Board Exam Compilation Book 2

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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 0.3mg 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 CORRECT ANSWER: C RATIONALE: Asthma is a chronic inflammatory disorder of the airways resulting in reversible bronchoconstriction and air hunger in response to triggers from a variety of sources. When exposed to a trigger, the hyperactivity of the medium-sized bronchi causes the release of leukotrienes, histamine and other substances from the mast cells of the lung; these agents intensify the inflammatory process and cause bronchospasm. When inhaled in small doses, epinephrine causes short-term relief from the symptoms by widening the bronchial tubes allowing air to pass through. Once again epinephrine is not the best cure, but a temporary relief when an asthma inhaler is not present. OPTIONS A & D are incorrect OPTION B: Epinephrine does have a direct effect to relieve hypersensitivity to allergen SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Pathophysiology.pp.4-5; http://www.udel.edu/chem/C465/senior/fall00/Performance1/epinephrine.htm.html 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 CORRECT ANSWER: B RATIONALE: In preparing medications in ampule or any form of medications, always check first the expiration date and discard outdated medication. Check the label on the ampule carefully to make sure that the correct medication is being prepared. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 816 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 CORRECT ANSWER: D RATIONALE:To determine the angle of insertion , a general rule to follow relates to the amount of tissue that can be grasped at the site. A 45-degree angle is used when 1 inch of tissue can be grasped at the site; a 90-degree angle is used when 2 inches of tissue can be grasped. OPTION A: Skin Test For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
OPTION C: IM SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 822 4. When preparing for a subcutaneous injection, the proper size of syringe and needle would be: a. Syringe 3ml and needle gauge 21 to 23 b. Tuberculin syringe 1 ml with needle gauge 26 or 27 c. Syringe 2ml and needle gauge 22 d. Syringe l-3ml and needle gauge 25 to 27 CORRECT ANSWER: D RATIONALE: The type of syringe used for subcutaneous injections depends on the medication given. Generally a 2-ml syringe is used for most SC injections. However, if insulin is being administered, an insulin syringe is used; and if heparin is being administered, a tuberculin syringe or prefilled cartridge may be used. Needle sizes and lengths are selected based on the clients body mass,the intended angle of insertion and the planned site. Generally a #25-gauge, 5/8-inch needle is used for adults. OPTIONS A, B & C are incorrect th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 822 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 CORRECT ANSWER: B RATIONALE: Subcutaneous injections are given because there is little blood flow to fatty tissue and the injected medication is generally absorbed more slowly, sometimes over 24 hours. Some medications injected subcutaneously are growth hormone, insulin, epinephrine and other substances. OPTIONS A, C & D are all secondary reasons. SOURCE: http://www.cc.nih.gov/ccc/patient_education/pepubs/subq.pdf 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 the 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 CORRECT ANSWER: B RATIONALE: Qualitative research is the investigation of phenomena, typically in an in depth and holistic fashion, through the collection of rich narrative materials using a flexible design. Qualitative research relies on reasons behind various aspects of behavior. Simply put, it investigates the why and how of decision making, not just what, where, and when. Hence, the need is for smaller but focused samples rather than large random samples, which qualitative research categorizes data into patterns as the primary basis for organizing and reporting results. Qualitative researchers typically rely on four methods for gathering information: (1) participation in the setting, (2) direct observation, (3) in depth interviews, and (4) analysis of documents and materials OPTION A: Applied research focuses on finding solutions to existing problems. For example, a study to determine the effectiveness of a nursing intervention to ease grieving would be applied reaserch.
