Beruflich Dokumente
Kultur Dokumente
SITUATIONAL
Situation 1 – Mr. Ibarra is assigned to the triage area and while on duty, he assesses the
condition of Mrs. Simon who came in with asthma. She has difficulty breathing and her
respiratory rate is 40 per minute. Mr. Ibarra is asked to inject the client epinephrine 0.3 mg
subcutaneously.
A. Reduce anaphylaxis
B. Relieve hypersensitivity to allergen
C. Relieve respiratory distress due to bronchial spasm
D. Restore client’s cardiac rhythm
2. When preparing the epinephrine injection from an ampule, the nurse initially:
A. Taps the ampule at the top to allow fluid to flow to the base of the ampule
B. Checks expiration date of the medication ampule
C. Removes needle cap of syringe and pulls plunger to expel air
D. Breaks the neck of the ampule with a gauze wrapped around it
A. Inject needle at a 15 degree angle over the stretched skin of the client
B. Pinch skin at the injection site and use airlock technique
C. Pull skin of patient down to administer the drug in a Z track
D. Spread skin or pinch at the injection site and inject needle at a 45-90
degree angle
4. When preparing for a subcutaneous injection, the proper size of syringe and needle would
be:
5. The rationale for giving medications through the subcutaneous route is:
Situation 2 – The use of massage and meditation to help decrease stress and pain have
been strongly recommended based on documented testimonials.
6. Martha wants to do a study on this topic: “Effects of massage and meditation on stress
and pain”. The type of research that best suits this topic is:
A. Applied research
B. Qualitative research
C. Basic research
D. Quantitative research
7. The type of research design that does not manipulate independent variable is:
A. Experimental design
B. Quasi-experimental design
C. Non-experimental design
D. Quantitative design
8. This research topic has the potential to contribute to nursing because it seeks to
10. Client’s rights should be protected when doing research using human subjects. Martha
identifies these rights as follows EXCEPT:
A. right of self-determination
B. right to compensation
C. right of privacy
D. right not to be harmed
11. Mario listens to Richard’s bilateral sounds and finds that congestion is in the upper lobes
of the lungs. The appropriate position to drain the anterior and posterior apical segments of
the lungs when Mario does percussion would be:
A. Client lying on his back then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting
position then flat on his back and on his abdomen
C. Client lying flat on his back and then flat on his abdomen
D. Client lying on his right then left side on Trendelenburg position
12. When documenting outcome of Richard’s treatment Mario should include the following in
his recording EXCEPT:
13. When assessing Richard for chest percussion or chest vibration and postural drainage,
Mario would focus on the following EXCEPT:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds and location of congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s tolerance for lying flat
14. Mario prepares Richard for postural drainage and percussion. Which of the following is a
special consideration when doing the procedure?
15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The
difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms
while vibration gently shakes secretion loose on the exhalation cycle
C. In both percussion and vibration the hands are on top of each other and hand
action is in tune with client’s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the
secretions along with the inhalation of air
Situation 4 – A 61 year old man, Mr. Regalado, is admitted to the private ward for
observation after complaints of severe chest pain. You are assigned to take care of the
client.
16. When doing an initial assessment, the best way for you to identify the client’s priority
problem is to:
17. Upon establishing Mr. Regalado’s nursing needs, the next nursing approach would be to:
A. Introduce the client to the ward staff to put the client and family at ease
B. Give client and relatives a brief tour of the physical set up the unit
C. Take his vital signs for a baseline assessment
D. Establish priority needs and implement appropriate interventions
18. Mr. Regalado says he has “trouble going to sleep”. In order to plan your nursing
intervention you will:
A. Observe his sleeping patterns in the next few days
B. Ask him what he means by this statement
C. Check his physical environment to decrease noise level
D. Take his blood pressure before sleeping and upon waking up
19. Mr. Regalado’s lower extremities are swollen and shiny. He has pitting pedal edema.
When taking care of Mr. Regalado, which of the following interventions would be the most
appropriate immediate nursing approach?
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when
preparing a client for discharge include all EXCEPT:
Situation 5 – Nancy, mother of 2 young kids, 36 years old, had a mammogram and was told
that she has breast cysts and that she may need surgery. This causes her anxiety as shown
by increase in her pulse and respiratory rate, sweating and feelings of tension.
21. Considering her level of anxiety, the nurse can best assist Nancy by:
22. Nancy blames God for her situation. She is easily provoked to tears and wants to be left
alone, refusing to eat or talk to her family. A religious person before, she now refuses to
pray or go to church stating that God has abandoned her. The nurse understands that
Nancy is grieving for her self and is in the stage of:
A. bargaining
B. denial
C. anger
D. acceptance
23. The nurse visits Nancy and prods her to eat her food. Nancy replies “what’s the use? My
time is running out.” The nurse’s best response would be:
A. “The doctor ordered full diet for you so that you will be strong for surgery”
B. “I understand how you feel but you have to try for your children’s sake”
C. “Have you told your doctor how you feel? Are you changing your mind about your
surgery?”
D. “You sound like you are giving up.”
24. The nurse feels sad about Nancy’s illness and tells her head nurse during the end of
shift endorsement that “it’s unfair for Nancy to have cancer when she is still so young and
with two kids”. The best response of the head nurse would be:
A. Advise the nurse to “be strong and learn to control her feelings”
B. Assign the nurse to another client to avoid sympathy for the client
C. Reassure the nurse that the client has hope if she goes through all treatments
prescribed for her
D. Ask the other nurses what they feel about the patient to find out if they share the
same feelings
25. Realizing that she feels angry about Nancy’s condition, the nurse learns that being self-
aware is a conscious process that she should do in any situation like this because:
Situation 6 – Mrs. Seva, 52 years old, asks you about possible problems regarding her
elimination now that she is in the menopausal stage.
26. Instruction on health promotion regarding urinary elimination is important. Which would
you include?
A. Hold urine as long as she can before emptying the bladder to strengthen her
sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple juice
C. After urination, wipe from anal area up towards the pubis
D. Tell client to empty the bladder at each voiding
27. Mrs. Seva also tells the nurse that she is often constipated. Because she is aging, what
physical changes predispose her to constipation?
28. The nurse understands that one of these factors contributes to constipation:
A. excessive exercise
B. high fiber diet
C. no regular time for defecation daily
D. prolonged use of laxatives
29. Mrs. Seva talks about fear of being incontinent due to a prior experience of dribbling
urine when laughing or sneezing and when she has a full bladder. Your most appropriate
instruction would be to:
30. Mrs. Seva asked for instructions for skin care for her mother who has urinary
incontinence and is almost always in bed. Your instruction would focus on prevention of skin
irritation and breakdown by:
Situation 7 – Using Maslow’s need theory, Airway, Breathing and Circulation are the
physiological needs vital to life. The nurse’s knowledge and ability to identify and
immediately intervene to meet these needs is important to save lives.
31. Which of these clients has a problem with the transport of oxygen from the lungs to the
tissues:
32. You noted from the lab exams in the chart of M. Santos that he has reduced oxygen in
the blood. This condition is called:
A. Cyanosis
B. Hypoxia
C. Hypoxemia
D. Anemia
33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of
insertion of the tubing for an adult would be:
34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the
area by:
A. Apply suction for at least 20-30 seconds each time to ensure that all secretions
are removed
B. Using gloves to prevent introduction of pathogens to the respiratory system
C. Applying no suction while inserting the catheter
D. Rotating catheter as it is inserter with gentle suction
35. Myrna has difficulty breathing when on her back and must sit upright in bed to breath
effectively and comfortably. The nurse documents this condition as:
A. Apnea
B. Orthopnea
C. Dyspnea
D. Tachypnea
Situation 8 – You are assigned to screen for hypertension. Your task is to take blood
pressure readings and you are informed about avoiding the common mistakes in BP taking
that lead to false or inaccurate blood pressure readings.
36. When taking blood pressure reading the cuff should be:
A. deflated fully then immediately start second reading for same client
B. deflated quickly after inflating up to 180 mmHg
C. large enough to wrap around upper arm of the adult client 1 cm above brachial
artery
D. inflated to 30 mmHg above the estimated systolic BP based on palpation
of radial or bronchial artery
37. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death
world wide and is a preventable disease. The primary cause of COPD is
A. tobacco hack
B. bronchitis
C. asthma
D. cigarette smoking
38. In your health education class for clients with diabetes you teach them the areas for
control of Diabetes which include all EXCEPT
39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM)
diabetes. Which of the following is true?
