NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice
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.
1. The indication for epinephrine injection for Mrs. Simon is to:
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
3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to:
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:
A. Syringe 3-5 ml and needle gauge 21 to 23
B. Tuberculin syringe 1 ml with needle gauge 26 or 27
C. Syringe 2 ml and needle gauge 22
D. Syringe 1-3 ml and needle gauge 25 to 27
5. The rationale for giving medications through the subcutaneous route is:
A. There are many alternative sites for subcutaneous injection
B. Absorption time of the medicine is slower
C. There are less pain receptors in this area
D. The medication can be injected while the client is in any position
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
A. include new modalities of care
B. resolve a clinical problem
C. clarify an ambiguous modality of care
D. enhance client care
9. Martha does review of related literature for the purpose of
A. determine statistical treatment of data research
B. gathering data about what is already known or unknown about the problem
C. to identify if problem can be replicated
D. answering the research question
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
Situation 3 – Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario’s nursing care plan is to loosen and remove excessive secretions in the airway.
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:
A. Color, amount and consistency of sputum
B. Character of breath sounds and respiratory rate before and after procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
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?
A. Respiratory rate of 16 to 20 per minute
B. Client can tolerate sitting and lying positions
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
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:
A. Interview the client for chief complaints and other symptoms
B. Talk to the relatives to gather data about history of illness
C. Do auscultation to check for chest congestion
D. Do a physical examination while asking the client relevant questions
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?
A. Moisturize lower extremities to prevent skin irritation
B. Measure fluid intake and output to decrease edema
C. Elevate lower extremities for postural drainage
D. Provide the client a list of food low in sodium
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT:
A. Making a final physical assessment before client leaves the hospital
B. Giving instructions about his medication regimen
C. Walking the client to the hospital exit to ensure his safety
D. Proper recording of pertinent data
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:
A. Giving her activities to divert her attention
B. Giving detailed explanations about the treatments she will undergo
C. Preparing her and her family in case surgery is not successful
D. Giving her clear but brief information at the level of her understanding
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:
A. This is a necessary part of the nurse – client relationship process
B. The nurse is a role model for the client and should be strong
C. How the nurse thinks and feels affect her actions towards her client and her work
D. The nurse has to be therapeutic at all times and should not be affected
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?
A. inhibition of the parasympathetic reflex
B. weakness of sphincter muscles of anus
C. loss of tone of the smooth muscles of the colon
D. decreased ability to absorb fluids in the lower intestines
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:
A. tell client to drink less fluids to avoid accidents
B. instruct client to start wearing thin adult diapers
C. ask the client to bring change of underwear “just in case”
D. teach client pelvic exercise to strengthen perineal muscles
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:
A. Using thick diapers to absorb urine well
B. Drying the skin with baby powder to prevent or mask the smell of ammonia
C. Thorough washing, rising and drying of skin area that get wet with urine
D. Making sure that linen are smooth and dry at all times
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:
A. Carol with tumor in the brain
B. Theresa with anemia
C. Sonnyboy with a fracture in the femur
D. Brigitte with diarrhea
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:
A. tip of the nose to the base of the neck
B. the distance from the tip of the nose to the middle of the neck
C. the distance from the tip of the nose to the tip of the ear lobe
D. eight to ten inches
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
A. regular physical activity
B. thorough knowledge of foot care
C. prevention nutrition
D. proper nutrition
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:
A. Assess damage to property
B. Assist in the police investigation since she is a witness
C. Report the incident immediately to the local police authorities
D. Assess the extent of injuries incurred by the victims of the accident
42. Priority attention should be given to which of these clients?
A. Linda who shows severe anxiety due to trauma of the accident
B. Ryan who has chest injury, is pale and with difficulty breathing
C. Noel who has lacerations on the arms with mild bleeding
D. Andy whose left ankle swelled and has some abrasions
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:
A. Apply antiseptic to prevent infection
B. Clean the wound vigorously of contaminants
C. Control and reduce bleeding of the wound
D. Bandage the wound and elevate the arm
44. The nurse applies dressing on the bleeding site. This intervention is done to:
A. Reduce the need to change dressing frequently
B. Allow the pus to surface faster
C. Protect the wound from microorganisms in the air
D. Promote hemostasis
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:
A. Encouraging the client to go to the outpatient clinic for follow up care
B. Accurate recording of treatment done and instructions given to client
C. Instructing the client to see you after discharge for further assistance
D. Providing instructions regarding wound care
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.
46. The purpose of your initial nursing interview is to:
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 problems
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 a few 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
answer key np1
note: guys pacensya na dont have time yet to post the rationales, super haba most of them, maybe later this month or maybe i'll post ung mga sources na lang na books so you can read them on your own.(^^,)
answers na lang muna for now po..
-diannemaydee
NURSING PRACTICE I – Foundation of PROFESSIONAL Nursing Practice
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.
1. The indication for epinephrine injection for Mrs. Simon is to:
Relieve respiratory distress due to bronchial spasm
2. When preparing the epinephrine injection from an ampule, the nurse initially:
Checks expiration date of the medication ampule
3. Mrs. Simon is obese. When administering a subcutaneous injection to an obese patient, it is best for the nurse to:
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:
Syringe 1-3 ml and needle gauge 25 to 27
5. The rationale for giving medications through the subcutaneous route is:
Absorption time of the medicine is slower
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:
Qualitative research
7. The type of research design that does not manipulate independent variable is:
Non-experimental design
8. This research topic has the potential to contribute to nursing because it seeks to
enhance client care
9. Martha does review of related literature for the purpose of
A. athering data about what is already known or unknown about the problem
10. Client’s rights should be protected when doing research using human subjects. Martha identifies these rights as follows EXCEPT:
right to compensation
Situation 3 – Richard has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Mario’s nursing care plan is to loosen and remove excessive secretions in the airway.
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:
Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen
12. When documenting outcome of Richard’s treatment Mario should include the following in his recording EXCEPT:
Amount of fluid intake of client before and after the procedure
13. When assessing Richard for chest percussion or chest vibration and postural drainage, Mario would focus on the following EXCEPT:
Teaching the client’s relatives to perform the procedure
14. Mario prepares Richard for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?
Client can tolerate sitting and lying positions
15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:
Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretion loose on the exhalation cycle
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:
Do a physical examination while asking the client relevant questions
17. Upon establishing Mr. Regalado’s nursing needs, the next nursing approach would be to:
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:
Ask him what he means by this statement
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?
Elevate lower extremities for postural drainage
20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT:
Walking the client to the hospital exit to ensure his safety
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:
Giving her clear but brief information at the level of her understanding
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:
anger
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:
“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:
Advise the nurse to “be strong and learn to control her 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:
How the nurse thinks and feels affect her actions towards her client and her work
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?
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?
loss of tone of the smooth muscles of the colon
28. The nurse understands that one of these factors contributes to constipation:
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:
teach client pelvic exercise to strengthen perineal muscles
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:
Thorough washing, rising and drying of skin area that get wet with urine
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:
Theresa with anemia
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:
Hypoxemia
33. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:
the distance from the tip of the nose to the tip of the ear lobe
34. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by:
Applying no suction while inserting the catheter
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:
Orthopnea
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:
deflated fully then immediately start second reading for same client
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
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
prevention nutrition
39. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) diabetes. Which of the following is true?
Type II (NIDDM) is more common and is also preventable compared to Type I (IDDM) diabetes which is genetic in etiology
40. Lifestyle-related diseases in general share areas common risk factors. These are the following except:
genetics
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:
Assess the extent of injuries incurred by the victims of the accident
42. Priority attention should be given to which of these clients?
Ryan who has chest injury, is pale and with difficulty breathing
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:
Bandage the wound and elevate the arm
44. The nurse applies dressing on the bleeding site. This intervention is done to:
Promote hemostasis
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:
Instructing the client to see you after discharge for further assistance
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.