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OPTION C: Basic research is undertaken to extend the base of knowledge in a discipline, or to formulate or refine theory. OPTION D: Quantitative research is the investigation of phenomena that lend themselves to precise measurement and quantification, often involving rigorous and controlled design. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition.pp 18, 729; http://en.wikipedia.org/wiki/Qualitative_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 CORRECT ANSWER: C RATIONALE: Non-experimental research- studies in which the researcher collects data without introducing an intervention. OPTION A: In experiment, the researcher controls the independent variable and randomly assigns subjects to different conditions. OPTION B: Quasi-experiment is an intervention study in which subjects are not randomly assigned to treatment conditions, but the researcher exercises certain controls to enhance the studys internal validity. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. th 7 Edition.pp. 718,725,729 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 CORRECT ANSWER: D Rationale: Nursing research is systematic inquiry designed to develop knowledge about issues of importance to the nursing profession, including nursing practice, education administration, and informatics. Research designed to generate knowledge and to improve the health and quality of life of nurses clients. Nurses increasingly are expected to adopt an evidenced-based practice, which is broadly defined as the use of best clinical evidence in making patient care decisions. OPTIONS A,B and C are also correct but the best is option D SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition.pp. 3-4 9. Martha does review of related literature for the purpose of: a. Determine statistical treatment of data research b. Orientation to what is already known or unknown c. To identify if problem can be replicated d. Answering the research question CORRECT ANSWER: D RATIONALE: All of the choices are correct except D. Answer to the research question may be found after conducting the study. The following are purposes of a literature review: Identification of a research problem and development or refinement of research questions or hypothesis Orientation to what is known and not known about an area of inquiry, to ascertain what research can best make a contribution to the existing base of evidence Determination of any gaps or inconsistencies in abody of research Determination of a need to replicate a prior study in a different setting or with a different study population
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Identification or development of new or reined clinical interventions to test through empirical research Identification of relevant theoretical or conceptual frameworks for a research problem Identification of suitable designs and data collection methods for a study For those developing research proposals for finding, identification of experts in the fields who could be used as consultants Assistance in interpreting study findings and in developing implications and recommendations SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. th 7 Edition.pp. 5 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 CORRECT ANSWER: B RATIONALE: All are the clients rights for being the subject in a research except option B. The following are the basic human rights of research subjects: Right to informed consent The right to refuse and/or withdraw from participation Right to privacy Right to confidentiality or anonymity of data Right to be protected from harm SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10th Edition.pp.110-111 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 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 CORRECT ANSWER: B RATIONALE: Postural Drainage involves a patient assuming various positions to facilitate the flow of secretions from various parts of the lung into the bronchi, trachea and throat so that they can be cleared and expelled from the lungs more easily. The diagram below shows the correct positions to assume for draining different parts of the lung. OPTIONS A and C are inappropriate OPTION D will drain the lower lobes of the lung SOURCE: http://www.huff-n-puff.net/posturaldrainage.htm
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12. When documenting outcome of Richard's treatment, Mario should include the following in his recording EXCEPT: a. Color, amount and consistent 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 CORRECT ANSWER: C RATIONALE: The nurse needs to evaluate the clients tolerance of postural drainage by assessing the stability of the clients vital signs, particularly the pulse and respiratory rates and by noting signs of intolerance, such as pallor, diaphoresis, dyspnea and fatigue.Following Postural drainage, the nurse should auscultates the clients lungs, compare the findings to the baseline data, and document the amount, color, and character of expectorated secretions. OPTION C is not part of the documentation. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305 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 restriction and client's tolerance for lying flat CORRECT ANSWER: C RATIONALE: Option C, though is part of nursing interventions but it is not the focus during this time. OPTION A is important to prevent vomiting and aspiration OPTION B will give the nurse baseline data OPTION D is important because certain position is contraindicated to the client that may further lead to dyspnea th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 1305 14. Mario prepares Richard for postural drainage and percussion. Which of the flowing is a special consideration when doing the procedure? a. Respiratory rate of 16 to 20 per minute b. Client can tolerate sitting and lying position c. Client has no signs of infection For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