A. both types diabetes mellitus clients are all prone to developing ketosis
B. Type II (NIDDM) is more common and is also preventable compared to
Type I (IDDM) diabetes which is genetic in etiology
C. Type I (IIDM) is characterized by fasting hyperglycemia
D. Type II (NIDDM) is characterized by abnormal immune response
40. Lifestyle-related diseases in general share areas common risk factors. These are the
following except:
A. physical activity
B. smoking
C. genetics
D. nutrition
Situation 9 – Nurse Rivera witnesses a vehicular accident near the hospital where she
works. She decides to get involved and help the victims of the accident
41. Her priority nursing action would be to:
43. In the emergency room, Nurse Rivera is assigned to attend to the client with lacerations
on the arms. While assessing the extent of the wound the nurse observes that the wound is
now starting to bleed profusely. The most immediate nursing action would be to:
44. The nurse applies dressing on the bleeding site. This intervention is done to:
45. After the treatment, the client is sent home and asked to come back for follow-up care.
Your responsibilities when the client is to be discharged include the following EXCEPT:
Situation 10 – While working in the clinic, a new client, Geline, 35 years old, arrives for her
doctor’s appointment. As the clinic nurse, you are to assist the client fill up forms, gather
data and make an assessment.
A. Record pertinent information in the client’s chart for health team to read
B. Assist the client find solutions to he her health concerns
C. Understand her lifestyle, health needs and possible problems to develop
a plan of care
D. Make nursing diagnoses for identified health prob;ems
47. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that
this pain occurs about an hour after taking black coffee without breakfast for three weeks
now. You will record this as follows:
A. Claims to have abdominal pains after intake of coffee unrelieved by analgesics
B. After drinking coffee, the client experienced severe abdominal pain
C. Client complained of intermittent abdominal pain an hour after drinking coffee
D. Client reported abdominal pain an hour after drinking black coffee for
three weeks now.
48. Geline tells you that she drinks black coffee frequently within the day to “have energy
and be wide awake” and she eats nothing for breakfast and eats strictly vegetable salads for
lunch and dinner to lose weight. She has lost weight during the past two weeks. In planning
a healthy balanced diet with Geline, you will:
A. Start her off with a cleansing diet to free her body of toxins then change to a
vegetarian diet and drink plenty of fluids
B. Plan a high protein diet, low carbohydrate diet for her considering her favorite
food.
C. Instruct her to attend classes in nutrition to find food rich in complex
carbohydrates to maintain daily high energy level.
D. Discuss with her the importance of eating a variety of food from major
food groups with plenty of fluids.
49. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also
smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of
pregnancy but does not want to become fat that is why she limits her food intake. You warn
or caution her about which of the following?
A. Caffeine products affect the central nervous system and may cause the mother to
have a “nervous breakdown”
B. Malnutrition and its possible effects on growth and development
problems in the unborn fetus
C. Caffeine causes a stimulant effect on both mother and the baby
D. Studies show conclusively that caffeine causes mental retardation
50. Your health education plan for Geline stresses proper diet for a pregnant woman and the
prevention of non-communicable diseases that are influenced by her lifestyle. These include
the following EXCEPT:
A. Cardiovascular diseases
B. Cancer
C. Diabetes Mellitus
D. Osteoporosis
53. When the head nurse in your ward plots and approves your work schedules and directs
your work, she is demonstrating:
A. Responsibility
B. Delegation
C. Accountability
D. Authority
54. The following tasks can be safely delegated by a nurse to a non-nurse health worker
EXCEPT:
55. You made a mistake in giving the medicine to the wrong client. You notify the client’s
doctor and write an incident report. You are demonstrating:
A. Responsibility
B. Accountability
C. Authority
D. Autocracy
Situation 12 – Mr. Dizon, 84 years old, brought to the Emergency Room for complaint of
hypertension, flushed face, severe headache, and nausea. You are doing the initial
assessment of vital signs.
56. You are to measure the client’s initial blood pressure reading by doing all of the
following EXCEPT:
A. Determine if the client’s hemoglobin level is low and if he needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s anti-hypertensive medications
D. Detect oxygen saturation of arterial blood before symptoms of
hypoxemia develops
58. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an
order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and
this will cause the blood pressure reading to be:
A. inconsistent
B. low systolic and high diastolic
C. higher than what the reading should be
D. lower than what the reading should be
59. Through the client’s health history, you gather that Mr. Dizon smokes and drinks coffee.
When taking the blood pressure of a client who recently smoked or drank coffee, how long
should the nurse wait before taking the client’s blood pressure for accurate reading?
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 5 minutes
60. While the client has pulse oximeter on his fingertip, you notice that the sunlight is
shining on the area where the oximeter is. Your action will be to:
61. The principles that govern right and proper conduct of a person regarding life, biology
and the health professionals is referred to as:
A. Morality
B. Religion
C. Values
D. Bioethics
63. The most important nursing responsibility where ethical situations emerge in patient
care is to:
65. This principle states that a person has unconditional worth and has the capacity to
determine his own destiny:
A. Bioethics
B. Justice
C. Fidelity
D. Autonomy
Situation 14 – Your director of nursing wants to improve the quality of health care offered in
the hospital. As a staff nurse in that hospital you know that this entails quality assurance
programs.
66. The following mechanisms can be utilized as part of the quality assurance program of
your hospital EXCEPT:
67. The use of the Standards of Nursing Practice is important in the hospital. Which of the
following statements best describes what it is?
A. These are statements that describe the maximum or highest level of acceptable
performance in nursing practice
B. It refers to the scope of nursing practice as defined in Republic Act 9173
C. It is a license issued by the Professional Regulation Commission to protect the
public from substandard nursing practice
D. The Standards of Care includes the various steps of the nursing process
and the standards of professional performance
68. you are taking care of critically ill client and the doctor in charge calls to order a DNR
(do not resuscitate) for the client. Which of the following is the appropriate action when
getting DNR order over the phone?
69. To ensure client safety before starting blood transfusions the following are needed
before the procedure can be done EXCEPT:
A. take baseline vital signs
B. blood should be warmed to room temperature for 30 minutes before
blood transfusions is administered
C. have two nurses verify client identification, blood type, unit number and
expiration date of blood
D. get consent signed for blood transfusion
70. Part of standards of care has to do with the use of restraints. Which of the following
statements is NOT true?
Situation 15 – During the NUTRITION EDUCATION class discussion a 58 year old man, Mr.
Bruno, shows increased interest.
71. Mr. Bruno asks what the “normal” allowable salt intake is. Your best response to Mr.
Bruno is:
72. Your instructions to reduce or limit salt intake include all the following EXCEPT:
73. Teaching strategies and approaches when giving nutrition education is influenced by
age, sex and immediate concerns of the group. Your presentation for a group of young
mothers would be best if you focus on:
Situation 16 – You are assigned to take care of 10 patients during the morning shift. The
endorsement includes the IV infusion and medications for these clients.
76. Mr. Felipe, 36 years old is to be given 2700 ml of D5LR to infuse for 18 hours starting at
8 am. At what rate should the IV fluid be flowing hourly?
77. Mr. Atienza is to receive 150 ml/hour of D% W IV infusion for 12 hours for a total of
1800ml. He is also losing gastric fluid which must be replaced every two hours. Between 8
am and 10 am, Mr. Atienza has lost 250 ml of gastric fluid. How much fluid should he
receive at 11 am?
A. 350 ml/hour
B. 275 ml/hour
C. 400 ml/hour
D. 200 ml/hour
78. You are to apply a transdermal patch of nitoglycerin to your client. The following are
important guidelines to observe EXCEPT:
A. Apply to hairless clean area of the skin not subject to much wrinkling
B. Patches may be applied to distal part of the extremities like forearm
C. Change application and site regularly to prevent irritation of the skin
D. Wear gloves to avoid any medication on your hand
79. You will be applying eye drops to Miss Romualdez. After checking all the necessary
information and cleaning the affected eyelid and eyelashes, you administer the ophthalmic
drops by instilling the eye drops:
80. When applying eye ointment, the following guidelines apply EXCEPT:
A. squeeze about 2 cm of ointment and gently close but not squeeze the eye
B. apply the ointment from the inner canthus going outward of the affected eye
C. discard the first bead of the eye ointment before application because the
tube is likely to expel more than desired amount of ointment
D. hold the tube above the conjunctival sac, do not let tip touch the conjunctiva
Situation 17 – The staff nurse supervisor requests all the staff nurses to “brainstorm” and
learn ways to instruct diabetic clients on self-administration of insulin. She wants to ensure
that there are nurses available daily to do health education classes.
82. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide
who is an unlicensed staff, Mrs. Guevarra
83. Connie, the new nurse, appears tired and sluggish and lacks the enthusiasm she had six
weeks ago when she started the job. The nurse supervisor should
A. grievance
B. arbitration
C. collective bargaining
D. strike
85. You are attending a certification on cardiopulmonary resuscitation (CPR) offered and
required by the hospital employing you. This is
Situation 18 – There are various developments in health education that the nurse should
know about:
86. The provision of health information in the rural areas nationwide through television and
radio programs and video conferencing is referred to as:
87. A nearby community provides blood pressure screening, height and weight
measurement, smoking cessation classes and aerobics class services. This type of program
is referred to as
A. outreach program
B. hospital extension program
C. barangay health program
D. wellness program
88. Part of teaching client in health promotion is responsibility for one’s health. When
Danica states she needs to improve her nutritional status this means:
89. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary
provestion is
A. Marriage counseling
B. Self-examination for breast cancer
C. Identifying complication of diabetes
D. Poison Control
90. Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical
cancer. This is an example of
A. tertiary prevention
B. secondary prevention
C. health screening
D. primary prevention
Situation 19 – Ronnie was in a vehicular accident where he sustained injury to his left ankle.
In the Emergency Room, you notice how anxious he looks.
91. You establish rapport with him and to reduce his anxiety you initially:
92. While doing your assessment, Ronnie asks you “Do I have a fracture? I don’t want to
have a cast.” The most appropriate nursing response would be:
A. Asking the doctor to give an order for a sedative to call him down
B. Informing him that he is being treated by a very competent health team so he
has nothing to worry about
C. Identifying his level of anxiety to determine how much information he
can understand
D. Allaying his anxiety by telling him that he only sustained a minor injury
94. After cleaning the abrasions and applying antiseptic, the nurse applies cold compress to
the swollen ankle as ordered by the physician. This statement shows that the nurse has
correct understanding of the use of cold compress:
95. After receiving prescription for pain medication, Ronnie is instructed to continue
applying 30 minute cold at home and start 30 minute hot compress the next day. You
explain that the use of hot compress:
96. She instructed the interviewees not to tell the interviewees that the data gathered are
for her own research project for publication. This teacher has violated the student’s right to:
A. Not be harmed
B. Disclosure
C. Privacy
D. Self-determination
97. A nurse preceptor observes that many clients are being readmitted in the ward for post-
operative infections. She suggests to the students that they do a research on this topic.
What research activity is this?
98. Quantitative research involves numerical data. Which of the following is based on
quantitative research?
A. A study on the effects of the white uniform of hospital personnel on pediatric
patients
B. The effects of regular nurse visits to client’s bedside on the number of
client’s calls to the nurse
C. A study on benefits of pre-operative health instructions to client’s feeling of
anxiety
D. A study on the effects of touch on the client’s feelings of isolation
99. Before the nurse researcher starts her study, she analyzes how much time, money,
materials and people she will need to complete the research project. This analysis prior to
beginning the study is called:
A. Validity
B. Feasibility
C. Reliability
D. Researchability
100. Data analysis is to be done and the nurse researcher wants to include variability.
These include the following EXCEPT:
A. Variance
B. Range
C. Standards of Deviation
D. Mean
NURSING PRACTICE II – Community Health Nursing and Care of the Mother and Child
SITUATIONAL
1. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first
home-care visit typically made?
2. Leah is developing constipation from being on bed rest. What measures would you
suggest she take to help prevent this?
A. Eat more frequent small meals instead of three large one daily
B. Walk for at least half an hour daily to stimulate peristalsis
C. Drink more milk, increased calcium intake prevents constipation
D. Drink eight full glasses of fluid such as water daily
3. If you were Minette, which of the following actions would alert you that a new mother is
entering a postpartal taking-hold phase?
A. She urges the baby to stay awake so that she can breast-feed him or her
B. She tells you she was in a lot of pain all during labor
C. She says that she has not selected a name for the baby as yet
D. She sleeps as if exhausted from the effort of labor
4. At 6-week postpartum visit what should this postpartal mother’s fundic height be?
5. This postpartal mother wants to loose the weight she gained in pregnancy, so she is
reluctant to increase her caloric intake for breast-feeding. By how much should a lactating
mother increase her caloric intake during the first 6 months after birth?
A. 350 kcal/day
B. 500 kcal/day
C. 200 kcal/day
D. 1000 kcal/day
Situation 2 – As the CPE is applicable for all professional nurse, the professional growth and
development of Nurses with specialties shall be addressed by a Specialty Certification
Council. The following questions apply to these special groups of nurses.
6. Which of the following serves as the legal basis and statute authority for the Board of
Nursing to promulgate measures to effect the creation of a Specialty Certification Council
and promulgate professional development programs for this group of nurse-professionals?
A. R.A. 7610
B. P.D. 223
C. R.A. 9173
D. R.A. 7164
7. By force of law, therefore, the PRC-Board of Nursing released Resolution No. 14 Series of
1999 entitled: “Adoption of a Nursing Specialty Certification Program and Creation of
Nursing Specialty Certification Council.” This rule-making power is called:
A. Quasi-Judicial Power
B. Regulatory Power
C. Quasi-Legislative Power
D. Executive/Promulgating Power
(a) Advances made in Science and Technology have provided the climate for specialization
in almost all aspects of human endeavor; and
(b) As necessary consequence, there has emerged a new concept known as globalization
which seeks to remove barriers in trade, industry and services imposed by the national
laws of countries all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare our people
in the services sector to meet the above challenge; and
(d) Current trends of specialization in nursing practice recognized by the International
Council of Nurses (ICN) of which the Philippines is a member for the benefit of the
Filipino in terms of deepening and refining nursing practice and enhancing the quality
of nursing care.
10. The NSCC was created for the purpose of implementing the Nursing Specialty policy
under the direct supervision and stewardship of the Board of Nursing. Who shall comprise
the NSCC?
A. A Chairperson who is the current President of the APO; a member from the
Academe; and the last member coming from the Regulatory Board
B. The chairperson and members of the Regulatory Board ipso facto acts as the CPE
Council
C. A Chairperson, chosen from among the Regulatory Board members; a Vice
Chairperson appointed by the BON at-large; two other members also chosen 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 following conditions
may be acceptable TRUTHS applied to Community Health Nursing Practice.
11. Which of the following is the primary focus of community health nursing practice?
A. Cure of illnesses
B. Prevention of illnesses
C. Rehabilitation back to health
D. Promotion of health
12. In community health nursing, which of the following is our unit of service as nurses?
A. The community
B. The extended members of every family
C. The individual members of the Barangay
D. The Family
13. A very important part of the Community Health Nursing Assessment Process includes:
14. In community health nursing it is important to take into account the family health data
coupled with an equally important need to perform ocular inspection of the area as activities
which are powerful elements of:
A. evaluation
B. assessment
C. implementation
D. planning
15. The initial step in PLANNING process in order to engage in any nursing project or
activities at the community level involves
A. goal-setting
B. monitoring
C. evaluation of data
D. provision of data
17. The medical record of a client reveals a condition in which the fetus cannot pass through
the maternal pelvis. The nurse interprets this as:
A. Contracted pelvis
B. Maternal disproportion
C. Cervical insufficiency
D. Fetopelvic disproportion
18. The nurse would anticipate a cesarean birth for a client who has which infection present
at the onset of labor?
A. Herpes-simplex virus
B. Human papilloma virus
C. Hepatitis
D. Toxoplasmosis
19. After a vaginal examination, the nurse determines that the client’s fetus is in an occiput
posterior position. The nurse would anticipate that the client will have:
A. A precipitous birth
B. Intense back pain
C. Frequent leg cramps
D. Nausea and vomiting
20. The rationales for using a prostaglandin gel for a client prior to the induction of labor is
to:
Situation 5 – Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently
attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions
pertain to meeting the nursing needs of this particular population group.