46. The purpose of your initial nursing interview is to:
Understand her lifestyle, health needs and possible problems to develop a plan of care
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 a few weeks now. You will record this as follows:
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:
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?
Malnutrition and its possible effects on growth and development problems in the unborn fetus
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:
Cancer
NURSING PRACTICE II – Community Health Nursing and Care of the Mother and Child
SITUATIONAL
Situation 1 – Nurse Minette is an Independent Nurse Practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTIAL MOTHER AND FAMILY focusing on HOME CARE.
1. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?
A. Within 4 days after discharge
B. Within 24 hours after discharge
C. Within 1 hour after discharge
D. Within 1 week of discharge
2. Leah is developing constipation from being on bed rest. What measures would you suggest she take to help prevent this?
A. Eat more frequent small meals instead of three large one daily
B. Walk for at least half an hour daily to stimulate peristalsis
C. Drink more milk, increased calcium intake prevents constipation
D. Drink eight full glasses of fluid such as water daily
3. If you were Minette, which of the following actions would alert you that a new mother is entering a postpartal taking-hold phase?
A. She urges the baby to stay awake so that she can breast-feed him or her
B. She tells you she was in a lot of pain all during labor
C. She says that she has not selected a name for the baby as yet
D. She sleeps as if exhausted from the effort of labor
4. At 6-week postpartum visit what should this postpartal mother’s fundic height be?
A. Inverted and palpable at the cervix
B. Six fingerbreadths below umbilicus
C. No longer palpable on her abdomen
D. One centimeter above the symphysis pubis
5. This postpartal mother wants to loose the weight she gained in pregnancy, so she is reluctant to increase her caloric intake for breast-feeding. By how much should a lactating mother increase her caloric intake during the first 6 months after birth?
A. 350 kcal/day
B. 500 kcal/day
C. 200 kcal/day
D. 1000 kcal/day
Situation 2 – As the CPE is applicable for all professional nurse, the professional growth and development of Nurses with specialties shall be addressed by a Specialty Certification Council. The following questions apply to these special groups of nurses.
6. Which of the following serves as the legal basis and statute authority for the Board of Nursing to promulgate measures to effect the creation of a Specialty Certification Council and promulgate professional development programs for this group of nurse-professionals?
A. R.A. 7610
B. P.D. 223
C. R.A. 9173
D. R.A. 7164
7. By force of law, therefore, the PRC-Board of Nursing released Resolution No. 14 Series of 1999 entitled: “Adoption of a Nursing Specialty Certification Program and Creation of Nursing Specialty Certification Council.” This rule-making power is called:
A. Quasi-Judicial Power
B. Regulatory Power
C. Quasi-Legislative Power
D. Executive/Promulgating Power
8. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty Certification Program and Council, which two (2) of the following serves as the strongest for its enforcement?
(a) Advances made in Science and Technology have provided the climate for specialization in almost all aspects of human endeavor; and
(b) As necessary consequence, there has emerged a new concept known as globalization which seeks to remove barriers in trade, industry and services imposed by the national laws of countries all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare our people in the services sector to meet the above challenge; and
(d) Current trends of specialization in nursing practice recognized by the International Council of Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of deepening and refining nursing practice and enhancing the quality of nursing care.
A. b & c are strong justifications
B. a & b are strong justifications
C. a & c are strong justifications
D. a & d are strong justifications
9. Which of the following IS NOT a correct statement as regards Specialty Certification?
A. The Board of Nursing intended to create the Nursing Specialty Certification Program as a means of perpetuating the creation of an elite force of Filipino Nurse Professionals.
B. The Board of Nursing shall oversee the administration of the NSCP through the various Nursing Specialty Boards which will eventually be created
C. The Board of Nursing at the time exercised their powers under R.A. 7164 in order to adopt the creation of the Nursing Specialty Certification Council and Program
D. The Board of Nursing consulted nursing leaders of national nursing associations and other concerned nursing groups which later decided to ask a special group of nurses of the program for nursing specialty Certification.
10. The NSCC was created for the purpose of implementing the Nursing Specialty policy under the direct supervision and stewardship of the Board of Nursing. Who shall comprise the NSCC?
A. A Chairperson who is the current President of the APO; a member from the Academe; and the last member coming from the Regulatory Board
B. The chairperson and members of the Regulatory Board ipso facto acts as the CPE Council
C. A Chairperson, chosen from among the Regulatory Board members; a Vice Chairperson appointed by the BON at-large; two other members also chosen 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
No answer..maybe a bonus question…
Situation 3 –Nurse Anna is a new BSN graduate and has just passed her Licensure Examination for Nurses in the Philippines. She has likewise been hired as a new Community Health Nurse in one of the Rural Health Units in their City, which of the following conditions may be acceptable TRUTHS applied to Community Health Nursing Practice.
11. Which of the following is the primary focus of community health nursing practice?
A. Cure of illnesses
B. Prevention of illnesses
C. Rehabilitation back to health
D. Promotion of health
12. In community health nursing, which of the following is our unit of service as nurses?
A. The community
B. The extended members of every family
C. The individual members of the Barangay
D. The Family
13. A very important part of the Community Health Nursing Assessment Process includes:
A. the application of professional judgment in estimating importance of facts to family and community
B. evaluation structures and qualifications of health center team
C. coordination with other sectors in relation to health concerns
D. carrying out nursing procedures as per plan of action
14. In community health nursing it is important to take into account the family health data coupled with an equally important need to perform ocular inspection of the area as activities which are powerful elements of:
A. evaluation
B. assessment
C. implementation
D. planning
15. The initial step in PLANNING process in order to engage in any nursing project or activities at the community level involves
A. goal-setting
B. monitoring
C. evaluation of data
D. provision of data
Situation 4 – Please continue responding as a professional nurse in these other health situations through the following questions.
16. Transmission of HIV from an infected individual to another person occurs:
A. Most frequently in nurses with needlesticks
B. Only if there is a large viral load in the blood
C. Most commonly as a result of sexual contact
D. In all infants born to women with HIV infection
17. The medical record of a client reveals a condition in which the fetus cannot pass through the maternal pelvis. The nurse interprets this as:
A. Contracted pelvis
B. Maternal disproportion
C. Cervical insufficiency
D. Fetopelvic disproportion
18. The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor?
A. Herpes-simplex virus
B. Human papilloma virus
C. Hepatitis
D. Toxoplasmosis
19. After a vaginal examination, the nurse determines that the client’s fetus is in an occiput posterior position. The nurse would anticipate that the client will have:
A. A precipitous birth
B. Intense back pain
C. Frequent leg cramps
D. Nausea and vomiting
20. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:
A. Soften and efface the cervix
B. Numb cervical pain receptors
C. Prevent cervical lacerations
D. Stimulate uterine contractions
Situation 5 – Nurse Lorena is a Family Planning and Infertility Nurse Specialist and currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following conditions pertain to meeting the nursing needs of this particular population group.
21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the best answer?
A. Prostaglandins released from the cut fallopian tubes can kill sperm
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is no where for them to go.
22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:
A. a woman has no uterus
B. a woman has no children
C. a couple has been trying to conceive for 1 year
D. a couple has wanted a child for 6 months
23. Another client named Lilia is diagnosed as having endometriosis. This condition interferes with fertility because:
A. endometrial implants can block the fallopian tubes
B. the uterine cervix becomes inflamed and swollen
C. the ovaries stop producing adequate estrogen
D. pressure on the pituitary leads to decreased FSH levels
24. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions would you give her regarding this procedure?
A. She will not be able to conceive for 3 months after the procedure
B. The sonogram of the uterus will reveal any tumors present
C. Many women experience mild bleeding as an after effect
D. She may feel some cramping when the dye is inserted
25. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena?
