to meet the mental health needs of the public is through programs with a priority goal of: A. B. C. D. treatment prevention rehabilitation research

78. Lorelie upon discharge was referred to a volunteer group where she has learn ed to read patterns, cut out fabric and use a sewing machine to make simple outfits that wi ll help her earn in the future. What type of therapy is this? A. B. C. D. Recreational therapy Art therapy Vocational therapy Educational therapy

79. In a residential treatment home for adolescent girls, the clients were becom ing increasingly tense and upset because of shortening of their recreation time. To deescalate possible anger and aggression among the clients it is BEST to play: A. B. C. D. religious music relaxation music dance music rock music

80. The parents of special children who are behaviorally disturbed need mental h ealth education. Which of these topics would the school nurse consider as priority for their parent s class? A. B. C. D. Drug education Child abuse Effective parenting Sex education

Situation 17 Nurses in all practice areas are likely to come in contact with cli ents suffering from acute or chronic drug abuse.

81. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is: A. a common problem brought about by socioeconomic deprivation B. caused by multiplicity of factors C. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses D. due to biochemical factors 82. Being in contact with reality and the environment is a function of the: A. B. C. D. conscience ego id super ego

83. Substance abuse is different from substance dependence in that, substance dependence: A. B. C. D. includes requires produces includes characteristics of adverse consequences and repeated use long term treatment in a hospital based program less severe symptoms than that of abuse characteristics of tolerance and withdrawal

84. During the detoxification stage, it is a priority for the nurse to: A. B. C. D. teach skills to recognize and respond to health threatening situations increase the client s awareness of unsatisfactory protective behaviors implement behavior modification promote homeostasis and minimize the client s withdrawal symptoms

85. Commonly known as shabu is: A. Cannabis Sativa B. Lysergic acid diethylamide C. Methylenedioxy methamphetamine D. Methamphetamine hydrochloride Situation 18 It is common that clients ask the nurse personal questions.

86. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship? A. B. C. D. Orientation phase Working phase Pre-interaction phase Termination phase

87. If the client asks for the nurse s telephone number, which of these responses is NOT appropriate? A. It is confidential I just don t give it to anyone. B. What would you do with my number if I give it to you? C. If I say No to your request, what are your thoughts about it? D. Are you asking for an official number of the hospital/clinic for your reference?

88. When the client asks about the family of the nurse, the MOST appropriate res ponse is: A. B. C. D. Avoid the situation and redirect the client s attention Give a brief and simple response and focus on the client. Why don t we talk about your family instead? Introduce another topic like the client s interests

89. When the nurse is asked a personal question, which of these reactions indica tes a need for her to introspect? A. B. C. D. The client is simply curious. His/Her right to privacy is being intruded. The client knows no other way to begin a conversation. Some patients are like children in seeking recognition from the nurse. What time is it? The nurse s

90. It is 10 o clock on your watch. The client asks, appropriate is: A. B. C. D. Are you getting bored? It is 10 o clock. Why do you ask? Guess, what time is it?

Situation 19 Ricky is a 12 year old boy with Down s syndrome. He stands 5 and weighs 100 lbs. he is slim and walks sluggishly with a limp. He wears a neck brace as a support for his neck. X-ray of cervical spine showed subluxation of C1 in relation to C2 with cord compression . He attends a school for a special education. 91. The classroom teacher consults the school nurse for guidance on how to take care of Ricky while inside of the classroom. The nurse considers as priority, Ricky s: A. B. C. D. Physiological needs Need for self esteem Needs for safety and security Needs for belonging What should I do when Ricky

92. Ricky s mother visited the school nurse. She asked,

fondles his genitalia? An appropriate response of the nurse is for the mother to: A. Divert Ricky s attention and engage him in satisfying activities B. Tell Ricky that it is wrong to keep fondling his genitalia C. Ignore Ricky s behavior because he will outgrow it later D. Engage him in computer TV games that engage his hands 93. The nurse had one on one health education sessions with Ricky s mother. The mo ther understood that for her son to learn to cope and be independent, she should constantly provide activities for Ricky to be able to:

A. B. C. D.

socialize with people eventually go to school alone select and prepare his own food do activities of daily living

94. All of the following activities are appropriate for Ricky EXCEPT: A. B. C. D. Working with clay Competitive sport Preparing and cooking simple menu Card and table games

95. Ricky s IQ falls within the range of 50-55. he can be expected to: A. B. C. D. Profit from vocational training with moderate supervision Live successfully in the community Perform simple tasks in closely supervised settings Acquire academic skills of 6th grade level

Situation 20 The abuse of dangerous drugs is a serious public health concern tha t nurses need to address. 96. 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. B. C. D. law enforcement agencies school church family

97. A drug dependent utilizes this defense mechanism and enables him to forget s hame and pain. A. B. C. D. repression rationalization projection sublimation

98. This drug produces mirthfulness, fantasies, flight of ideas, loss of train o f thought, distortion of size, distance and time, and bloodshot eyes due to dilated pupils. A. B. C. D. Opiates LSD Marijuana Heroin

99. 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. A. B. C. D. Sudden death from cardiac or respiratory depression Danger of acquiring hepatitis or AIDS Experience of blackout Psychological dependence after prolonged use

100. 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. The mother s behavior can be described as: A. Unhelpful B. Codependent C. Caretaking D. Supportive ***END***