21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be
the best answer?
A. Prostaglandins released from the cut fallopian tubes can kill sperm
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are
blocked
D. The ovary no longer releases ova as there is no where for them to go.
22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist
when:
23. Another client named Lilia is diagnosed as having endometriosis. This condition
interferes with fertility because:
25. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what
artificial insemination by donor entails. Which would be your best answer if you were Nurse
Lorena?
Situation 6 – There are other important basic knowledge in the performance of our task as
Community Health Nurse in relation to IMMUNIZATION, these include:
27. Which of the following vaccines is not done by intramuscular (IM) injection?
A. Measles vaccine
B. DPT
C. Hepa-B vaccine
D. Tetanus toxoids
A. Measles
B. Tetanus toxoids
C. Hepatitis B vaccines
D. DPT
29. This is the vaccine needed before a child reaches one (1) year in order for him/her to
qualify as a :fully immunized child”.
A. DPT
B. Measles
C. Hepatitis B
D. BCG
30. Which of the following dose of tetanus toxoid is given to the mother to protect her infant
from neonatal tetanus and likewise provide 10 years protection for the mother?
A. Tetanus toxoid 3
B. Tetanus toxoid 2
C. Tetanus toxoid 1
D. Tetanus toxoid 4
31. This special form is used when the patient is admitted to the unit. The nurse completes
the information in this record particularly his/her basic personal data, current illness,
previous health history, health history of the family, emotional profile, environmental
history as well as physical assessment together with nursing diagnosis on admission. What
do you call this record?
A. Nursing Kardex
B. Nursing Health History and Assessment Worksheet
C. Medicine and Treatment Record
D. Discharge Summary
32. These are sheets/forms which provide an efficient and time saving way to record
information that must be obtained repeatedly at regular and/or short intervals of time. 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 regimen, etc.
This is used whenever specific measurements or observations are needed to be documented
repeatedly. What is this?
A. Nursing Kardex
B. Graphic Flow Sheets
C. Discharge Summary
D. Medicine and Treatment Record
33. These records show all medications and treatment provided on a repeated basis. What
do you call this 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 physician to
be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and
procedures, safety precautions in patient care and factors related to daily living activities.
This record is used in the charge-of-shift reports or during the bedside rounds or walking
rounds. What record is this?
A. Discharge Summary
B. Medicine and Treatment Record
C. Nursing Health History and Assessment Worksheet
D. Nursing Kardex
35. Most nurses regard this conventional recording of the date, time, and mode by which
the patient leaves a healthcare unit but this record includes importantly, directs of planning
for discharge that starts soon after the person is admitted to a healthcare institution. 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. Discharge Summary
B. Nursing Kardex
C. Medicine and Treatment Record
D. Nursing Health History and Assessment Worksheet
36. Which of the following is TRUE about the Code of Ethics of Filipino Nurses?
37. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of
nursing responsibility and accountability?
38. Which of the following nurses behavior is regarded as a violation of the Code of Ethics of
Filipino Nurses?
39. A nurse should be cognizant that professional programs for specialty certification by the
Board of Nursing accredited through the:
40. Mr. Santos, R.N. works in a nursing home, and he knows that one of his duties is to be
an advocate for his patients. Mr. Santos knows a primary duty of an advocate is to;
Situation 9 – Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK
PREGNANCIES: Particular women with preexisting or Newly Acquired illness. The following
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?
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?
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?
44. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should she limit
or discontinue this toward the end of pregnancy?
45. Bernadette received a laceration on her leg from her automobile accident. Why are
lacerations of lower extremities potentially more serious in pregnant women than others?
46. Josie brought her 3 months old child to your clinic because of cough and colds. Which of
the following is your primary action?
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 following?
A. Wheezing
B. Stop feeding well
C. Fast breathing
D. Difficulty to awaken
48. Which of the following is the most important responsibility of a nurse in the prevention
of unnecessary deaths from pneumonia and other severe diseases?
A. Giving antibiotics
B. Taking of the temperature of the sick child
C. Provision of Careful Assessment
D. Weighing of the sick child
49. You were able to identify factors that lead to respiratory problems in the community
where your health facility serve. Your primary role therefore in order to reduce morbidity
due to pneumonia is to:
50. Which of the following is the principal focus of the CARI program of the Department of
Health?
Situation 11 – You are working as a Pediatric Nurse in you own Child Health Nursing 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 common in
the family?” Your answer to this is:
A. At 2 years you may
B. As early as 1 year old
C. When she’s 3 years old
D. When she’s 6 years old
52. You typically gag children to inspect the back of their throat. When is it important NOT
to elicit a gag reflex?
53. Baby John was given a drug at birth to reverse the effects of a narcotic given to his
mother in labor. What drug is commonly used for this:
A. Naloxone (Narcan)
B. Morphine Sulfate
C. Sodium Chloride
D. Penicillin G
54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body
temperature?
Situation 12 – You are the nurse in the Out-Patient Department and during your shift you
encountered multiple children’s condition. The following questions apply.
A. edema
B. LBM
C. Kwashiorkor
D. Marasmus
57. Which of the following conditions is NOT true about contraindication to immunization?
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
A. A child with diarrhea who is due for OPV should receive the OPV and make extra
dose on the next visit
B. There is no contraindication to immunization if the child is well enough to go
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 classified as:
A. moderate malnutrition/anemia
B. severe malnutrition/anemia
C. not very low weight no anemia
D. anemia/very low weight
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.
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 considered 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 occurs
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:
65. Mrs. Medina comes to you for check-up on June 2, her EDC is June 11, what do you
expect during assessment?
66. Which of the following medications would the nurse expect the physician to order for
recurrent convulsive seizures of a 10-year old child brought to your clinic?
A. Phenobarbital
B. Nifedipine
C. Butorphanol
D. Diazepam
68. Which of the following would the nurse include when describing the pathophysiology of
gestational diabetes?
69. When providing prenatal education to a pregnant woman with asthma, which of the
following would be important for the nurse to do?
70. Which of the following conditions would cause an insulin-dependent diabetic client the
most difficulty during her pregnancy?
A. Rh incompatibility
B. Placenta Previa
C. Hyperemesis Gravidarum
D. 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?
72. What is the rationale in the use of bag technique during home visits?
73. Which among the following is important in the use of the bag technique during home
visit?
75. In consideration of the steps in applying the bag technique, which side of the paper
lining of the CHN bag is considered clean to make a non-contaminated work area?
76. The following statements can correctly be made about Organization and management:
77. Management by Filipino values advocate the consideration of the Filipino goals trilogy
according to the Filipino priority-values which are:
78. Since the advocacy for the utilization of Filipino value-system in management has been
encouraged, the Nursing sector is no except, management needs to examine Filipino values
and discover its positive potentials and harness them to achieve:
A. Employee satisfaction
B. Organizational commitments, organizational objectives and employee satisfaction
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 efficient
community or even agency managerial-leader.
80. Whether management at the community or agency level, there are 3 essential types of
skills managers must have, these are:
Situation 17 – You are actively practicing nurse who just finished your Graduate Studies.
You learned the value of Research and would like to utilize the knowledge and skills 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. Logical position
B. Naturalistic inquiry
C. Positivism
D. Quantitative Research
84. An 85 year old client in a nursing home tells a nurse, “I signed the papers for that
research study because the doctor was so insistent and I want him to continue taking care
of me”. Which client right is being violated?
A. a paradigm
B. a concept
C. a theory
D. a conceptual framework
Situation 18 – Nurse Michelle works with a Family Nursing Team in Calbayog Province
specifically handling a UNICEF Project for Children. The following conditions pertain 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. 1,200 or more
B. Less than 50
C. 100-200
D. 300-400
87. Ronnie will need to change to a new bed because his baby sister will need Ronnie’s old
crib. What measure would you suggest that his parents take to help decrease sibling rivalry
between Ronnie and his new sister?
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. About 12 words
B. Twenty or more words
C. About 50 words
D. Two, plus “mama” and “papa”
90. As a nurse. You reviewed infant safety procedures with Bryan’s mother. What are two of
the most common types of accidents among infants?