A. Donor sperm are introduced vaginally into the uterus or cervix
B. Donor sperm are injected intra-abdominally into each ovary
C. Artificial sperm are injected vaginally to test tubal patency
D. The husband’s sperm is administered intravenously weekly
Situation 6 – There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION, these include:
26. The correct temperature to store vaccines in a refrigerator is:
A. between -4 deg C and +8 deg C
B. between 2 deg C and +8 deg C
C. between -8 deg C and 0 deg C
D. between -8 deg C and +4 deg C
27. Which of the following vaccines is not done by intramuscular (IM) injection?
A. Measles vaccine
B. DPT
C. Hepa-B vaccine
D. Tetanus toxoids
28. This vaccine content is derived from RNA recombinants.
A. Measles
B. Tetanus toxoids
C. Hepatitis B vaccines
D. DPT
29. This is the vaccine needed before a child reaches one (1) year in order for him/her to qualify as a :fully immunized child”.
A. DPT
B. Measles
C. Hepatitis B
D. BCG
30. Which of the following dose of tetanus toxoid is given to the mother to protect her infant from neonatal tetanus and likewise provide 10 years protection for the mother?
A. Tetanus toxoid 3
B. Tetanus toxoid 2
C. Tetanus toxoid 1
D. Tetanus toxoid 4
Situation 7 – Records contain those comprehensive descriptions of patient’s health conditions and needs and at the same serve as evidences of every nurse’s accountability in the care giving process. Nursing records normally differ from institution to institution nonetheless they follow similar patterns of meeting needs for specific types of information. The following pertains to documentation/records management.
31. This special form is used when the patient is admitted to the unit. The nurse completes the information in this record particularly his/her basic personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record?
A. Nursing Kardex
B. Nursing Health History and Assessment Worksheet
C. Medicine and Treatment Record
D. Discharge Summary
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?
A. Nursing Health History and Assessment Worksheet
B. Discharge Summary
C. Nursing Kardex
D. Medicine and Treatment Record
34. This flip-over card is usually kept in a portable file at the Nurse’s Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the 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
Situation 8 – As Filipino Professional Nurses we must be knowledgeable about the Code of Ethics for Filipino Nurse and practice these by heart. The next questions pertain to this Code of Ethics.
36. Which of the following is TRUE about the Code of Ethics of Filipino Nurses?
A. The Philippine Nurses Association for being the accredited professional organization was given the privilege to formulate a Code of Ethics for Nurses which the Board of Nursing promulgated
B. Code for Nurses was first formulated in 1982 published in the Proceedings of the Third Annual Convention of the PNA House of Delegates
C. The present code utilized the Code of Good Governance for the Professions in the Philippines
D. Certificates of Registration of registered nurses may be revoked or suspended for violations of any provisions of the Code of Ethics.
37. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability?
A. Human rights of clients, regardless of creed and gender
B. The privilege of being a registered professional nurses
C. Health, being a fundamental right of every individual
D. Accurate documentation of actions and outcomes
38. Which of the following nurses behavior is regarded as a violation of the Code of Ethics of Filipino Nurses?
A. A nurse withholding harmful information to the family members of a patient
B. A nurse declining commission sent by a doctor for her referral
C. A nurse endorsing a person running for congress.
D. Nurse Reviewers and/or nurse review center managers who pays a considerable amount of cash for reviewees who would memorize items from the licensure exams and submit these to them after the examination.
39. A nurse should be cognizant that professional programs for specialty certification by the Board of Nursing accredited through the:
Professional Regulation Commission
Nursing Specialty Certification Council
Association of Deans of Philippine Colleges of Nursing
Philippine Nurse Association
40. Mr. Santos, R.N. works in a nursing home, and he knows that one of his duties is to be an advocate for his patients. Mr. Santos knows a primary duty of an advocate is to;
A. act as the patient’s legal representative
B. complete all nursing responsibilities on time
C. safeguard the well being of every patient
D. maintain the patient’s right to privacy
Situation 9 – Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particular women with preexisting or Newly Acquired illness. 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?
A. Her husband plays golf 6 days a week
B. She was over 35 when she became pregnant
C. She usually drinks tomato juice for breakfast
D. She has developed gestational diabetes
42. Bernadette develops a deep vein thrombosis following an auto accident and is prescribed heparin sub-Q. What should Joanna educate her about in regard to this?
A. Some infants will be born with allergic symptoms to heparin
B. Her infant will be born with scattered petechiae on his trunk
C. Heparin can cause darkened skin in newborns
D. Heparin does not cross placenta and so does not affect a fetus
43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. What statement signifies this fact?
A. I’ve stopped jogging so I don’t risk becoming dehydrated.
B. I take an iron pill every day to help grow new red blood cells
C. I am careful to drink at least eight glasses of fluid every day
D. I understand why folic acid is important for red cell formation
44. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should she limit or discontinue this toward the end of pregnancy?
A. Aspirin can lead to deep vein thrombosis following birth
B. Newborns develop a red rash from salicylate toxicity
C. Newbors develop withdrawal headaches from salicylates
D. Salicylates can lead to increased maternal bleeding at childbirth
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?
A. Lacerations can provoke allergic responses because of gonadothropic hormone
B. Increased bleeding can occur from uterine pressure on leg veins
C. A woman is less able to keep the laceration clean because of her fatigue
D. Healing is limited during pregnancy, so these will not heal until after birth.
Situation 10 – Still in your self-managed Child Health Nursing Clinic, you encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.
46. Josie brought her 3 months old child to your clinic because of cough and colds. Which of the following is your primary action?
A. Give cotrimoxazole tablet or syrup
B. Assess the patient using the chart on management of children with cough
C. Refer to the doctor
D. Teach the mother how to count her child’s breathing
47. In responding to the care concerns of children with sever 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:
A. Teach mothers how to recognize early signs and symptoms of pneumonia
B. Make home visits to sick children
C. Refer cases to hospitals
D. Seek assistance and mobilize the BHWs to have a meeting with mothers
50. Which of the following is the principal focus of the CARI program of the Department of Health?
A. Enhancement of health team capabilities
B. Teach mothers how to detect signs and where to refer
C. Mortality reduction through early detection
D. Teach other community health workers how to assess patients.
answer key np
note: guys, i'll post the rationales later this month na lang ha, super hectic lang talaga my sched (^^,)
NURSING PRACTICE II – Community Health Nursing and Care of the Mother and Child
SITUATIONAL
Situation 1 – Nurse Minette is an Independent Nurse Practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTIAL MOTHER AND FAMILY focusing on HOME CARE.
1. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?
Within 24 hours after discharge
2. Leah is developing constipation from being on bed rest. What measures would you suggest she take to help prevent this?
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?
She urges the baby to stay awake so that she can breast-feed him or her
4. At 6-week postpartum visit what should this postpartal mother’s fundic height be?
No longer palpable on her abdomen
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?
500 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?
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:
Quasi-Legislative Power
8. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing Specialty Certification Program and Council, which two (2) of the following serves as the strongest for its enforcement?
(a) Advances made in Science and Technology have provided the climate for specialization in almost all aspects of human endeavor; and
(b) As necessary consequence, there has emerged a new concept known as globalization which seeks to remove barriers in trade, industry and services imposed by the national laws of countries all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare our people in the services sector to meet the above challenge; and
(d) Current trends of specialization in nursing practice recognized by the International Council of Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of deepening and refining nursing practice and enhancing the quality of nursing care.
a & b are strong justifications
9. Which of the following IS NOT a correct statement as regards Specialty Certification?
The Board of Nursing intended to create the Nursing Specialty Certification Program as a means of perpetuating the creation of an elite force of Filipino Nurse Professionals.
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
No answer..maybe a bonus question…
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?
Promotion of health
12. In community health nursing, which of the following is our unit of service as nurses?
The Family
13. A very important part of the Community Health Nursing Assessment Process includes:
the application of professional judgment in estimating importance of facts to family and community
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:
assessment
15. The initial step in PLANNING process in order to engage in any nursing project or activities at the community level involves
goal-setting
Situation 4 – Please continue responding as a professional nurse in these other health situations through the following questions.
