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NURSING PRACTICE II

Situation 1: The knowledge of ethical and legal responsibilities in the practice


of professional nursing is important. The following questions apply.
1. As a nurse, you should know the scope of professional nursing
practice. Which of the following professionals is encroaching on
professional nursing practice
A. A physician who administers a parenteral medication
!. A medical technologist who administers dobutamine
before a cardiac stress test
". A teacher who conducts lecture on health and nutrition
#. A lawyer who acts as an ad$ocate for a client whose
rights are $iolated
%. &r. !rown, a '%(year(old American who is on short stay in the
)hilippines was brought to *+ unconscious. ,n admission, his
son presented a li$ing will. The nurse knows that which of the
following should be done
A. The lawyer or administrator of &r. !rown needs to be
called since the li$ing will is not the concern of health
care workers.
!. #isregard the li$ing will because &r. !rown is in an
emergency situation.
". -onor the li$ing will e$en if &r. !rown is an American
#. *nsure the $alidity of the li$ing will by referring the
issue to the American *mbassy.
.. /inda, an American +0, who completed an Associate #egree in
0ursing )rogram in the 1S, has decided to 2oin her 3ilipino
husband in the )hilippines. To practice her profession, /inda is
seeking licensure in the )hilippines. Which of the following will be
required of /inda
A. 0othing because /inda may be registered in the
)hilippines by mere endorsement
!. "omplete a !S 0ursing degree
". Take an oath of allegiance to the )hilippines
#. Acquire 3ilipino citi4enship first
5. A policy of the hospital where you work $iolates patient6s rights.
What would be your appropriate action
A. 7uestion policy through proper channels but respect
the patient6s right when faced with the situation calling
for it
!. 3ollow the hospital policy. There6s no )atient6s !ill of
+ights in the )hilippines
". "all the police and blotter the incident
#. +esign from the hospital because this is incompatible
with the professional standards set by the "ode of
*thics for 3ilipino 0urses
8. 9ou admitted 0ena, : years old, at the *+ with bruises,
hematoma and multiple fractures. When asked what happened,
0ena was silent and withdrawn. 9ou suspect child abuse. What
would be your best course of action if you want to protect the
rights of 0ena
A. "all the police, blotter the incident and refer the matter
to social ser$ices
!. )roceed to inter$ene medically and ne$er mind the
cause of the in2uries
". "all up the hospital6s legal counsel immediately
#. Apply for court guardianship
Situation %: 9ou are now in the entry phase of community organi4ing process
after establishing rapport with the people of !arangay /aging -anda.
;. With the community health acti$ities started during the entry
phase, which of these acti$ities should not be included
A. "ore group formation
!. "onduct of deepening social in$estigation
". )ro2ect management
#. <nformation campaign on health programs
'. <dentification of potential leaders is crucial during the entry phase.
Which of the characteristics may not be necessary to an efficient
and effecti$e community leader
A. &ust ha$e relati$ely good communication
!. A college graduate with management skills
". +esponsi$e and willing to work for change
#. A respected member of the community
:. The best techniques in identifying potential leaders in the
community pro$en to be effecti$e is to
A. Ask community residents to directly name persons
whom they consider as community leaders
!. Ask $olunteers who are willing to become community
leaders
". +e$iew family background, properties and academic
records of community residents
#. ,bser$e people who are acti$e in small mobili4ation
acti$ities that moti$ate residents to start working
=. The core group is composed of indi$iduals in the community who
possess the leadership potentials organi4ed into a cohesi$e
working unit. The core group works with the team in
A. Setting(up community organi4ation that will ser$e the
interest of a sector in the community
!. &obili4ing the community to act on their most
immediate felt needs and participate in the deli$ery of
essential health ser$ices
". &onitoring the performance of the barangay
#. Selecting community acti$ities according to their
preferences
1>. The nurse as a community health practitioner functions as a
community
A. *$aluator
!. )lanner
". /eader
#. 3acilitator
Situation .: "ommunity health nursing practice in the )hilippines is a
challenging area of nursing practice. As a result of the global financial crisis,
some authorities are led to think this arena may well be e?plored for
strengthening application in countries most affected.