91. A child with ear problem should be assessed for the following, EXCEPT:
92. If the child does not have ear problem, using IMCI, what should you as the nurse do?
93. A ear discharge that has been present for more than 14 days can be classified as:
A. mastoiditis
B. chronic ear infection
C. acute ear infection
D. complicated ear infection
94. An ear discharge that has been present for less than 14 days can be classified as:
95. If the child has severe classification because of ear problem, what would be the best
thing that you as the nurse can do?
Situation 20 – If the child with diarrhea registers one sign in the pink row and one in the
yellow row in the IMCI Chart –
A. moderate dehydration
B. some dehydration
C. no dehydration
D. severe dehydration
97. The child with no dehydration needs home treatment. Which of the following is not
included in the rules for home treatment in this case:
98. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as:
99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back slowly,
the classification would be:
A. no dehydration
B. moderate dehydration
C. some dehydration
D. severe dehydration
100. Carlo has had diarrhea for 5 days. There is no blood in the stool, he is irritable. 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. severe dehydration
B. no dehydration
C. some dehydration
D. moderate dehydration
NURSING PRACTICE III – Care of Clients with Physiologic and Psychosocial Alterations (Part
A)
SITUATIONAL
Situation 1 – Concerted work efforts among members of the surgical team is essential to
the success of the surgical procedure.
1. The sterile nurse or sterile personnel touch only sterile supplies and instruments. 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. Circulating Nurse
B. Anaesthesiologist
C. Surgeon
D. Nursing Aide
2. The OR team performs distinct roles for one surgical procedure to be accomplished within
a prescribed time frame and deliver a standard patient outcome. While the surgeon
performs the surgical procedure, who monitors the status of the client like urine output,
blood loss?
A. Scrub Nurse
B. Surgeon
C. Anaesthesiologist
D. Circulating Nurse
3. Surgery schedules are communicated to the OR usually a day prior to the procedure by
the nurse of the floor or ward where the patient is confined. For orthopedic cases, what
department is usually informed to be present in the OR?
A. Rehabilitation department
B. Laboratory department
C. Maintenance department
D. 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. Information technician
B. Biomedical technician
C. Electrician
D. Laboratory technician
A. Security Division
B. Chaiplaincy
C. Social Service Section
D. Pathology department
Situation 2 – You are assigned in the Orthopedic Ward where clients are complaining of pain
in varying degrees upon movement of body parts.
6. Troy is a one day post open reduction and internal fixation (ORIF) of the left hip and is in
pain. Which of the following observation would prompt you to call the doctor?
7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected
Demerol at 5 pm. The next dose of Demerol 50 mg I.M. is given:
8. You continuously evaluate the client’s adaptation to pain. Which of the following
behaviors indicate appropriate adaptation?
9. Pain in ortho cases may not be mainly due to the surgery. There might be other factors
such as cultural or psychological that influence pain. How can you alter these factors as the
nurse?
A. Explain all the possible interventions that may cause the client to worry
B. Establish trusting relationship by giving his medication on time
C. Stay with the client during pain episodes
D. Promote client’s sense of control and participation in control by listening
to 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?
Situation 3 – Records are vital tools in any institution and should be properly maintained for
specific use and time.
11. The patient’s medical record can work as a double edged sword. When can the medical
record become the doctor’s/nurse’s worst enemy?
13. In the hospital, when you need the medical record of a discharged patient for research
you will request permission through:
A. Doctor in charge
B. The hospital director
C. The nursing service
D. 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?
15. Records Management and Archives Office of the DOH is responsible for implementing its
policies on record disposal. You know that your institution is covered by this policy if:
Situation 4 – In the OR, there are safety protocols that should be followed. The OR nurse
should be well versed with all these to safeguard the safety and quality of patient delivery
outcome.
16. Which of the following should be given highest priority when receiving patient in the
OR?
17. Surgeries like I and D (incision and drainage) and debridement are relatively short
procedures but considered ‘dirty cases’. When are these procedures best scheduled?
A. Last case
B. In between cases
C. According to availability of anaesthesiologist
D. 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…
19. Another nursing check that should not be missed before the induction of general
anesthesia is:
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 increased risk
for:
A. perioperative anxiety and stress
B. delayed coagulation time
C. delayed wound healing
D. postoperative respiratory function
Situation 5 – Nurses hold a variety of roles when providing care to a perioperative patient.
21. Which of the following role would be the responsibility of the scrub nurse?
22. As a perioperative nurse, how can you best meet the safety need of the client after
administering preoperative narcotic?
A. Put side rails up and ask the client not to get out of bed
B. Send the client to OR with the family
C. Allow client to get up to go to the comfort room
D. Obtain consent form
23. It is the responsibility of the pre-op nurse to do skin prep for patients undergoing
surgery. If hair at the operative site is not shaved, what should be done to make suturing
easy and lessen chance of incision infection?
A. Draped
B. Pulled
C. Clipped
D. Shampooed
24. It is also the nurse’s function to determine when infection is developing in the surgical
incision. The perioperative nurse should observe for what signs of impending infection?
25. Which of the following nursing interventions is done when examining the incision wound
and changing the dressing?
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.
27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse,
what is its indication, the nurse will say:
28. You will give health instructions to Carlo, a case of bronchial asthma. The health
instruction will include the following, EXCEPT:
29. The asthmatic client asked you what breathing techniques he can best practice when
asthmatic attack starts. What will be the best position?
30. As a nurse, you are always alerted to monitor status asthmaticus who will likely and
initially manifest symptoms of:
A. metabolic alkalosis
B. respiratory acidosis
C. respiratory alkalosis
D. metabolic acidosis
31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm
systems?
32. Overdosage of medication or anesthetic can happen even with the aid of technology like
infusion pumps, sphygmomanometer and similar devices/machines. As a staff, how can you
improve the safety of using infusion pumps?
A. Check the functionality of the pump before use
B. Select your brand of infusion pump like you do with your cellphone
C. Allow the technician to set the infusion pump before use
D. Verify the flow rate against your computation
33. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site,
wrong person, and wrong procedure/surgery includes the following, EXCEPT:
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. Assess potential risk of fall associated with the patient’s medication regimen
B. Take action to address any identified risks through Incident Report (IR)
C. Allow client to walk with relative to the OR
D. 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 by 2
patient identifiers, EXCEPT:
A. identify the client by his/her wrist tag and verify with family members
B. identify client by his/her wrist tag and call his/her by name
C. call the client by his/her case and bed number
D. call the patient by his/her name and bed number
36. If you are the nurse in charge for scheduling surgical cases, what important information
do you need to ask the surgeon?
37. In the OR, the nursing tandem for every surgery is:
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 comprise this
team?
39. When surgery is on-going, who coordinates the activities outside, including the family?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication
41. Skin care around the stoma is critical. Which of the following is not indicated as a skin
care barriers?
42. What health instruction will enhance regulation of a colostomy (defecation) of clients?
A. Increased weight
B. Irritation of skin around the stoma
C. Liquid stool
D. Establishment of regular bowel movement
44. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:
A. Increase the irrigating solution flow rate when abdominal cramps is felt
B. Insert 2-4 inches of an adequately lubricated catheter to the stoma
C. Position client in semi-Fowler
D. Hang the solution 18 inches above the stoma
45. What sensation is used as a gauge so that patients with ileostomy can determine how
often their pouch should be drained?
A. Sensation of taste
B. Sensation of pressure
C. Sensation of smell
D. Urge to defecate
A. Control group
B. Study subjects
C. General population
D. Universe
A. Randomization
B. Appropriate location
C. Appropriate number
D. Representativeness
49. Which of the following methods allows the use of any group of research subject?
A. Purposive
B. Convenience
C. Snow-ball
D. 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 appropriate
method ofor you to use in this care?
A. Cluster sampling
B. Random sampling
C. Startified ampling
D. Systematic sampling
Situation 11 – After an abdominal surgery, the circulating and scrub nurses have critical
responsibility about sponge and instrument count.
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. Fascia
B. Muscle
C. Peritoneum
D. Skin
53. Like sutures, needles also vary in shape and uses. If you are the scrub nurse for a
patient who is prone to keloid formation and has low threshold of pain, what needle would
you prepare?
A. Round needle
B. Atraumatic needle
C. Reverse cutting needle
D. Tapered needle
54. Another alternative “suture” for skin closure is the use of ____________
A. Staple
B. Therapeutic glue
C. Absorbent dressing
D. Invisible suture
55. Like any nursing interventions, counts should be documented. To whom does the scrub
nurse report any discrepancy of counts so that immediate and appropriate action is
instituted?