16. Transmission of HIV from an infected individual to another person occurs:
Most commonly as a result of sexual contact
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. Fetopelvic disproportion
18. The nurse would anticipate a cesarean birth for a client who has which infection present at the onset of labor?
Herpes-simplex virus
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:
Intense back pain
20. The rationales for using a prostaglandin gel for a client prior to the induction of labor is to:
Soften and efface the cervix
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?
Sperm can no longer reach the ova, because the fallopian tubes are blocked
22. The Dators are a couple undergoing testing for infertility. Infertility is said to exist when:
a couple has been trying to conceive for 1 year
23. Another client named Lilia is diagnosed as having endometriosis. This condition interferes with fertility because:
endometrial implants can block the fallopian tubes
24. Lilia is scheduled to have a hysterosalphingogram. Which of the following instructions would you give her regarding this procedure?
She may feel some cramping when the dye is inserted
25. Lilia’s cousin on the other hand, knowing nurse Lorena’s specialization asks what artificial insemination by donor entails. Which would be your best answer if you were Nurse Lorena?
Donor sperm are introduced vaginally into the uterus or cervix
Situation 6 – There are other important basic knowledge in the performance of our task as Community Health Nurse in relation to IMMUNIZATION, these include:
26. The correct temperature to store vaccines in a refrigerator is:
between 2 deg C and +8 deg C
27. Which of the following vaccines is not done by intramuscular (IM) injection?
Measles vaccine
28. This vaccine content is derived from RNA recombinants.
Hepatitis B vaccines
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”.
Measles
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?
Tetanus toxoid 4
Situation 7 – Records contain those comprehensive descriptions of patient’s health conditions and needs and at the same serve as evidences of every nurse’s accountability in the care giving process. Nursing records normally differ from institution to institution nonetheless they follow similar patterns of meeting needs for specific types of information. The following pertains to documentation/records management.
31. This special form is used when the patient is admitted to the unit. The nurse completes the information in this record particularly his/her basic personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record?
Nursing Health History and Assessment Worksheet
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?
Graphic Flow Sheets
33. These records show all medications and treatment provided on a repeated basis. What do you call this record?
Medicine and Treatment Record
34. This flip-over card is usually kept in a portable file at the Nurse’s Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the 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?
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?
Discharge Summary
Situation 8 – As Filipino Professional Nurses we must be knowledgeable about the Code of Ethics for Filipino Nurse and practice these by heart. The next questions pertain to this Code of Ethics.
36. Which of the following is TRUE about the Code of Ethics of Filipino Nurses?
The present code utilized the Code of Good Governance for the Professions in the Philippines
37. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark of nursing responsibility and accountability?
Accurate documentation of actions and outcomes
38. Which of the following nurses behavior is regarded as a violation of the Code of Ethics of Filipino Nurses?
Nurse Reviewers and/or nurse review center managers who pays a considerable amount of cash for reviewees who would memorize items from the licensure exams and submit these to them after the examination.
39. A nurse should be cognizant that professional programs for specialty certification by the Board of Nursing accredited through the:
Nursing Specialty Certification Council
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;
maintain the patient’s right to privacy
Situation 9 – Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particular women with preexisting or Newly Acquired illness. 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?
She has developed gestational diabetes
42. Bernadette develops a deep vein thrombosis following an auto accident and is prescribed heparin sub-Q. What should Joanna educate her about in regard to this?
Heparin does not cross placenta and so does not affect a fetus
43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. What statement signifies this fact?
I take an iron pill every day to help grow new red blood cells
44. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should she limit or discontinue this toward the end of pregnancy?
Salicylates can lead to increased maternal bleeding at childbirth
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?
Increased bleeding can occur from uterine pressure on leg veins
Situation 10 – Still in your self-managed Child Health Nursing Clinic, you encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.
46. Josie brought her 3 months old child to your clinic because of cough and colds. Which of the following is your primary action?
Assess the patient using the chart on management of children with cough
A. Refer to the doctor
B. Teach the mother how to count her child’s breathing
47. In responding to the care concerns of children with sever disease, referral to the hospital is of the essence especially if the child manifests which of the following?
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?
Provision of Careful Assessment
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:
Teach mothers how to recognize early signs and symptoms of pneumonia
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
5. In massive blood loss, prompt replacement of compatible blood is crucial. What department needs to be alerted to coordinate closely with the patient’s family for immediate blood component therapy?
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?
A. Dressing is intact but partially soiled
B. Left foot is cold to touch and pedal pulse is absent
C. Left leg in limited functional anatomic position
D. BP 114/78, pulse of 82 beats/minute
7. There is an order of Demerol 50 mg I.M. now and every 6 hours p r n. You injected Demerol at 5 pm. The next dose of Demerol 50 mg I.M. is given:
A. When the client asks for the next dose
B. When the patient is in severe pain
C. At 11 pm
D. At 12 pm
8. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors indicate appropriate adaptation?
A. The client reports pain reduction and decreased activity
B. The client denies existence of pain
C. The client can distract himself during pain episodes
D. The client reports independence from watchers
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?
A. Instruct client to observe strict bed rest
B. Check for epidural catheter drainage
C. Administer analgesia through epidural catheter as prescribed
D. Assess respiratory rate carefully
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?
A. When the record is voluminous
B. When a medical record is subpoenaed in court
C. When it is missing
D. When the medical record is inaccurate, incomplete, and inadequate
12. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency?
A. Department of Interior and Local Government (DILG)
B. Metro Manila Development Authority (MMDA)
C. Records Management Archives Office (RMAO)
D. Department of Health (DOH)
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?
A. Central supply section
B. Previous doctor’s clinic
C. Department where the patient was previously admitted
D. Medical records section
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:
A. Your hospital is considered tertiary
B. Your hospital is in Metro Manila
C. It obtained permit to operate from DOH
D. Your hospital is PhilHealth accredited
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?
A. Assess level of consciousness
B. Verify patient identification and informed consent
C. Assess vital signs
D. Check for jewelry, gown, manicure, and dentures
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…
A. the surgeon greets his client before induction of anesthesia
B. the surgeon and anesthesiologist are in tandem
C. strap made of strong non-abrasive materials are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board.
D. Client is monitored throughout the surgery by the assistant anesthesiologist
19. Another nursing check that should not be missed before the induction of general anesthesia is:
A. check for presence underwear
B. check for presence dentures
C. check patient’s ID
D. check baseline vital signs
20. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate 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?
A. Assess the readiness of the client prior to surgery
B. Ensure that the airway is adequate
C. Account for the number of sponges, needles, supplies, used during the surgical procedure.
D. Evaluate the type of anesthesia appropriate for the surgical client
22. As a perioperative nurse, how can you best meet the safety need of the 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?
A. Localized heat and redness
B. Serosanguinous exudates and skin blanching
C. Separation of the incision
D. Blood clots and scar tissue are visible
25. Which of the following nursing interventions is done when examining the incision wound and changing the dressing?
A. Observe the dressing and type and odor of drainage if any
B. Get patient’s consent
C. Wash hands
D. Request the client to expose the incision wound
Situation 6 – Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress.
26. Which of the following nursing actions should be initiated first?
A. Promote emotional support
B. Administer oxygen at 6L/min
C. Suction the client every 30 min
D. Administer bronchodilator by nebulizer
27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what is its indication, the nurse will say:
A. Relax smooth muscles of the bronchial airway
B. Promote expectoration
C. Prevent thickening of secretions
D. Suppress cough
28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT:
A. Avoid emotional stress and extreme temperature
B. Avoid pollution like smoking
C. Avoid pollens, dust, seafood
D. Practice respiratory isolation
29. The asthmatic client asked you what breathing techniques he can best practice when asthmatic attack starts. What will be the best position?