11. 9ou are at the +-1 clinic when mother brought in her infant
@un2un for his ,)A immuni4ation. 9ou ha$e assesses that the
infant has diarrhea. What will be your ne?t action
A. 0otify the physician
!. Bi$e the ,)A
". +efer immediately
#. #o not gi$e the ,)A
1%. After assessing @un2un, your nursing diagnosis is dehydration
secondary to diarrhea. ,+S was administered. Which health
instruction regarding ,+S therapy will you gi$e the mother once
the diarrhea has stopped
A. <ncrease the administration of ,+S
!. +eturn to the clinic
". Stop the administration of ,+S
#. #ecrease the administration of ,+S
1.. Which of the following is not true about home care for all sick
infants
A. !lood in the stool is a danger sign that needs to be
reported
!. !ring the infant to the clinic if he shows signs of
difficulty of breathing
". !reastfeed frequently, day and night, during sickness
and health
#. &ake sure the young infant stays cool at all times
15. Aitamins help fight $arious deficiencies which affect the eye. As a
health care pro$ider, you are aware that one of the following is a
sign of $itamin A deficiency:
A. "orneal clouding
!. 3atigue
". Chalo signsD
#. ,paque lens
18. "ora4on brought her child to the clinic for palmar pallor
suggesti$e of anemia. The doctor prescribed iron medication and
it was only the .
rd
day of taking such medication. 9our ne?t action
would be to:
A. Bi$e iron medication .? a day
!. Bi$e iron and return tomorrow
". <nstruct the mother to continue gi$ing iron for 15 days
#. +efer the child immediately
Situation 5: <n the growth and de$elopment of any child you are fully aware
that your responsibility for caring encompasses physical and
psychologicalEemotional dimensions.
1;. A worried mother of a pre(school age child says to the nurse, C&y
5 year(old frequently touches his genitals.D Which of the following
statements would be appropriate for the nurse to make
A. C&asturbation is embarrassing to the parentsF scolding
the child will stop the beha$ior.D
!. CWhen this child masturbates, it can be unhealthy and
dangerous.D
". CWhen children are angry or upset, they often
masturbate.D
#. C&asturbation is normal beha$ior, so pro$iding another
acti$ity for the child would be appropriate.D
1'. A hospitali4ed child, *arl, 5 years old, being away from his home
and normal en$ironment goes through separation an?iety. Which
of the following beha$iors might indicates that *arl is in the denial
stage of separation an?iety -e
A. Searches for the caregi$er and waits for her to arri$e
!. <gnores caregi$ers when they $isit
". 7uietly lies in the crib when no one is in the room
#. "ries loudly e$en when being helped by the nurse
1:. After *arl6s discharge from the hospital, which of the following
beha$iors might indicate that he is afraid of another separation
-e
A. )lays with siblings for long periods of time
!. +equest to go $isit the nurses at the hospital
". Wakes up $ery early in the morning
#. "arries a fa$orite blanket around the house
1=. When caring for )rincess, a . G year old child, who is recei$ing
o?ygen in an o?ygen tent, which of the following toys or acti$ities
would be best to offer
A. Age(appropriate book
!. A fa$orite blanket belonging to the child
". A radio playing soothing music
#. !oard games the child can play with while alone
%>. Tonton, a = year(old and 5
th
grader, bed wets. The mother asks
your ad$ice how this can be corrected. 9our most appropriate
response is
1. C<t is normal for his age. #on6t scold him.D
%. C/imit his fluids before sleeping.D
.. CWake him up %(. hours from the time he sleeps.D
5. C-e might ha$e problems at home and school.D
A. 1 and %
!. . and 5
". % and .
#. 1 and 5
Situation 8: While working in the community, nurses obser$e $arious
situations that require attention.
%1. 0urse 0ikki was doing case finding in a barangay in the rural
communities of /agonoy, "amarines Sur. -er target is to identify
undocumented -ansen6s disease cases. Seeing her in
uniform, a woman remarks, C9ou6re not a nursing student, are
you < ha$e many chores today. )leaseHD and ignores the nurse.
0ikki6s immediate course of action would be to:
A. Aisit the ne?t house so as not to waste the day6s
acti$ity and return to re($isit this home after a day or
two
!. "ommunicate the incident to the barangay captain and
get himEher to 2oin her in her ne?t $isit
". <gnore the woman6s beha$ior, turn around and simply
lea$e her home
#. The feelings and beha$iors manifested by the woman
and get to the root causes of such beha$ior
%%. A student nurse $isits Aling &ercy who immediately stated that
she has Ctoo much work to do and she has been $isited and
inter$iewed by student nurses almost daily.D After e?plaining the
purpose of her $isit the student6s appropriate action would be to:
A. Set an appointment at Aling &ercy6s con$enient time
!. Select another family as a client
". Tell her clinical instructor about the problem
#. Ask the barangay chairman for assistance
%.. 0urse +ina intends to get ma?imum participation from the
community members to get an accurate assessment of their
health needs. To do this, nurse +ina collaborates with the
community to do a situational analysis. This process entails the
following e?cept
A. Allowing people to freely e?press what they consider
their health problem
!. Asking people why they think the health problems e?ist
". Assisting the community to identify health situations
that need change
#. )ro$iding immediate solution to identified health
problems
%5. The community health nurse noticed that there are many out(of(
school teenagers in the neighborhood who use drugs, smoke and
drink alcohol. Their parents are working o$erseas and these
teenagers li$e with their aging grandparents who ha$e difficulty
controlling them. !efore arri$ing at a social diagnosis, the nurse
should
1. #etermine if this situation results in breakdown of
families
%. *?plore to what e?tent the situation affects the
life in the neighborhood
.. #etermine what policies should be enacted to
promote lifestyle changes
5. Assess how the educational le$el of the
community affects its ability to cope with the
problem
A. 1 and .
!. 1 and %
". % and 5
#. . and 5
%8. <nspired by the singing 2ail inmates, the nurse suggests to the
barangay chairman that the out(of(school teenagers may be
encouraged to stay Cout of troubleD by organi4ing acti$ities that will
occupy their time, use up their energy and unify them. To reali4e
such goalsEob2ecti$es, the nurse6s and community6s actions
should proceed in which order
1. <dentify what manpower and money resources are needed
to implement the program
%. #esign the program that will meet goalsEob2ecti$es
.. <dentify support acti$ities that will sustain the programs
5. #etermine the program6s impact on the target group
A. 1, %, ., 5
!. ., %, 1, 5
". %, 1, ., 5
#. 5, ., %, 1
Situation ;: "ommunity empowerment is an important aspect of a community
health nurse.
%;. To empower community members, the community nurse performs
which acti$ity
A. #o all the acti$ities for community members
B. Step back at the beginning and gi$ing little input
C. #efine the community needs for the members
D. Bi$e ownership and leadership to the community
%'. #escriptors of a community include:
A. A community where the members are disease(free
!. Seeking to make all the resources a$ailable to all
members
". Ieeping the subgroups informed of changes whene$er
necessary
#. The leaders making decision for the community
members
%:. When a community health nurse works as a client ad$ocate, the
nurse
A. 1ses a passi$e approach in sol$ing identified problem
!. Attempts to smooth problems o$er to keep the
community calm
". <s asserti$e in speaking and acting on behalf of the
client
#. <s aggressi$e in pursuing the achie$ement of the
client6s goals
%=. The community health nurse leads a class on breastfeeding with
a group of prenatal parents. The nurse allows the participants to
ask questions, make comments, and reason out loud as feedback
is gi$en. Which of the following techniques is the nurse using
A. /ecture
!. #emonstration
". +ole playing
#. #iscussion
.>. When beginning a relationship with a family on home $isit, the
community health nurse
A. <s accepting and listens carefully to the problems of all
family members
!. Allows the discussion to be open and non(directional
". 3ocuses on the problem of one of the family members
#. *ncourages others to speak for the main client to get
an unbiased $iew
Situation ': &ichelle, %1, single college student, thinks she is pregnant. She
described herself as a Cparty animalD, smokes, drinks and uses mari2uana.
She said she has always been CcarefulD, she is not sure who the father is.
She missed three menstrual cycles and shows abdominal enlargement. She
is $ery concerned about her predicament and her situation has e?acerbated
her drinking of alcohol.
.1. &ichelle started drinking alcohol in high school and is used to
Chard drinksD. 9ou inform her that drinking while pregnant e?poses
the fetus to the possibility of ha$ing fetal alcohol syndrome J3ASK
with these characteristics e?cept:
A. /owered birth weight
!. "ogniti$e impairments
". 3acial anomalies
#. #ecreased muscle tone
.%. Additional information gi$en to &ichelle about alcohol intake
during pregnancy includes
A. 0o safe le$el of drinking has been set during
pregnancy therefore abstinence is ad$ised
!. Alcohol intake is linked to increased risk of
spontaneous abortion
". A woman can safely drink a glass of wine if she has
heart problems to aid in circulation
#. Alcohol has no known teratogenic effects on the fetus
at low or high intake le$els
... &ichelle tells you, C< don6t want this pregnancy. < am not ready to
raise a child alone. < want an abortion.D Which of the following is
your most appropriate response to &ichelle
A. CWhy don6t you get married so you can ha$e support
during pregnancyD
!. C9ou ha$e to ha$e a lot of faith, pray for guidance so
you can make a wise choice.D
". C9ou are not ready to face the consequences of this
pregnancyD
#. CAll you ha$e to do is stop drinking, is that difficult for
youD
.5. &ichelle continues to smoke 1(% sticks of mari2uana when with
friends. 9ou ad$ice her to refrain from smoking mari2uana
because it
A. <ncrease risk for cerebral abnormalities of the fetus
!. <ncrease risk of sudden infant death syndrome
". -as strong e$idence of teratogenic effects on the fetus
#. <mpairs her coordination and critical thinking that puts
her at risk
.8. When taking care of &ichelle who smokes, your inter$ention
should focus on: risk for fetal in2ury resulting from maternal
smoking. 9ou inform &ichelle about the ha4ards of smoking which
include:
1. -igh incidence of premature birth
%. <ncreased incidence of sudden infant death syndrome
..