A. Anesthesiologist
B. Surgeon
C. OR nurse supervisor
D. Circulating nurse
Situation 12 – As a nurse, you should be aware and prepared of the different roles you play.
56. What role do you play when you hold all client’s information entrusted to you in the
strictest confidence?
A. Patient’s advocate
B. Educator
C. Patient’s Liaison
D. Patient’s arbiter
57. As a nurse, you can help improve the effectiveness of communication among healthcare
givers by:
A. Formal training
B. Posters
C. Posting IR in the bulletin board
D. Use of labels and signs
59. As a nurse, what is one of the best way to reconcile medications across the continuum
of care?
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 alleviate
the client’s pain and other conditions
B. Advising the client, by virtue of your expertise, that which can contribute to 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 complaining 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 severe
throbbing abdominal pain described as 9 in a 1-10 pain rating. Your assessment revelas
bowel sounds on all quadrants and the dressing is dry and intact. What nursing intervention
would you take
62. Pentoxidone 5 mg IV every 8 hours was prescribed for post abdominal pain. Which will
be your priority nursing action?
63. The client complained of abdominal distention and pain. Your nursing intervention that
can alleviate pain is:
A. Instruct client to go to sleep and relax
B. Advice the client to close the lips and avoid deep breathing and talking
C. Offer hot and clear soup
D. Turn to sides frequently and avoid too much talking
64. Surgical pain might be minimized by which nursing action in the O.R.
Situation 14 – You were on duty at the medical ward when Zeny came in for admission for
tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor’s
diagnosis was hypothyroidism.
67. As the nurse, you should anticipate to administer which of the following medications to
Zeny who is diagnosed to be suffering from hypothyroidism?
A. Levothyroxine
B. Lidocaine
C. Lipitor
D. Levophed
68. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would
probably include which of the following?
69. Myxedema coma is a life threatening complication of long standing and untreated
hypothyroidism with one of the following characteristics.
A. Hyperglycemia
B. Hypothermia
C. Hyperthermia
D. Hypoglycemia
70. As a nurse, you know that the most common type of goiter is related to a deficiency of:
A. thyroxine
B. thyrotropin
C. iron
D. 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?
72. Mrs. Pichay who is for thoracentesis is assigned by the nurse to which of the following
positions?
A. Trendelenburg position
B. Supine position
C. Dorsal Recumbent position
D. Orthopneic position
73. During thoracentesis, which of the following nursing intervention will be most crucial?
74. To prevent leakage of fluid in the thoracic cavity, how will you position the client after
thoracentesis?
75. Chest x-ray was ordered after thoracentesis. When your client asks what is the reason
for another chest x-ray, you will explain:
76. You are to initiate an IV line to your patient, Kyle, 5, who is febrile. What IV
administration set will you prepare?
77. Kyle is diagnosed to have measles. What will your protective personal attire include?
A. Gown
B. Eyewear
C. Face mask
D. Gloves
78. What will you do to ensure that Kyle, who is febrile, will have a liberal oral fluid intake?
79. Before bedtime, you went to ensure Kyle’s safety in bed. You will do which of the
following:
80. Kyle’s room is fully mechanized. What do you teach the watcher and Kyle to alert the
nurses for help?
Situation 17 – Tony, 11 years old, has ‘kissing tonsils’ and is scheduled for tonsillectomy
and adenoidectomy or T and A.
81. You are the nurse of Tony who will undergo T and A in the morning. His mother 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 what food
to prepare and give their children after surgery. You as the nurse will say:
83. The RR nurse should monitor for the most common postoperative complication of:
A. hemorrhage
B. endotracheal tube perforation
C. osopharyngeal edema
D. epiglottis
84. The PACU nurse will maintain postoperative T and A client in what position?
85. Tony is to be discharged in the afternoon of the same day after tonsillectomy and
adenoidectomy. You as the RN will make sure that the family knows to:
Situation 18 – Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered so
that an A-V shunt was surgically created.
86. Which of the following action would be of highest priority with regards to the external
shunt?
A. Avoid taking BP or blood sample from the arm with the shunt
B. Instruct the client not to exercise the arm with the shunt
C. Heparinize the shunt daily
D. Change dressing of the shunt daily
87. Diet therapy for Rudy, who has acute renal failure is low-protein, low potassium 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 diet
88. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium
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 failure. Which
delegated function to the aide would you particularly check?
90. A renal failure patient was ordered for creatinine clearance. As the nurse you will
collect…
Situation 19 – Fe is experiencing left sharp pain and occasional hematuria. She was advised
to undergo IVP by her physician.
91. Fe was so anxious about the procedure and particularly expressed her low pain
threshold. Nursing health instruction will include:
A. assure the client that the pain is associated with the warm sensation
during the administration of the Hypaque by IV
B. assure the client that the procedure painless
C. assure the client that contrast medium will be given orally
D. assure the client that x-ray procedure like IVP is only done by experts
92. What will the nurse monitor and instruct the client and significant others post IVP?
93. Post IVP, Fe should excrete the contrast medium. You instructed the family to include
more vegetables in the diet and:
94. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously.
To increase the chance of passing the stones, you instructed her to force fluids and do
which of the following?
A. Balanced diet
B. Ambulate more
C. Strain all urine
D. Bed rest
A. Colelithiasis
B. Nephrolithiasis
C. Ureterolithiasis
D. Urolithiasis
Situation 20 – At the medical-surgical ward, the nurse must also be concerned about drug
interactions.
96. You have a client with TPN. You know that in TPN like blood transfusion, these should be
no drug incorporation. However the MD’s order read; incorporate insulin to present TPN. Will
you follow the order?
97. The RN should also know that some drugs have increased adsorption when infused in
the PVC container. How will you administer drugs such as insulin, nitroglycerine hydralazine
to promote better therapeutic drug effects?
98. One patient had a ‘runaway’ IV of 50% dextrose. To prevent temporary excess of insulin
or transient hyperinsulin reaction what solution you prepare in anticipation of the doctor’s
order?
100. In insulin administration, it should be understood that our body normally releases
insulin according to our blood glucose level. When is insulin and glucose level highest?
A. After excitement
B. After a good night’s rest
C. After an exercise
D. After ingestion of food
GENERAL INSTRUCTIONS
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
1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burns into
flames. The most effective way to extinguish the flames with as little further
damage as possible is to:
4. During the first 24 hours after the thermal injury, you should asses Sergio for:
5. Teddy, who sustained deep partial thickness and full thickness burns of the face,
whole anterior chest and both upper extremities two days ago begins to exhibit
extreme restlessness. You recognize that this most likely indicates that Teddy is
developing:
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 prisoner
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. He
denied the matter. Which among the following activities will you do first?
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?
8. You are on duty in the medical ward. You were asked to check the narcotics cabinet.
You found out that what is on record does not tally with the drugs used. Which
among the following will you do first?
A. Write an incident report and refer the matter to the nursing director
B. Keep your findings to yourself
C. Report the matter to your supervisor
D. 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.
10. You are admitting Jorge to the ward and you found out that he is positive for HIV.
Which among the following will you do first?
Situation 3 - Colorectal cancer can affect old and younger people. Surgical procedures
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 admitted to the
CI. After taking the history and vital signs the physician does which test as a
screening test for colorectal cancer.
A. Barium enema
B. Carcinoembryonic antigen
C. Annual digital rectal examination
D. Proctosigmoidoscopy
12. To confirm his impression of colorectal cancer, Larry will require which diagnostic
study?
A. Carcinoembryonic antigen
B. Proctosigmoidoscopy
C. Stool hematologic test
D. Abdominal computed tomography (CT) test
13. The following are risk factors for colorectal cancer, EXCEPT:
A. Inflammatory bowels
B. High fat, high fiber diet
C. Smoking
D. Genetic factors-familial adenomatous polyposis
15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and
neomycin primarily to:
16. You plan to teach Fermin how to irrigate the colostomy when:
A. The perineal wound heals And Fermin can sit comfortably on the commode
B. Fermin can lie on the side comfortably, about the 3rd postoperative day
C. The abdominal incision is closed and contamination is no longer a danger
D. 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. 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 instilled
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. If I have any difficulty inserting the irrigating tub into the stoma.”