A. Sit in high-Fowler’s position with extended legs
B. Sit-up with shoulders back
C. Push on abdomen during exhalation
D. Lean forward 30-40 degrees with each exhalation
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
Situation 7 – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility.
31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?
A. Limit suppliers to a few so that quality is maintained
B. Implement a regular inventory of supplies and equipment
C. Adherence to manufacturer’s recommendation
D. Implement a regular maintenance and testing of 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:
A. Mark the operative site if possible
B. Conduct pre-procedure verification process
C. Take a video of the entire intra-operative procedure
D. Conduct ‘time out’ immediately before starting the procedure
34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following, EXCEPT:
A. 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
Situation 8 – Team efforts is best demonstrated in the OR.
36. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?
A. Who is your internist
B. Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery?
C. Who are your anesthesiologist, internist, and assistant
D. Who is your anesthesiologist
37. In the OR, the nursing tandem for every surgery is:
A. Instrument technician and circulating nurse
B. Nurse anesthetist, nurse assistant, and instrument technician
C. Scrub nurse and nurse anesthetist
D. Scrub and circulating nurses
38. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team?
A. Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
B. Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
C. Surgeon, assistant surgeon, anesthesiologist, scrub nurse, pathologist
D. Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse
39. When surgery is on-going, who coordinates the activities outside, including the family?
A. Orderly/clerk
B. Nurse Supervisor
C. Circulating Nurse
D. Anesthesiologist
40. The breakdown in teamwork is often times a failure in:
A. Electricity
B. Inadequate supply
C. Leg work
D. Communication
Situation 9 – Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition.
41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?
A. Apply liberal amount of mineral oil to the area
B. Use karaya paste and rings around the stoma
C. Clean the area daily with soap and water before applying bag
D. Apply talcum powder twice a day
42. What health instruction will enhance regulation of a colostomy (defecation) of clients?
A. Irrigate after lunch everyday
B. Eat fruits and vegetables in all three meals
C. Eat balanced meals at regular intervals
D. Restrict exercise to walking only
43. After ileostomy, which of the following condition is NOT expected?
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
Situation 10 – As a beginner in research, you are aware that sampling is an essential elements of the research process.
46. What does a sample group represent?
A. Control group
B. Study subjects
C. General population
D. Universe
47. What is the most important characteristic of a sample?
A. Randomization
B. Appropriate location
C. Appropriate number
D. Representativeness
48. Random sampling ensures that each subject has:
A. Been selected systematically
B. An equal chance of selection
C. Been selected based on set criteria
D. Characteristics that match other samples
49. Which of the following methods allows the use of any group of research 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
answer key np3
note: later na po ung rationales! (^^,)
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?
Circulating Nurse
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?
Anaesthesiologist
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?
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?
Biomedical technician
5. In massive blood loss, prompt replacement of compatible blood is crucial. What department needs to be alerted to coordinate closely with the patient’s family for immediate blood component therapy?
Social Service Section
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?
Left foot is cold to touch and pedal pulse is absent
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:
At 11 pm
8. You continuously evaluate the client’s adaptation to pain. Which of the following behaviors indicate appropriate adaptation?
The client can distract himself during pain episodes
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?
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?
Assess respiratory rate carefully
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?
When the medical record is inaccurate, incomplete, and inadequate
12. Disposal of medical records in government hospitals/institutions must be done in close coordination with what agency?
Department of Health (DOH)
13. In the hospital, when you need the medical record of a discharged patient for research you will request permission through:
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?
Medical records section
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:
It obtained permit to operate from DOH
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?
Verify patient identification and informed consent
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?
Last case
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…
strap made of strong non-abrasive materials are fastened securely around the joints of the knees and ankles and around the 2 hands around an arm board.
19. Another nursing check that should not be missed before the induction of general anesthesia is:
check baseline vital signs
20. Some lifetime habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the past 10 years, you will anticipate increased risk for:
delayed wound healing
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?
Account for the number of sponges, needles, supplies, used during the surgical procedure.
22. As a perioperative nurse, how can you best meet the safety need of the client after administering preoperative narcotic?
Put side rails up and ask the client not to get out of bed
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?
Clipped
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?
Localized heat and redness
25. Which of the following nursing interventions is done when examining the incision wound and changing the dressing?
Observe the dressing and type and odor of drainage if any
Situation 6 – Carlo, 16 years old, comes to the ER with acute asthmatic attack. RR is 46/min and he appears to be in acute respiratory distress.
26. Which of the following nursing actions should be initiated first?
Administer bronchodilator by nebulizer
27. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what is its indication, the nurse will say:
Relax smooth muscles of the bronchial airway
28. You will give health instructions to Carlo, a case of bronchial asthma. The health instruction will include the following, EXCEPT:
Practice respiratory isolation
29. The asthmatic client asked you what breathing techniques he can best practice when asthmatic attack starts. What will be the best position?
Lean forward 30-40 degrees with each exhalation
30. As a nurse, you are always alerted to monitor status asthmaticus who will likely and initially manifest symptoms of:
respiratory acidosis
Situation 7 – Joint Commission on Accreditation of Hospital Organization (JCAHO) patient safety goals and requirements include the care and efficient use of technology in the OR and elsewhere in the healthcare facility.
31. As the head nurse in the OR, how can you improve the effectiveness of clinical alarm systems?
Implement a regular maintenance and testing of 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?
Check the functionality of the pump before use
33. JCAHOs universal protocol for surgical and invasive procedures to prevent wrong site, wrong person, and wrong procedure/surgery includes the following, EXCEPT:
Take a video of the entire intra-operative procedure
34. You identified a potential risk of pre-and postoperative clients. To reduce the risk of patient harm resulting from fall, you can implement the following, EXCEPT:
Allow client to walk with relative to the OR
35. As a nurse, you know you can improve on accuracy of patient’s identification by 2 patient identifiers, EXCEPT:
call the client by his/her case and bed number
Situation 8 – Team efforts is best demonstrated in the OR.
36. If you are the nurse in charge for scheduling surgical cases, what important information do you need to ask the surgeon?
Who is your assistant and anesthesiologist, and what is your preferred time and type of surgery?
37. In the OR, the nursing tandem for every surgery is:
Scrub and circulating nurses
38. While team effort is needed in the OR for efficient and quality patient care delivery, we should limit the number of people in the room for infection control. Who comprise this team?
Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist
39. When surgery is on-going, who coordinates the activities outside, including the family?
Circulating Nurse
40. The breakdown in teamwork is often times a failure in:
Communication
Situation 9 – Colostomy is a surgically created anus. It can be temporary or permanent, depending on the disease condition.
41. Skin care around the stoma is critical. Which of the following is not indicated as a skin care barriers?
Apply liberal amount of mineral oil to the area
42. What health instruction will enhance regulation of a colostomy (defecation) of clients?
Eat balanced meals at regular intervals
43. After ileostomy, which of the following condition is NOT expected?
Increased weight
44. The following are appropriate nursing interventions during colostomy irrigation, EXCEPT:
Increase the irrigating solution flow rate when abdominal cramps is felt
45. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?
Sensation of pressure
Situation 10 – As a beginner in research, you are aware that sampling is an essential elements of the research process.
46. What does a sample group represent?
General population
47. What is the most important characteristic of a sample?
Representativeness
48. Random sampling ensures that each subject has:
An equal chance of selection
49. Which of the following methods allows the use of any group of research subject?
Convenience
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?
Cluster sampling
NURSING PRACTICE IV – Care of Clients with Physiologic and
Psychosocial Alterations (Part B)
MULTIPLE CHOICE
Situation 1 – Because of the serious consequences of severe burns, management requires a multidisciplinary approach. You have important responsibilities as a nurse.