5. /ow birth weight
A. 1, % and 5
!. 1, %, . and 5
". 1, . and 5
#. %, . and 5
Situation :: -ealth education among pregnant women is important
.;. An understanding of physiologic adaptations to pregnancy is
important. The following changes in pregnancy are important to
keep in mind in order to address client6s needs e?cept
A. "ardiac output increased by %8L to 8>L during
pregnancy
!. The temperature decrease slightly early in pregnancy
". The anterior pituitary gland secretes o?ytocin late in
pregnancy
#. The circulating fibrinogen le$el decreased as much as
8>L during pregnancy
.'. Which statement by a client indicates that the teaching about
nausea and $omiting of pregnancy needs to be done by the
nurse
A. C< need to drink an e?tra glass of water with e$ery
mealD
!. C< will ask my husband not to wear aftersha$e because
it upsets my stomachD
". C< will try to eat 8 or ; smaller meals during the dayD
#. C< hope that taking a nap when < got home from work
makes me feel betterD
.:. Amanda is now 1; weeks pregnant. <f the pregnancy is
progressing as e?pected, where would the practitioner find the
uterine fundus
A. -alfway between the pubic bone and the umbilicus
!. The uterine fundus would not be palpable at 1; weeks
". At the umbilicus
#. @ust abo$e the pubic bone
.=. 9ou are teaching Amanda about proper diet during pregnancy. <f
Amanda understands your instructions, how will she reply when
you ask her appro?imately how many more calories per day she
needs now that she is pregnant
A. CAppro?imately 8>> caloriesD
!. C< should not increase my calories while <6m pregnantD
". CAbout .>> caloriesD
#. C< need to double my calories because <6m eating for
twoD
5>. A 1'(year(old primigra$ida client at appro?imately 18 weeks
gestation is to undergo alpha(fetoprotein JA3)K screening. When
de$eloping the teaching plan for this client, the nurse should
include which of the followingM
A.
!. +esults are usually $ery accurate until %> weeks
gestation
". <ncreased le$els of A3) are associated with neural
tube defects
#. 1ltrasonography usually accompanies A3) testing
Situation =: 3amilyE-ome -ealth 0ursing has currently become a significant
area of nursing. "ommunity health nurse Anna is taking care of different
clients in her caseload.
51. Anna has been caring for a child in the home. She has a
tracheostomy tube and is o?ygen N dependent. Anna prefers to do
the care early in the morning due to a hea$y caseload. The family
requests that care be done when the child is awake by 1> am.
The best response by Anna would be
A. C< will see if < can find another nurse who can meet
your preferred schedule.D
!. C<6ll gi$e care at 1> am, other children needing my care
may not be attended to.D
". C<6m sorry < wish < could, but < cannot do so due to
hea$y workload.D
#. C/et6s look at what time is in the child6s best interest
and then we can work out a better schedule.D
5%. Anna best e?emplifies primary pre$ention by which of the
following acti$ities
A. Teaching new mothers infant care
!. <nfant phototherapy
". ,?ygen humidification
#. Tracheostomy care
5.. Which of Anna6s teaching acti$ities would be considered primary
pre$ention when caring for clients in her case load
A. )ro$iding families with her telephone number for any
home emergencies
!. *ducating parents on the importance of routine
immuni4ation
". Teaching first aid for insect bites
#. *ducating parents on the signs of lead poisoning
55. Anna finds that a toddler has some de$elopmental delays during
a home $isit. When looking for a cause of contributing factor,
which of the following en$ironmental factors would she consider
most important to assess
A. #ust mites in child6s toys
!. /ead paint in the crib
". -ouse pets
#. )resence of asbestos in the home
58. Anna6s functions include acti$ities for secondary pre$ention. <n a
family, the health profile re$eals diabetes in the father of the
family. A classic demonstration of secondary pre$ention would be
A. Teaching the diabetic client about foot care
!. Assisting the diabetic client in his daily insulin
in2ections
". -elping the client obtain a glucometer for accurate
monitoring of blood sugar
#. <nforming the client how to maintain -b A1c $alue at
8.8 or less
Situation 1>: )romotion of safe motherhood in $aried clinical settings is
consistent with safety and quality concerns of e$ery nurse in the care of
women during normal pregnancy.
5;. 0urse @ulie is taking care of a pregnant client whose last day of
menstrual period was @une %%, %>1>. 1sing the 0agele6s rule, the
estimated date of birth would be
A. &arch 18, %>11
!. April %=, %>11
". &arch %=, %>11
#. April 15, %>11
5'. 0urse @ulie attends to another pregnant client who has % children.