B. If I noticed a loss of sensation to touch in the stoma tissue.”
C. The expulsion of flatus while the irrigating fluid is running out.”
D. 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.”
21. Randy has chest tubes attached to a pleural drainage system. When caring for
him you should:
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:
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?
25. When caring for Larry after an exploratory chest surgery and pneumonectomy,
your priority would be to maintain:
A. supplementary oxygen
B. ventilation exchange
C. chest tube drainage
D. blood replacement
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:
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. stomatitis
B. hepatitis
C. dysrhythmia
D. infection
A. Dakin’s solution
B. Half-strength hydrogen peroxide
C. Acetic acid
D. Betadine
30. Which of the following is the most reliable in diagnosing a wound infection?
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?
32. Knowing that for a comatose patient hearing is the last sense to be lost, as
Judy’s nurse, what should you do?
33. Which among the following interventions should you consider as the highest
priority when caring for June who has hemiparesis secondary to stroke?
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?
36. Hypoxia may occur in the older patients because of which of the following
physiologic changes associated with aging.
37. The older patient is at higher risk for incontinence because of:
A. dilated urethra
B. increased glomerular filtration rate
C. diuretic use
D. decreased bladder capacity
38. Merle, age 86, is complaining of dizziness when she stands up. This may
indicate:
A. dementia
B. a visual problem
C. functional decline
D. drug toxicity
40. The most dependable sign of infection in the older patient is:
A. Recovery
B. Mitigation
C. Response
D. 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. Tertiary prevention
B. Primary prevention
C. Aggregate care prevention
D. 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 even
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. Immediate
B. Emergent
C. Non-acute
D. 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?
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 bleeds.
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. Acetone
B. Alcohol
C. Ammonia
D. 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?
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 consideration
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 for
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?
50. You are invited to participate in the medical mission activity of your alumni
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?
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?
52. Ruby who has been told she has terminal cancer, turns away and refuses to
respond to you. You can best help her by:
54. Which of the following statements would best indicate that Ruffy, who is
dying, has accepted his impending death?
55. Marla, 90 years old has planned ahead for her death-philosophically, socially,
financially and emotionally. This is recognized as:
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?
58. Which of the following activities may increase intracranial pressure (ICP)?
A. Raising the head of the bed
B. Manual hyperventilation
C. Use of osmotic diuretics
D. Valsalva’s maneuver
59. After you asses Conrad, you suspected increased ICP. Your most
appropriate respiratory goal is to:
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?
61. The essential components of professional nursing practice are all the following
EXCEPT:
A. Culture C. Cure
B. Care D. Coordination
62. You are assigned to care for four (4) patients. Which of the following patients
should you give first priority?
63. Brenda, the Nursing Supervisor of the intensive care unit (ICU) is not on duty
when a staff nurse committed a serious medication error. Which statement
accurately reflects the accountability of the nursing supervisor?
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?
66. Which one of the following nursing interventions would be most helpful in
preparing the patient for radiation therapy?
67. What side effects are most apt to occur the patient during radiation therapy
to the pelvis?
A. Urinary retention
B. Abnormal vaginal or perineal discharge
C. Paresthesia of the lower extremities
D. Nausea and vomiting and diarrhea
68. Which of the following can be used on the irradiated skin during a course of
radiation therapy?
A. Adhesive tape
B. Mineral oil
C. Talcum powder
D. Zinc oxide ointment
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?
71. As a nurse to which of the following groups are you best prepared to join?
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
A. perfusion C. respiration
B. locomotion D. mentation
A. pupil reactivity
B. vital sign assessment
C. cranial nerve assessment
D. level of consciousness/responsiveness
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 disease,
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. urinary/bowel changes
B. pain in pelvis, leg or flank
C. uterine bleeding
D. lymph edema of lower extremities
79. The primary modalities of treatment for Stage 1 and IIA cervical cancer
include the following:
81. You are caring for Leda who is scheduled to undergo total thyroidectomy because
of a diagnosis of thyroid cancer. Prior to total thyroidectomy, you should
instruct Leda to:
82. As Leda’s nurse, you plan to set up an emergency equipment at her beside
following thyroidectomy. You should include:
85. After surgery Leda develops peripheral numbness, tingling and muscle
twitching and spasm. What would you anticipate to administer?
87. For a patient experiencing pruritus, you recommend which type of bath.
A. water C. saline
B. colloidal (oatmeal D. sodium bicarbonate
88. Induction of vomiting is indicated for the accidental poisoning patient who has
ingested.
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?
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 C. Independent
B. Correlational D. Demographic
92. You would like to compare the support system of patients with chronic illness
to those with acute illness. How will you best state your problem?
93. You would like to compare the support system of patients with chronic illness
to those with acute illness. What type of research it this?
A. Correlational
B. Descriptive
C. Experimental
D. Quasi-experimental
94. You are shown a Likert Scale that will be used in evaluating your performance
in the clinical area. Which of the following questions will you not use in
critiquing the Likert Scale?
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. Interventional C. Surgical
B. Mechanical D. Chemical
97. Which topical antimicrobial is most frequently used in burn wound care?
A. Neosporin
B. Silver nitrate
C. Silver sulfadiazine
D. Sulfamylon
A. exaggerated contraction
B. random layering of collagen
C. wound ischemia
D. delayed epithelialization
A. patient hypothermia
B. cross contamination of wound
C. patient discomfort
D. excessive manpower requirement
100. Oral analgesics are most frequently used to control burn injury pain:
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.
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 priority
goal in the care plan is:
2. The nurse is guided that Jimmy is aware of his concerns of the “here and now” when he
crossed out which item from this “list of what to know”.
4. Jimmy initiates independence and takes an active part in his self care with the following
EXCEPT:
5. The nurse notes effectiveness of interventions in using subjective and objective data in
the:
Situation 2 – A research study was undertaken in order to identify and analyze a disabled
boy’s coping reaction pattern during stress.
A. case study
B. longitudinal study
C. cross-sectional study
D. evaluative study
7. The process recording was the principal tool for data collection. Which of the following is
NOT a part of a process recording?
9. The investigator also provided the nursing care of the subject. The investigator is referred
to as a/an:
A. Participant-observer
B. Observer researcher
C. Caregiver
D. Advocate
10. To ensure reliability of the study, the investigator’s analysis and interpretations were:
Situation 3 – During the morning endorsement, the outgoing nurse informed the nursing
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 communicate
attention and care for her needs for information about her medicine?
A. Guided by a medication teaching plan, go over with her the purpose, indications
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
medication.
13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for
Regina to:
!4. Which of these responses indicate that Regina needs further discussion regarding special
instructions?
15. Regina commits to herself that she understood and will observe all the medicine
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. theoretical knowledge
B. personality make up
C. emotional reactions
D. 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:
18. One way to increase objectivity in dealing with one’s fears and anxieties is through the
process of:
A. observation
B. intervention
C. validation
D. collaboration
19. All of the following responses are non therapeutic. Which is the MOST direct violation of
the concept, congruence of behavior?
20. The mentally ill person responds positively to the nurse who is warm and caring. This is
a demonstration of the nurse’s role as:
A. counselor
B. mother surrogate
C. therapist
D. 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 relationship is:
22. The client says, “I want to tell you something but can you promise that you will keep
this a secret?” A therapeutic response of the nurse is:
23. When the nurse respects the client’s self-disclosure, this is a gauge for the nurse’s:
A. trustworthiness
B. loyalty
C. integrity
D. professionalism
24. Rapport has been established in the nurse-client relationship. The client asks to visit the
nurse after his discharge. The appropriate response of the nurse would be:
25. The client has not been visited by relatives for months. He gives a telephone number
and requests the nurse to call. An appropriate action of the nurse would be:
Situation 6 – Camila, 25 years old, was reported to be gradually withdrawing and isolating
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 personality
is:
A. schizoid
B. extrovert
C. ambivert
D. cycloid
A. is irritable
B. feels superior of others
C. anticipates rejection
D. is depressed
28. Which of the following disturbances in interpersonal relationships MOST often predispose
to the development of schizophrenia?