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:
A. log roll on the grass/ground
B. slap the flames with his hands
C. remove the burning clothes
D. pour cold liquid over the flames
2. Once the flames are extinguished, it is most important to:
A. cover Sergio with a warm blanket
B. give him sips of water
C. calculate the extent of his burns
D. assess the Sergio’s breathing
3. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means? Your most accurate response would be:
A. Structures beneath the skin are damage
B. Dermis is partially damaged
C. Epidermis and dermis are both damaged
D. Epidermis is damaged
4. During the first 24 hours after the thermal injury, you should asses Sergio for:
A. hypokalemia and hypernatremia
B. hypokalemia and hyponatremia
C. hyperkalemia and hyponatremia
D. hyperkalemia and hypernatremia
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:
A. Cerebral hypoxia C. metabolic acidosis
B. Hypervolemia D. Renal failure
Situation 2 – You are now working as a staff nurse in a general hospital. You have to be prepared to handle situations with ethico-legal and moral implifications.
6. You are in night duty in surgical ward. One of your patients Martin is a 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?
A. Write an accident report
B. Call security officer and report the incident
C. Call your nurse supervisor and report the incident
D. Call the physician on duty
7. You are on morning duty in the medical ward. You have 10 patients assigned to you. During your endorsement rounds, you found out that one of your patients was not in bed. The patient next to him informed you that he went home without notifying the nurses. Which among the following will you do first?
A. Make an incident report
B. Call security to report the incident
C. Wait for 2 hours before reporting
D. Report the incident to your supervisor
8. You are on duty in the medical ward. You were asked to check the narcotics 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.
A. Start basic life support measures
B. Call for the Code
C. Bring the crash cart to the room
D. Go to see Fiolo and assess for airway patency and breathing problems
10. You are admitting Jorge to the ward and you found out that he is positive for HIV. Which among the following will you do first?
A. Take note of it and plan to endorse this to next shift
B. Keep this matter to yourself
C. Write an incident report
D. Report the matter to your head nurse
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
14. Symptoms associated with cancer of the colon include:
A. constipation, ascites and mucus in the stool
B. diarrhea, heart burn and eructation
C. blood in the stools, anemia, and “pencil shaped” stools
D. anorexia, hematemesis, and increased peristalasis
15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to:
A. promote rest of the bowel by minimizing peristalsis
B. reduce the bacterial content of the colon
C. empty the bowel of solid waste
D. soften the stool by retaining water in the colon
Situation 4 – ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS.
16. You plan to teach Fermin how to irrigate the colostomy when:
A. 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. When Fermin would have normal bowel movement
B. At least 2 hours before visiting hours
C. Prior to breakfast and morning care
D. After Fermin accepts alteration in body image
18. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin:
A. Lubricates the tip of the catheter prior to inserting into the stoma
B. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
C. Discontinues the insertion of fluid after only 500 ml of fluid has been 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.”
Situation 5 – Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications.
21. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
A. empty the drainage system at the end of the shift
B. clamp the chest tube when suctioning
C. palpate the surrounding areas for crepitus
D. change the dressing daily using aseptic techniques
22. Fanny, came in from PACU after pelvic surgery. As Fanny’s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be:
A. a tender, painful area on the leg
B. a pitting edema of the ankle
C. a reddened area at the ankle
D. pruritus on the calf and ankle
23. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to:
A. seek early treatment for respiratory infections
B. take showers instead of tub bath
C. continue to take the same restrictions on fluid intake
D. avoid situations that involve physical activity
24. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged. What should you teach him first?
A. Recognize that prompt closure of the tracheal opening may occur
B. Keep calm because there is no immediate emergency
C. Reinsert another tubing immediately
D. Notify the physician at once
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
Situation 6 – Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care.
26. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for herself and her household help. Your most appropriate response would be:
A. “Don’t worry your husband’s type of hepatitis is no longer communicable”
B. “Gamma globulin provides passive immunity for hepatitis B”
C. “You should contact your physician immediately about getting gammaglobulin.”
D. “A vaccine has been developed for this type of hepatitis”
27. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your best response would be:
A. “You acquired the infection after you have been admitted to the hospital.”
B. “This is a highly contagious infection requiring complete isolation.”
C. “The infection you had prior to hospitalization flared up.”
D. “As a result of medical treatment, you have acquired a secondary infection.’
28. As a nurse you know that one of the complications that you have to watch out for when caring for Omar who is receiving total parenteral nutrition is:
A. stomatitis
B. hepatitis
C. dysrhythmia
D. infection
29. A solution used to treat Pseudomonas wound infection is:
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?
A. Culture and sensitivity
B. Purulent drainage from a wound
C. WBC count of 20,000/μL
D. Gram stain testing
Situation 7 – As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented.
31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on admission. A central venous catheter was inserted an I.V. infusion was started. As a nurse assigned to Wendy what will be your priority goal?
A. Prevent skin breakdown
B. Preserve muscle function
C. Promote urinary elimination
D. Maintain a patent airway
32. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?
A. Tell her family that probably she can’t hear them
B. Talk loudly so that Wendy can hear you
C. Tell her family who are in the room not to talk
D. Speak softly then hold her hands gently
33. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke?
A. Place June on an upright lateral position
B. Perform range of motion exercises
C. Apply antiembolic stockings
D. Use hand rolls or pillows for support
34. Ivy, age 40, was admitted to the hospital with a severe headache, stiff neck and photophobia. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured aneurysm. While waiting for surgery, you can provide a therapeutic environment by doing which of the following?
A. honoring her request for a television
B. placing her bed near the window
C. dimming the light in her room
D. allowing the family unrestricted visiting privileges
35. When performing a neurologic assessment on Walter, you find that his pupils are fixed and dilated. This indicated that he:
A. probably has meningitis
B. is going to be blind because of trauma
C. is permanently paralyzed
D. has received a significant brain injury
Situation 8 – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and issues relevant to the older patients.
36. Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging.
A. Ineffective airway clearance
B. Decreased alveolar surfaced area
C. Decreased anterior-posterior chest diameter
D. Hyperventilation
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
39. Cardiac ischemia in an older patient usually produces:
A. ST-T wave changes
B. Very high creatinine kinase level
C. Chest pain radiating to the left arm
D. Acute confusion
40. The most dependable sign of infection in the older patient is:
A. change in mental status
B. fever
C. pain
D. decreased breath sounds with crackles
Situation 9 – A “disaster” is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster. Disaster preparedness is crucial and is everybody’s business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector.
41. Which of the four phases of emergency management is defined as “sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects.”?
A. 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?
A. Clinical incident stress management
B. Follow-up
C. Defriefing
D. Defusion
Situation 10 – As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.
46. While eating his meal, Matthew accidentally dislodges his IV lines and 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?
A. Establish policies for surveillance and monitoring
B. Do data gathering about the possible sources of infection (observation, chart review, interview).
C. Assign point persons who can implement policies.
D. Meet with the nursing group working in the burn unit and discuss problem with them.
48. Part of your responsibility as a member of the diabetes core group is to get referrals from the various wards regarding diabetic patients needing diabetes education. Prior to discharge today, 4 patients are referred to you. How would you start prioritizing your activities?
A. Bring your diabetes teaching kit and start your session taking into 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?
A. Find out if there is a budget for this activity
B. Clarify objectives of the activity with the task force before contacting the support groups
C. Determine the VIPs and Celebrities who will be invited
D. Find out how many support groups there are in the hospital and get the contact number of their president
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?
A. Conduct health education on healthy life style
B. Be a triage nurse
C. Take the initial history and document findings
D. Act as a coordinator
np4 practice exam answer key
note: i may not be able to post the rationales, its start of the review season and i am super busy, plus there are people na nangpipirate ng materials...so so so bad
NURSING PRACTICE IV – Care of Clients with Physiologic and
Psychosocial Alterations (Part B)
MULTIPLE CHOICE
Situation 1 – Because of the serious consequences of severe burns, management requires a multidisciplinary approach. You have important responsibilities as a nurse.