-er history re$eals that her first pregnancy ended in stillbirth at .%
weeks of gestation, her second pregnancy with the birth of her
daughter at .8 weeks, and her third pregnancy with the birth of
her son at 51 weeks. 1sing the B) T)A/& format, 0urse @ulie
would record the woman6s current obstetrical history as
A. B.). JT1 )1 A1 /. &>K
!. B5). JT1 )% /% &>K
". B5)5 JT% )1 A> /1 &>K
#. B.). JT1 )% A> /1 &>K
5:. A %>(year(old client $isits @ulie at her 0ursing )renatal "linic
because she suspects that she is pregnant. She tells the nurse
that she missed one menstrual period and that she e?perienced
nausea and $omiting, urinary frequency and fatigue. !ased on her
assessment, 0urse @ulie suspects that her client has signs of
pregnancy categori4ed as which of the following
A. )resumpti$e
!. )redicti$e
". )robable
#. )ositi$e
5=. While doing /eopold6s maneu$er on a client, 0urse @ulie notes
the presence of a firm round prominence o$er the symphysis
pubis, a smooth con$e? structure down her right side, an irregular
lump down on her left side, and soft roundness in the fundus. The
nurse should conclude that the fetal position is
A. /,A Jleft occiput anteriorK
!. /,) Jleft occiput posteriorK
". +SA Jright shoulder anteriorK
#. +,) Jright occiput posteriorK
8>. When performing /eopold6s maneu$er to a primigra$ida client, the
nurse is aware that to make her more comfortable during the
procedureF she should prepare the client by asking her to
A. *mpty her bladder prior to the procedure
!. /ie on her left side drug during the procedure
". A$oid eating immediately before the procedure
#. -yper$entilate for a short time before beginning the
procedure
81. A .(year(old child weighing, 15 kgs. has anemia with some pallor
and needs iron and mebenda4ole pre$iously. As the nurse you
should gi$e the child iron folate and mebenda4ole in what
dosage
A. '.8 ml or 1 tsp daily for 15 days and mebenda4ole 8>>
mg single dose
!. 1> cc or % tsp daily for .> days and mebenda4ole 8>>
mg single dose
". 1> cc or % tsp daily for .> days and mebenda4ole %8>
mg single dose
#. 8 ml or 1 tsp daily for 15 days and mebenda4ole 8>>
mg single dose
8%. Aitamin A is gi$en to the child with measles because it
A. +esists the $iral infection in the eyes, cell layers in the
lungs, gastrointestinal tract, mouth and throat
!. +einforces the body6s immune system
". <s needed for supplementation
#. -elps the immune system pre$ent other infections
8.. <n gi$ing chloroquine you should
A. -ea$ily guard the client
!. *?plain to the mother that she should watch her child
carefully for .> minutes after gi$ing the medicine
". *?plain to the mother that it should be gi$en for % days
only
#. <nstruct the mother to gi$e the first dose at home
85. The child6s symptoms are under the classification of se$ere
dengue hemorrhagic fe$er of the <&"< strategy. Which of the
following treatments should be done immediately
A. ,bser$e the client at the health center and refer
urgently if the condition worsens
!. Bi$e fluids or ,+S and refer urgently to the hospital
". <mmuni4e the child before referral
#. Bi$e the first dose of the appropriate antibiotics and
refer urgently to the hospital
88. A child needs urgent referral for mastoiditis. The following is a list
of treatments for all ear problems in <&"< classification. Which
among these pre(referral treatments should not be included
A. Bi$e the child appropriate antibiotics for 8 days
!. #o not gi$e any medications
". Bi$e the child first dose of antibiotics
#. Bi$e the first dose of paracetamol for pain
Situation 1%: Among the nurse6s responsibility after deli$ery is the pro$ision
of safe physical, emotional, and psychological support for the mother6s well(
being.
8;. What nursing inter$ention would be most helpful in pro$iding
emotional support to /ydia and her family after a cesarian
deli$ery
A. +ecommending frequent rest periods for the new
mother
!. *ncouraging the father to obser$e the infant6s first bath
". )ro$iding opportunities to discuss reaction to the birth
e?perience
#. )ositioning the infant with pillows during feeding
8'. The nurse assesses /ydia after deli$ery. What data suggests that
/ydia is at increased risk for hemorrhage
A. -istory of gestational diabetes
!. <nfant birth weight of ' lbs 11 o4 J.5': gK
". : hours length of labor
#. Bra$ida ' )ara 8
8:. Another postpartum woman had post(partum bleeding. Which
areas would the nurse need to assess before the client
ambulates
A. Attachment, lochia color, complete blood cell count
!. -eight, le$el of orientation, support system
". #egree of responsi$eness, respiratory rate, fundus
location
#. !lood pressure, pulse, complaints of di44iness
8=. When assessing another client who ga$e birth 5 hours ago, the
nurse finds the uterus to be firm, % fingerbreadths abo$e the
umbilicus, and displaced to the right. /ochia rubra is moderate.