d. Time of last food and fluid intake of the client CORRECT ANSWER:D RATIONALE: Postural drainage treatments are scheduled two or three times daily, depending on the degree of lung congestion. The best times include before breakfast, before lunch, in the late afternoon and before bedtime. It is best to avoid hours shortly after meals because postural drainage at these times can be tiring and can induce vomiting. OPTION A has no special consideration since it is normal OPTIONS B & C dont have any special considerations SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1305 15. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedure is; a. Percussion uses only one hand white 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 CORRECT ANSWER: A RATIONALE: Percussion sometimes called clapping is forceful striking of the skin with cupped hands. Vibration is a series of vigorous quiverings produced by hands that are placed flat against the clients chest wall. Option A is true to both percussion and vibration. OPTION B is not the correct way OPTION C: percussion can be done with one hand OPTION D: percussion is not slapping th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp.1303,1305 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 white asking the client relevant questions CORRECT ANSWER: A RATIONALE: An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluating change, teach, provide support or provide counseling or therapy. Initially during an assessment, the nurse first asks the complaints of the client and the associated symptoms so that initial intervention can be done. OPTION B: the client is the primary source of data OPTIONS C and D: may follow after SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.265 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 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
d. Establish priority needs and implement appropriate interventions CORRECT ANSWER: C RATIONALE: Assessment is always done first before anything else. OPTION A and B are interventions OPTION D is diagnosing, planning and 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 CORRECT ANSWER: B RATIONALE: It is another question for prioritization. Clarifying what the patient mean of trouble going to sleep enable the nurse to plan for the appropriate intervention. OPTION A is inappropriate, may require some time before the intervention OPTIONS C is judgmental that the noise is the cause of trouble in sleeping OPTION D is inappropriate without further assessment 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 intervention 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 CORRECT ANSWER: A RATIONALE: All of the options are interventions for edema but option A is the immediate intervention. SOURCE: Black and Hawks. Medical Surgical Nursing.Vol. 1.7th Edition.pp. 217-218 20. Mr. Regalado will be discharged from your unit within the hour. Nursing actions when preparing a client for discharge include all EXCEPT: a. Teaching the factors that may trigger chest pain b. Giving instructions about his medication regimen c. Telling the patient to see the doctor for the final instruction d. Proper recording of pertinent data CORRECT ANSWER: C RATIONALE: Nurse preparing to send clients home needs to assess the following parameters in their clients: personal and health data, abilities to perform the activities of daily living (ADLs), any physical, cognitive or other functional limitations, caregivers responses and abilities, adequacy of financial resources, community supports, hazards or barriers that the home environment presents and need for health care assistance in the home. Essential information before discharge includes information about medications, dietary, and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments an telephone numbers, and where supplies can be obtained. OPTION C is inappropriate. The nurse is giving the patient discharge instruction before leaving the hospital. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 114 Situation 5 - Accurate computation prior to drug administration is a basic skill all nurses must have.
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21. Rudolf is diagnosed with amoebiasis and is to receive metronidazole (Flagyl) tablets 1.5 gm daily in 3 divided doses for 7 consecutive days. Which of the following is the correct dose of the drug that the client will receive per oral administration? a. 1,000 mg tid b. 500 mg tid c. 1,500 mg tid d. 250 mg tid CORRECT ANSWER: B RATIONALE: 1gram=1,000 milligram 1.5 gm x 1,000 mg = 1,500 mg 1,500 /3doses= 500 per oral administration 22. Rhona, a 2 year old female was prescribed to receive 62.5 mg suspension three times a day. The available dose is 125 mg/ml. Which of the following should Nurse Paulo prepare for each oral dose? a. .5 ml b. 1.25 ml c. 2.5 ml d. 1 ml CORRECT ANSWER: A RATIONALE: Q= Drug prescribed/ drug available or stock = 62.5 mg/125mg/ml = 0.5 ml 23. A client is ordered to take Lasix, a diuretic, to be taken orally daily. Which of the following is an appropriate instruction by the nurse? a. Report to the physician the effects of the medication on urination b. Take the medication early in the morning c. Take a full glass of water with the medication d. Measure frequency of urination in 24 hours. CORRECT ANSWER: B RATIONALE: furosemide (Lasix) is a diuretic that will increase urination so it is important to instruct patient to take the drug early in the morning to prevent problems in sleep because when taken at night, it will produced urinary frequency. OPTION A: Effects on urination is normal since it is a diuretics OPTION C: is not that important OPTION D: measuring the total amount of output is more important than the frequency Situation 6 - Mrs. Seva, 32 years old, asks you about possible problems regarding her elimination now that she is in the menopausal stage. 24. 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 sphincters 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 CORRECT ANSWER: D RATIONALE: Promoting Urinary Elimination For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