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:
log roll on the grass/ground
2. Once the flames are extinguished, it is most important to:
assess the Sergio’s breathing
3. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means? Your most accurate response would be:
Epidermis and dermis are both damaged
4. During the first 24 hours after the thermal injury, you should asses Sergio for:
hyperkalemia and hyponatremia
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:
metabolic acidosis
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?
Call your nurse supervisor and report the incident
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?
Report the incident to your supervisor
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?
Report the matter to your supervisor
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.
Bring the crash cart to the room
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?
Report the matter to your head nurse
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.
Annual digital rectal examination
12. To confirm his impression of colorectal cancer, Larry will require which diagnostic study?
Proctosigmoidoscopy
13. The following are risk factors for colorectal cancer, EXCEPT:
Smoking
14. Symptoms associated with cancer of the colon include:
blood in the stools, anemia, and “pencil shaped” stools
15. Several days prior to bowel surgery, Larry may be given sulfasuxidine and neomycin primarily to:
reduce the bacterial content of the colon
Situation 4 – ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS.
16. You plan to teach Fermin how to irrigate the colostomy when:
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:
When Fermin would have normal bowel movement
18. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin:
Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion
19. You are aware that teaching about colostomy care is understood when Fermin states, “I will contact my physician and report:
If I have any difficulty inserting the irrigating tub into the stoma.”
20. You would know after teaching Fermin that dietary instruction for him is effective when he states, “It is important that I eat:
A. Everything that I ate before the operation, while avoiding foods that cause gas.”
Situation 5 – Ensuring safety is one of your most important responsibilities. You will need to provide instructions and information to your clients to prevent complications.
21. Randy has chest tubes attached to a pleural drainage system. When caring for him you should:
palpate the surrounding areas for crepitus
22. Fanny, came in from PACU after pelvic surgery. As Fanny’s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be:
a tender, painful area on the leg
23. To prevent recurrent attacks on Terry who has acute glumerulonephritis, you should instruct her to:
seek early treatment for respiratory infections
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?
Notify the physician at once
25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain:
ventilation exchange
Situation 6 – Infection can cause debilitating consequences when host resistance is compromised and virulence of microorganisms and environmental factors are favorable. Infection control is one important responsibility of the nurse to ensure quality of care.
26. Honrad, who has been complaining of anorexia and feeling tired, develops jaundice, after a workup he is diagnosed of having Hepatitis A. his wife asks you about gamma globulin for herself and her household help. Your most appropriate response would be:
“You should contact your physician immediately about getting gammaglobulin.”
27. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your best response would be:
“You acquired the infection after you have been admitted to the hospital.”
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:
infection
29. A solution used to treat Pseudomonas wound infection is:
Dakin’s solution
30. Which of the following is the most reliable in diagnosing a wound infection?
WBC count of 20,000/μL
Situation 7 – As a nurse you need to anticipate the occurrence of complications of stroke so that life threatening situations can be prevented.
31. Wendy is admitted to the hospital with signs and symptoms of stroke. Her Glasgow Coma Scale is 6 on admission. A central venous catheter was inserted an I.V. infusion was started. As a nurse assigned to Wendy what will be your priority goal?
Maintain a patent airway
32. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do?
Speak softly then hold her hands gently
33. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparesis secondary to stroke?
Perform range of motion exercises
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?
dimming the light in her room
35. When performing a neurologic assessment on Walter, you find that his pupils are fixed and dilated. This indicated that he:
has received a significant brain injury
Situation 8 – With the improvement in life expectancies and the emphasis in the quality of life it is important to provide quality care to our older patients. There are frequently encountered situations and issues relevant to the older patients.
36. Hypoxia may occur in the older patients because of which of the following physiologic changes associated with aging.
Decreased alveolar surfaced area
37. The older patient is at higher risk for incontinence because of:
decreased bladder capacity
38. Merle, age 86, is complaining of dizziness when she stands up. This may indicate:
functional decline
39. Cardiac ischemia in an older patient usually produces:
Acute confusion
40. The most dependable sign of infection in the older patient is:
change in mental status
Situation 9 – A “disaster” is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster. Disaster preparedness is crucial and is everybody’s business. There are agencies that are in charge of ensuring prompt response. Comprehensive Emergency Management (CEM) is an integrated approach to the management of emergency programs and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all types of emergencies and disasters (natural, man-made, and attack) and for all levels of government and the private sector.
41. Which of the four phases of emergency management is defined as “sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects.”?
Mitigation
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:
Tertiary prevention
43. During the disaster you see a victim with a green tag, you know that the person:
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:
Emergent
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?
Defusion
Situation 10 – As a member of the health and nursing team you have a crucial role to play in ensuring that all the members participate actively is the various tasks agreed upon.
46. While eating his meal, Matthew accidentally dislodges his IV lines and 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:
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?
Do data gathering about the possible sources of infection (observation, chart review, interview).
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?
Determine their learning needs then prioritize
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?
Clarify objectives of the activity with the task force before contacting the support groups
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?
Conduct health education on healthy life style
NURSING PRACTICE V- Care of Clients with physiologic and Psychosocial
Alterations (Part C).
SITUATIONAL
Situation 1 – Jimmy developed this goal for hospitalization. “To get a handle on my nervousness.” The nurse is going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help.
1. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is:
A. help the client find meaning in his experience
B. help the client to plan alternatives
C. help the client cope with the present problem
D. help the client to communicate
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”.
A. anxiety laden unconscious conflicts
B. subjective idea of the range of mild to severe anxiety
C. early signs of anxiety
D. physiologic indices of anxiety
3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that complete disruption of the ability to perceive occurs in:
A. panic state of anxiety
B. severe anxiety
C. moderate anxiety
D. mild anxiety
4. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT:
A. agreeing to contact the staff when he is anxious
B. becoming aware of the conscious feeling
C. assessing need for medication and medicating himself
D. writing out a list of behaviors that he identified as anxious
5. The nurse notes effectiveness of interventions in using subjective and objective data in the:
A. initial plans or orders
B. database
C. problem list
D. progress notes
Situation 2 – A research study was undertaken in order to identify and analyze a disabled boy’s coping reaction pattern during stress.
6. This study which is an in depth study of one boy is a:
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?
A. Non verbal narrative account
B. Analysis and interpretation
C. Audio-visual recording
D. Verbal narrative account
8. Which of these does NOT happen in a descriptive study?
A. Exploration of relationship between two or more phenomena.
B. Explanation of relationship between two or more phenomena.
C. Investigation of a phenomenon in real life context.
D. Manipulation of variable
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:
A. subjected to statistical treatment
B. correlated with a list of coping behaviors
C. subjected to an inter-observer agreement
D. scored and compared standard criteria
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:
A. face emerging problems realistically
B. conceptualize her problem
C. cope with her present problem
D. perceive her participation in an experience
!4. Which of these responses indicate that Regina needs further discussion regarding special instructions?
A. “I have to take this medicine judiciously”
B. “I know I will stop taking the medicine when there is advice from the doctor for me to discontinue.”
C. “I will inform you and the doctor any untoward reactions I have.”
D. “I like taking this sleeping pill. It solves my problem of insomnia. I wish I can take it for life.”
15. Regina commits to herself that she understood and will observe all the 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:
A. All behavior is meaningful, communicating a message or a need.
B. Human beings are systems of interdependent and interrelated parts.
C. Each individual has the potential for growth and change in the direction of positive mental health.
D. There is a basic similarity among all human beings.
18. One way to increase objectivity in dealing with one’s fears and anxieties is 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?