What would be the first nursing action
A. Bently massage the fundus
!. <nsert a foley catheter
". *ncourage the woman to urinate
#. +ecord these as normal findings
;>. When assessing a client 15 hours postpartum, the following data
are collected: T N .:.1O", pulse 1>5, respirations 1=, blood
pressure 11:E'%. What would be the best nursing action
A. &assage the uterus and e?press clots
!. Assess for uterine tenderness and odor of lochia
". *ncourage the client to increase her fluid intake
#. +eport these findings to the health care pro$ider
Situation 1.: <n the care of pregnant women, the nurse is always mindful of
her quality and safety responsibilities for both mother and her unborn child.
;1. A client who is 1> weeks pregnant calls the clinic complaining of
morning sickness. <n order to promote relief, the nurse6s best
suggestion is for the client to
A. <ncrease her fat intake before bedtime
!. #rink more high(calorie fluids with her meals
". *at dry crackers before arising
#. -a$e % small meals daily and snack at noon
;%. Another client who is on her 1
st
trimester of pregnancy complains
of heartburn. The most appropriate inter$ention to reli$e this
condition is to
A. *at small frequent meals
!. /ie down after eating
". ,mit fluid while eating
#. *?ercise before eating
;.. As pregnancy progresses and the date of deli$ery draws near, the
nurse constantly monitors the child6s position in the womb of her
mother. The nurse is aware that the most fa$orable fetal position
for birth is
A. )osterior position of the fetal head
!. Trans$erse lie
". Aerte? position
#. 3rank breech presentation
;5. A client who is .8 weeks pregnant arri$es at the labor and
deli$ery unit with leaking clear $aginal fluid. Which of the following
inter$entions is the most appropriate for the nurse to take
A. ,btain a catheteri4ed urine specimen
!. *ncourage the client to ambulate
". )erform $aginal e?amination
#. ,btain a sterile sample of the fluid
;8. The nurse recei$es a client, 5% weeks gestation, . cm dilated with
..L effacement, membranes intact, and the fetus is at P% station.
The fetal heart rate is 15> N 18> beats per minute. Two hours
later, the nurse recogni4es that for the past 1> minutes, the 3-+
ranged from 1;> N 1=> bpm, uterine contractions ha$e been
strong occurring between . N 5 mintues and lasting 5> N ;>
seconds. The client uttered, C&y baby has been e?tremely acti$e.D
The nurse should be concerned about which symptom that is
indicati$e of fetal hypo?ia
A. Abnormally long uterine contractions
!. *?cessi$e fetal acti$ity and fetal tachycardia
". *?cessi$e frequent contractions with rapid fetal
mo$ement
#. Abnormally strong uterine intensity
Situation 15: &anagement of resources and en$ironment includes e$ery
potential and e?isting resources which the nurse can utili4e to promote and
maintain health, pre$ent illness, and assist in the task of cure and
rehabilitation. The <&"< chart prescribed by the World -ealth ,rgani4ation is
one such resource.
;;. The <&"< chart pro$ides the necessary procedure when
identifying the appropriate inter$entions to be done. -owe$er, the
community health nurse should be aware that the following factor
should be considered in utili4ing the case management chart:
A. Age of the child
!. #anger signs
". "hief complaint
#. )roblem of the child
;'. <n the <&"< classification tables, the color yellow indicates that a
A. "hild needs an appropriate antibiotic or other
treatment
!. "hild does not need specific medical treatment
". +eferral or admission is needed
#. "hief complaint needs an urgent attention
;:. 1pon assessment, the nurse notes that a child has fe$er. <n the
presence of mosquito bites, the nurse would suspect the following
illnesses e?cept
A. &easles
!. &alaria
". -emorrhagic fe$er
#. #-3
;=. All of the following illnesses are caused by a $irus e?cept
A. &easles
!. &alaria
". -(fe$er
#. )arotitis
'>. Which of the following laboratory tests would classify the
presence of fe$er as positi$e for malaria
A. Tourniquet
!. ,ccult blood
". "!"
#. !lood smear
Situation 18: Iarina, 8 months old, weighs 8.% kilograms as a temperature of
.:O". She is brought to the health center. -er mother says she is not eating
well, feels hot to touch, able to drink, not $omiting, no con$ulsions and not
lethargic, and not coughing. They li$e in a malaria(risk area. -er fe$er
started % days ago. She has no signs of measles, no stiff neck or runny nose.