A. Guilt feelings
B. Ambivalence
C. Narcissistic behavior
D. Insecurity feelings
A. anxiety disorder
B. neurosis
C. psychosis
D. personality disorder
Situation 7 – Salome, 80 year old widow, has been observed to be irritable, demanding
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 tendency
to become aggressive is a/an:
A. sensory deprivation
B. social isolation
C. cognitive impairment
D. ego despair
33. The nurse will assist Salome and her daughter to plan a goal which is for Salome to:
34. The daughter understood, the following ways to assist Salome meet her needs and
avoiding which of the following:
35. Salome was fitted a hearing aid. She understood the proper use and wear of this device
when she says that the battery should be functional, the device is turned on and
adjusted to a:
A. therapeutic level
B. comfortable level
C. prescribed level
D. 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.
A. acrophobia
B. claustrophobia
C. agoraphobia
D. 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. organic
B. psychosomatic
C. psychotic
D. neurotic
38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:
A. communication
B. cognition
C. observation
D. perception
39. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety
reactions. Which of the following should the nurse implement?
A. assist her in recognizing irrational beliefs and thoughts
B. help find meaning in her behavior
C. provide positive reinforcement for acceptable behavior
D. Administer anxiolytic drug
40. After discharge, which of these behaviors indicate a positive result of being able to
overcome her phobia?
Situation 9 – It is the first day of clinical experience of nursing students at the 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 because
doing so is a violation of patients’ rights to:
A. Informed consent
B. Confidentiality
C. Least restrictive environment
D. Civil liberty
42. The nurse must see to it that the written consent of mentally ill patients must be taken
from:
A. Doctor
B. Social worker
C. Parents or legal guardian
D. Law enforcement authorities
43. In an extreme situation and when no other resident or intern is available, should a
nurse receive telephone orders, the order has to be correctly written and signed by the
physician within:
A. 24 hours
B. 36 hours
C. 48 hours
D. 12 hours
44. The following are SOAP (Subjective – Objective – Analysis – Plan) statements on a
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:
Situation 10 – Marie is 5½ years old and described by the mother as bedwetting at night.
46. Which of the following is the MOST common physiological cause of night bed wetting?
47. All of the following, EXCEPT one compromise the concepts of behavior therapy program.
48. To help Marie who bed wets at night practice acceptable and appropriate behavior, it is
important for the parents to be consistent with the following approaches EXCEPT:
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 prize.
B. Tokens make her materialistic at an early age. Give praise and hugs occasionally.
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 become
angry and hostile.
51. To maintain a therapeutic eye contact and body posture while interacting with angry
and aggressive individual, the nurse should:
52. During the pre-interaction phase of the N-P relationship, the nurse recognizes this
normal INITIAL reaction to an assaultive or potentially assaultive person.
53. Which of the following is an accurate way of reporting and recording an incident?
A. “When asked about his relationship with his father, client became anxious.”
B. “When asked about his relationship with his father, client clenched his
jaw/teeth, made a fist and turned away from the nurse.”
C. “When asked about his relationship with his father, client was resistant to
respond”
D. “When asked about his relationship with his father, his anger was suppressed”
55. A patient grabs and about to throw it. The nurse best responds saying.
56. In planning care for a patient with Parkinson’s disease, which of these nursing diagnoses
should have priority?
A. Number of accomplishments
B. Ability to avoid interpersonal conflict
C. Physical health throughout life
D. 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. Loneliness
B. Suspicion
C. Grief
D. Confusion
59. An elderly confused client gets out of bed at night to go to the bathroom and tries to go
to another bed when she returns. The MOST appropriate action the nurse would take is
to:
60. An elderly who has lots of regrets, unhappy and miserable is experiencing:
A. Crisis
B. Despair
C. Loss
D. Ambivalence
Situation 13 – Graciela 1½ year old is admitted to the hospital from the emergency room
with a fracture of the left femur due to a fall down a flight of stairs. Graciela
is placed on Bryant’s traction.
61. While on Bryant’s traction, which of these observations of Graciela and her traction
apparatus would indicate a decrease in the effectiveness of her traction?
62. The nurse notes that the fall might also cause a possible head injury. She will be
observed for signs of increased intracranial pressure which include:
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?
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 understood an
important aspect of cast care?
65. The nurse counsels Graciela’s mother ways to safeguard safety while providing
opportunities for Graciela to develop a sense of:
A. Trust
B. Initiative
C. Industry
D. Autonomy
Situation 14 – Jolina is an 18 year old beginning college student. Her mother observed
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 chemistry, therefore
they would be useful in which type of depression?
A. exogenous depression
B. neurotic depression
C. endogenous depression
D. psychotic depression
A. Venlafaxine (Effexor)
B. Flouxetine (Prozac)
C. Sertraline (Zoloft)
D. Imipramine (Tofranil)
68. After one week of antidepressant medication, Jolina still manifests depression. The
nurse evaluates this as:
70. During the predischarge conference, the nurse suggests vocational guidance because it
should help Jolina to:
72. Which of the following questions illustrates the group role of encourager?
A. Insight
B. Productivity
C. Socialization
D. Intimacy
74. The treatment of the family as a unit is based on the belief that the family:
75. The working phase in a therapy group is usually characterized by which of the following?
A. Caution
B. Cohesiveness
C. Confusion
D. Competition
Situation 16 – The mental health – psychiatric nurse functions in a variety of setting with
different types of clients.
76. Poverty as reflected in prevalence of communicable diseases, malnutrition and social ills
such as street children, homeless and prostitution is a predisposing factor to mental
illness. A community approach to cope with this problem is for the nurse to support:
77. The MOST cost effective way to meet the mental health needs of the public is through
programs with a priority goal of:
A. treatment
B. prevention
C. rehabilitation
D. research
78. Lorelie upon discharge was referred to a volunteer group where she has learned to read
patterns, cut out fabric and use a sewing machine to make simple outfits that will help
her earn in the future. What type of therapy is this?
A. Recreational therapy
B. Art therapy
C. Vocational therapy
D. Educational therapy
79. In a residential treatment home for adolescent girls, the clients were becoming
increasingly tense and upset because of shortening of their recreation time. To de-
escalate possible anger and aggression among the clients it is BEST to play:
A. religious music
B. relaxation music
C. dance music
D. rock music
80. The parents of special children who are behaviorally disturbed need mental health
education. Which of these topics would the school nurse consider as priority for their
parent’s class?
A. Drug education
B. Child abuse
C. Effective parenting
D. Sex education
Situation 17 – Nurses in all practice areas are likely to come in contact with clients
suffering from acute or chronic drug abuse.
81. The psychodynamic therapy of substance abuse is based upon the premise that drug
abuse is:
82. Being in contact with reality and the environment is a function of the:
A. conscience
B. ego
C. id
D. super ego
84. During the detoxification stage, it is a priority for the nurse to:
A. Cannabis Sativa
B. Lysergic acid diethylamide
C. Methylenedioxy methamphetamine
D. Methamphetamine hydrochloride
86. Anticipation of personal questions is given adequate attention during which phase of the
nurse patient relationship?
A. Orientation phase
B. Working phase
C. Pre-interaction phase
D. 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 response is:
89. When the nurse is asked a personal question, which of these reactions indicates a need
for her to introspect?
90. It is 10 o’clock on your watch. The client asks, “What time is it?” The nurse’s
appropriate is:
Situation 19 – Ricky is a 12 year old boy with Down’s syndrome. He stands 5’ ½” 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. Physiological needs
B. Need for self esteem
C. Needs for safety and security
D. Needs for belonging
92. Ricky’s mother visited the school nurse. She asked, “What should I do when Ricky
fondles his genitalia?” An appropriate response of the nurse is for the mother to:
93. The nurse had one on one health education sessions with Ricky’s mother. The mother
understood that for her son to learn to cope and be independent, she should
constantly provide activities for Ricky to be able to:
A. socialize with people
B. eventually go to school alone
C. select and prepare his own food
D. do activities of daily living
94. All of the following activities are appropriate for Ricky EXCEPT:
95. Ricky’s IQ falls within the range of 50-55. he can be expected to:
Situation 20 – The abuse of dangerous drugs is a serious public health concern that 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:
97. A drug dependent utilizes this defense mechanism and enables him to forget shame and
pain.
A. repression
B. rationalization
C. projection
D. sublimation
98. This drug produces mirthfulness, fantasies, flight of ideas, loss of train of thought,
distortion of size, distance and time, and “bloodshot eyes” due to dilated pupils.
A. Opiates
B. LSD
C. Marijuana
D. 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. Unhelpful
B. Codependent
C. Caretaking
D. Supportive
***END***