A. Responding in a punitive manner to the client.
B. Rejecting the client as a unique human being
C. Tolerating all behavior in the client.
D. Communicating ambivalent messages to the client.
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:
A. when the client asks how long the relationship would be
B. during the working phase
C. towards the end of the relationship
D. at the start of the relationship
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:
A. “Yes, our interaction is confidential provided the information you tell me is not detrimental to your safety.”
B. “Of course yes, this is just between you and me. Promise!”
C. “Yes, it is my principle to uphold my client’s rights.”
D. “Yes, you have the right to invoke confidentiality of our interaction.”
23. When the nurse respects the client’s self-disclosure, this is a gauge for the nurse’s:
A. 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:
A. “The best time to talk is during the nurse-client interaction time. I am committed to have this time available for us while you are at the hospital and ends after your discharge.”
B. “Yes, If you keep it confidential, this is part of privileged communication.”
C. “I am committed for your care.”
D. “I am sorry, though I would want to, it is against hospital policy.”
25. The client has not been visited by relatives for months. He gives a telephone number and requests the nurse to call. An appropriate action of the nurse would be:
A. Inform the attending physician about the request of the client.
B. Assist the client to bring his concern to the attention of the social worker.
C. “Here (gives her mobile phone). You may call this number now”.
D. Ask the client what is the purpose of contacting his relatives.
Situation 6 – Camila, 25 years old, was reported to be gradually withdrawing and 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
27. Camila refuses to relate with to others because she:
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. Lack of participation in peer groups
B. Faulty family atmosphere and interaction
C. Extreme rebellion towards authority figures
D. Solo parenting
29. Camila’s indifference toward the environment is a compensatory behavior to overcome:
A. Guilt feelings
B. Ambivalence
C. Narcissistic behavior
D. Insecurity feelings
30. Schizophrenia is a/an:
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. beginning indifference to the world around her
B. attempt to maintain authoritative role
C. overcompensation for hearing loss
D. behavior indicative of unresolved repressed conflict of the past
32. A nursing diagnosis for Salome is:
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:
A. adjust to the loss of sensory and perceptual function
B. participate in conversation and other social situations
C. accept the steady loss of hearing that occurs with aging
D. increase her self-esteem to maintain her authoritative role
34. The daughter understood, the following ways to assist Salome meet her needs and avoiding which of the following:
A. Using short simple sentences
B. Speaking distinctly and slowly
C. Speaking at eye level and having the client’s attention
D. Allowing her to take her meals alone
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.
36. Cecilia is demonstrating:
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?
A. She reads a book in the public library
B. She drives alone along the long expressway.
C. She watches television with the family in the recreation room
D. She joins an art therapy group
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:
A. Summary of chronological notations made by individual health team members
B. Identification of patient’s responses to medical diagnoses and treatment
C. Patient’s responses to health and illness as a total person in interaction with the environment
D. Step by step procedures for the management of common problems
Situation 10 – 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?
A. deep sleep factors
B. abnormal bladder development
C. infections
D. familial and genetic factors
47. All of the following, EXCEPT one compromise the concepts of behavior therapy program.
A. reward and punishment
B. extinction
C. learning
D. placebo as a form of treatment
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. discipline with a kind attitude
B. matter of fact in handling the behavior
C. sympathize for the child
D. be loving yet firm
49. A therapeutic verbal approach that communicates strong disapproval is:
A. “You are supposed to get up and go in the toilet when you feel you have to go and did not. The next time you bed wet, I’ll tell your friends and hang your sheets out the window for them to see.”
B. “You are supposed to get up and go in the toilet when you feel you have to go and did not. I expect you to from now on without fail.”
C. “If you bed wet, you will change your bed linen and wash the sheets.”
D. “If you don’t make an effort to control your bedwetting, I’d be upset and disappointed.”
50. During your conference, the parent inquires how to motivate Marie to be dry in the morning. Your response which is an immediate intervention would be:
A. Give a star each time she wakes up dry and every set of five stars, give a 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.
NP5 practice exam answer key
note: rationales will be for classroom discussion to avoid piracy
NURSING PRACTICE V- Care of Clients with physiologic and Psychosocial
Alterations (Part C).
SITUATIONAL
Situation 1 – Jimmy developed this goal for hospitalization. “To get a handle on my nervousness.” The nurse is going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help.
1. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the care plan is:
help the client to plan alternatives
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”.
subjective idea of the range of mild to severe anxiety
3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that complete disruption of the ability to perceive occurs in:
panic state of anxiety
4. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT:
agreeing to contact the staff when he is anxious
5. The nurse notes effectiveness of interventions in using subjective and objective data in the:
progress notes
Situation 2 – A research study was undertaken in order to identify and analyze a disabled boy’s coping reaction pattern during stress.
6. This study which is an in depth study of one boy is a:
case study
7. The process recording was the principal tool for data collection. Which of the following is NOT a part of a process recording?
Audio-visual recording
8. Which of these does NOT happen in a descriptive study?
Manipulation of variable
9. The investigator also provided the nursing care of the subject. The investigator is referred to as a/an:
Observer researcher
10. To ensure reliability of the study, the investigator’s analysis and interpretations were:
subjected to an inter-observer agreement
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?
“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?”
12. Regina is a high school teacher. Which of these information LEAST communicate attention and care for her needs for information about her medicine?
Provide a drug literature.
13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to:
perceive her participation in an experience
!4. Which of these responses indicate that Regina needs further discussion regarding special instructions?
“I like taking this sleeping pill. It solves my problem of insomnia. I wish I can take it for life.”
15. Regina commits to herself that she understood and will observe all the medicine precautions by:
committing what she learned to her memory
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
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:
All behavior is meaningful, communicating a message or a need.
18. One way to increase objectivity in dealing with one’s fears and anxieties is through the process of:
validation
19. All of the following responses are non therapeutic. Which is the MOST direct violation of the concept, congruence of behavior?
Communicating ambivalent messages to the client.
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:
mother surrogate
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:
at the start of the relationship
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:
“Yes, our interaction is confidential provided the information you tell me is not detrimental to your safety.”
23. When the nurse respects the client’s self-disclosure, this is a gauge for the nurse’s:
trustworthiness
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:
“The best time to talk is during the nurse-client interaction time. I am committed to have this time available for us while you are at the hospital and ends after your discharge.”
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:
Ask the client what is the purpose of contacting his relatives.
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:
schizoid
27. Camila refuses to relate with to others because she:
anticipates rejection
28. Which of the following disturbances in interpersonal relationships MOST often predispose to the development of schizophrenia?
Faulty family atmosphere and interaction
29. Camila’s indifference toward the environment is a compensatory behavior to overcome:
Insecurity feelings
30. Schizophrenia is a/an:
psychosis
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:
overcompensation for hearing loss
32. A nursing diagnosis for Salome is:
social isolation
33. The nurse will assist Salome and her daughter to plan a goal which is for Salome to:
adjust to the loss of sensory and perceptual function
34. The daughter understood, the following ways to assist Salome meet her needs and avoiding which of the following:
Allowing her to take her meals alone
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:
prescribed level
Situation 8 – For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if something dreadful is going to happen. She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her.
36. Cecilia is demonstrating:
agoraphobia
37. Cecilia’s problem is that she always sees and thinks negative things hence she is always fearful. Phobia is a symptom described as:
neurotic
38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:
cognition
39. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. Which of the following should the nurse implement?
provide positive reinforcement for acceptable behavior
40. After discharge, which of these behaviors indicate a positive result of being able to overcome her phobia?
She drives alone along the long expressway.
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:
Confidentiality
42. The nurse must see to it that the written consent of mentally ill patients must be taken from:
Parents or legal guardian
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:
24 hours
44. The following are SOAP (Subjective – Objective – Analysis – Plan) statements on a problem: Anxiety about diagnosis. What is the objective data?
Has periods of crying; frequently verbalizes fear of what diagnostic tests will reveal
45. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the:
Identification of patient’s responses to medical diagnoses and treatment
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?
familial and genetic factors
47. All of the following, EXCEPT one compromise the concepts of behavior therapy program.
placebo as a form of treatment
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:
49. A therapeutic verbal approach that communicates strong disapproval is:
“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:
What does your child want that you can give every time he/she wakes up dry in the morning?
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