'1. -ow will you classify Iarina6s illness
A. )ain fe$er
!. Se$ere febrile disease
". &alaria
#. 3e$er, no malaria
'%. The following treatments are appropriate for Iarina e?cept
A. 3ollow(up in % days
!. Bi$e oral anti(malaria drugs
". Ad$ise when to return immediately
#. Bi$e 1 dose of paracetamol for temperature of .'.8O"
'.. A child should be checked for capillary refill if
A. The child has petechiae
!. The child6s e?tremities feel warm
". There is fe$er for more than ' days
#. The e?tremity feels cold
'5. <f the capillary refill takes more than . seconds, it may mean that
the child is in
A. Se$ere febrile disease
!. "irculatory failure
". Shock
#. #ehydrated state
'8. A child li$ing in a non(malaria risk area who has stiff neck may be
classified as ha$ing
A. &alaria
!. Se$ere febrile disease
". +E, &alaria
#. 3e$er, no malaria
Situation 1;: "ommunity health nurses take care of clients with $arying
health conditions.
';. A population group that should be gi$en attention by the
community health nurse is obese women who become pregnant.
,besity is responsible for what complications during pregnancy
A. )rematurity
!. Anemia
". Bestational diabetes
#. Spontaneous abortion
''. A community health nurse $isits a child with e?acerbation of
asthma. The nurse would most likely assess for which one of the
following in determining what e?acerbates the child6s asthma
A. The educational le$el of the child6s caregi$er
!. The child6s height and weight
". The amount of e?clusion the child is e?periencing
#. Air pollution and second(hand cigarette smoke
':. Which of the following best describes an ad$anced practice
nurse
A. An +0 who assists the physician during a cesarian
section deli$ery
!. An +0 who works in the high(risk newborn nursery
". A master6s prepared +0 who is a manager of a large
labor and deli$ery unit
#. A certified +0 who pro$ides primary care to low(risk
clients in a community health center
'=. The four ma2or change agents that impact the future of community
health care for children and families are demographics, science
and
A. The amount of influence the public has on legislator
and the political party in power
!. The stock market and recession periods
". -ospital administrati$e policies and health care
reimbursement
#. &arket(dri$en economic policy and technology
:>. A home health nurse is made aware that a client and family are
about to lose their home due to foreclosure. The nurse contacts
the social ser$ice department of the home health care agency for
assistance in finding housing for the family. The actions taken by
the nurse best e?emplifies which of the following roles of the
community health care nurse
A. "linician
!. "onsultant
". Ad$ocate
#. +esearcher
Situation 1': "arol is 18 months old, weighs :.8 kgs, is not eating well and is
unable to breastfeed. She is not $omiting, has no con$ulsion and not
abnormally sleepy or difficult to awaken. -er temperature is .:.8O". 1se the
<&"< strategy for this situation.
:1. <f you were the nurse in charge of "arol, how will you classify her
illness
A. A child with a general danger sign
!. Aery se$ere febrile disease
". Se$ere pneumonia
#. Se$ere malnutrition
:%. Which of the following is considered as a general danger sign in
the case of "arol
A. 0o $omiting
!. -as no con$ulsion
". Temperature of .:.8O"
#. 1nable to breastfeed
:.. Which of the following is not considered as a general danger
sign
A. Aomits e$erything
!. 1nable to drink or breastfeed
". -as had con$ulsion
#. 3ast breathing
:5. Which of the following steps is not included in the <&"< strategy
A. <dentify treatment
!. "ounsel and follow(up
". +eferral
#. Assess and classify
:8. Which of the following should not be included in deciding that Cthe
child $omits e$erythingD
A. "hild e?periences occasional $omiting
!. When offered fluids, may not be able to drink
". &aybe too weak to drink and eat at all
#. "hild is not able to keep anything down at all
Situation 1:: The nurse is taking care of clients who are in their %
nd
and .
rd

trimester of pregnancy.
:;. Amor, .8 years old and .; weeks pregnant, B1 )>, goes to the
hospital reporting a feeling of Cwanting to pushD, lower back pains,
abdominal cramps, and passage of mucous with some blood.
With the presenting symptoms of the client, the nurse suspects
that the client is ha$ing
A. Abruption placenta
!. )reterm labor
". Spontaneous abortion
#. Threatened abortion
:'. Amor6s bag of waters ruptures spontaneously and she deli$ers
the baby within the hour after the premature rupture of
membranes J)+,&K. The nurse should watch out for the most
immediate danger to the fetus:
1. <nfection during the intra and postpartum periods
%. <nfant respiratory distress syndrome
.. 1mbilical cord compression
5. 3etal abnormality
A. 1 and 5
!. % and .
". % and 5
#. 1 and .
::. &anagement of clients with premature rupture of membranes
during the early stages of pregnancy without laborEdeli$ery
includes the use of maternal antibiotics. After the premature
rupture of membranes, the nurse should closely obser$e the
client. The immediate nursing action would be to
A. Teach the client breast stimulation
!. +eport presence of uterine contractions
". Take the client6s $ital signs and 3-+ e$ery 5 hours and
report significant changes
#. +eport foul or strong odor with yellowish color of
$aginal discharge
:=. /ower back pain in pregnant women is caused by the body6s
attempt to balance as the uterus enlarges. To help reduce the
lower back pain of a client who is in her ;
th
month of pregnancy,
the nurse ad$ises her to
A. Walk long distance until she feels out of breathe
!. *le$ate her feet
". #o pel$ic rocking
#. #o Iegel6s e?ercise
=>. Allison is ' months pregnant, B%)1, 5% years old and is e?pecting
twin girl. She has shown symptoms of mild pregnancy(induced
hypertension with a blood pressure of 15>E=> mm-g and protein
in her urine tests. An appropriate nursing action would be to gi$e
Allison important health information while she is managed at
home. The nurse tells Allison to
A. -a$e frequent bed rest on left side(lying position to
facilitate placental and renal blood flow
!. )erform mild .> minute e?ercise daily
". *liminate sodium from the diet
#. +egularly monitor her pulse rate
Situation 1=: Total 7uality &anagement JT7&K and "ontinuous 7uality
<mpro$ement J"7<K are considered sound tools in the management of
organi4ations, groups, agencies in $arious care settings where professional
nurses are in$ol$ed.
=1. A nurse manager understands that the de$elopment of T7& and
"7< are meant to
A. Ser$e as a system of e?ternal measures and balance
!. )rotect patients and families during a health care crisis
". Assure society that cost containment would not
compromise safety
#. +esult in e?tensi$e statistical bases needed to pro$ide
patient care
=%. Which of these does not belong as a general principle of total
quality management
A. <mpro$ing the quality of ser$ice is a continuous
process
!. 3ocusing on the work process de$elops impro$ement
opportunities
". 7uality is achie$ed by the participation of e$eryone
#. #ecisions to impro$e or change a process are based
on the ma2ority rule
=.. Which of the following are e?amples of structure standards that
are critical to the success of different public health programs
1. "old chain in *?panded )rogram on
<mmuni4ation J*)<K
%. *ssential #rugs in &aternal "are -ealth J&"-K
.. 0ursing care of patients with Acute +espiratory
<nfections
5. T! "ontrol )rogram &anagement
A. 1 and %
!. All e?cept .
". . and 5
#. All of the abo$e
=5. ,ne of the ma2or challenges in nursing management is the
pro$ision of an en$ironment that is conduci$e to legal and ethical
practice. Which of the following is not considered part of ethical
nursing practice
A. )ro$iding care to clients regardless of social class and
political beliefs
!. &aintaining confidentiality of information
". !eha$ing in a manner that is consistent with $alues,
professional code of ethics and norms of community
#. Working in accordance with the nursing law and other
related laws affecting nursing practice
=8. To ensure the pro$ision of safe and quality nursing care, clinical
practice guidelines ha$e been de$eloped. Which of the following
is not an e?ample of clinical practice guidelines
A. )rotocol
!. "linical pathways
". +esearch e?pectations
#. Algorithms
Situation %>: 9ou are conducting a mother6s class at the barangay health
station and the participants are in $arying periods of pregnancy. After the
class session, the mothers started asking more information from you.
=;. +hoda asks you why she could not feel fetal mo$ements all the
time. 9our most appropriate response is that fetal mo$ements
A. #ecrease as the mother nears her term
!. <ncrease if the mother drinks alcohol
". #ecreases as the mother6s acti$ity decreases
#. Are usually not present during the fetal sleep cycle
='. At .; weeks gestation, 0ina tells the nurse that she has been
e?periencing shortness of breath. Which of the following
suggestions would be most helpful
A. *mpty bladder regularly
!. Sleep with e?tra pillows
". Warm shower before sleeping
#. A$oid gas forming foods
=:. "ynthia, %5 weeks pregnant, tells the nurse that she is bothered
by pruritus. Which of the following would you suggest
A. #o deep breathing e?ercises
!. Apply anti(pruritus ointment
". #rink si? glasses of water a day
#. +egular tepid bath then apply lotion
==. &yra states that she is uncomfortable with her e?perience of
flatulence, bloating, and belching now that she is %: weeks of
gestation. What would be your most appropriate suggestion
A. #ecrease intake of fluids
!. *at small and frequent meals
". "hew food slowly
#. &aintain regular bowel habits
1>>. 0orie complains of leg cramps especially after reclining. She is
now on her .;
th
week of gestation. Which of the following
instructions will help the client when she has leg cramps
A. Stand and lean forward dorsifle?ing foot of affected leg
!. -a$e another person antefle? the foot of the affected
leg and e?tend the knee
". Stand and fle? the affected leg
#. Sit and hypere?tend the affected leg