Instruct the client to respond to urge to void as soon as possible; avoid voluntary urine retention Teach the client to empty the bladder completely at each voiding Emphasize the importance of drinking 9-10 glasses of water daily Teach female clients about Kegels exercises to strengthen perineal muscles Etc. OPTION A is incorrect OPTION B might not always be correct, pineapple juice increase the acidity of urine but burning sensation may be an indication already of an existing disease. OPTION C: wiping should be from front to back 25. 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 the anus c. loss of tone of the smooth muscles of the colon d. decreased ability to absorb fluids in the lower intestines CORRECT ANSWER: C RATIONALE: If the feces are very hard or if there is great difficulty in passing it out, then it is constipation. Causes of constipation Peristalsis of the intestine in the elderly is usually weakened, hence they are more prone to constipation. Aging may also affect bowel regularity because a slower metabolism results in less intestinal activity and muscle tone. Inadequate water or lack of fibre in food, leading to hard faeces. Psychological factors, e.g. using bedpan or commode chair without privacy, a dirty toilet, depression, etc. Drugs such as morphine group pain killers, certain diuretics, calcium tablets. Diseases, e.g. diabetic mellitus, hypothyroidism. SOURCE:http://healthlink.mcw.edu/article/930592170.html;http://www.info.gov.hk/elderly/english/ healthinfo/healthproblems/constipation.htm 26. 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 CORRECT ANSWER: D Rationale: Laxatives contain chemicals that help increase stool motility, bulk, and frequency -thus relieving temporary constipation. But when misused or overused, they can cause problems, including chronic constipation! A healthy diet filled with fresh fruits, vegetables, and whole-grain products; regular exercise; and drinking at least eight cups of water daily can help prevent constipation in most people. Still, 85% of doctor visits for constipation result in a prescription for a laxative. So it's important to understand how laxatives work and how to use them safely. OPTION A&B will not cause constipation OPTION C: Some people think they are constipated if they do not have a bowel movement every day. However, normal stool elimination may be three times a day or three times a week, depending on the person. SOURCE: http://www.webmd.com/digestive-disorders/laxatives-for-constipation-using-themsafely?src=RSS_PUBLIC 27. Mrs. Seva talks about her 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: For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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 CORRECT ANSWER: D RATIONALE: It is important to remember that urinary incontinence is not part of normal aging and often treatable. Independent nursing interventions for clients with urinary incontinence include (a)a behavior-oriented continence training program that may consist of bladder training, habit training, prompted voiding, pelvic muscle exercises and positive reinforcement; (b) meticulous skin care and (c) for males, application of an external drainage device (condom-type catheter device). Pelvic muscle exercises (also known as Kegel exercises) work the muscles that you use to stop urinating. Making these muscles stronger helps you hold urine in your bladder longer. These exercises are easy to do. They can lessen or get rid of stress and urge incontinence. Kegel Exercises The muscles you want to exercise are your pelvic floor muscles. These are the ones you use to stop the flow of urine or to keep from passing gas. Often doctors suggest that you squeeze and hold these muscles for a certain count, and then relax them. Then you repeat this a number of times. You will probably do this several times a day. Your doctor will give you exact directions. OPTIONS A,B and C are inappropriate th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 1270; http://www.niapublications.org/agepages/urinary.asp 28. 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, rinsing and drying of skin area that get wet with urine d. Making sure that linen are smooth and dry at all times CORRECT ANSWER: C RATIONALE: Skin that is continually moist becomes macerated (softened). Urine that accumulates on the skin is converted to ammonia, which is very irritating to the skin. Because both skin irritation and maceration predispose the client to skin breakdown and ulceration, the incontinent person requires meticulous skin care. To maintain skin integrity, the nurse washes the clients perineal area with soap and water after episodes of incontinence, rinses it thoroughly, dries it gently and thoroughly and provides clean, dry clothing or bed linen. If the skin is irritated, the nurse applies barrier creams such as zinc oxide ointment to protect it from contact with urine. If it is necessary to pad the clients clothes for protection, the nurse should use products that absorb wetness and leave a dry surface in contact with the skin. OPTION A and B: Use of diapers and other containment devices may prevent the bedding and clothing from getting soiled, however they tend to keep the urine or stool in constant contact with the skin. Within a short period of time, the skin can become damaged. Special care must be taken to prevent skin breakdown by keeping the skin clean and dry. OPTION D is also correct but the best is option C SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1271; http://www.healthcentral.com/ency/408/003976.html 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. 29. Which of these clients has a problem with the transport of oxygen from the lungs to the tissues? a. Carol with a tumor in the brain b. Theresa with anemia For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. Sonny Boy with a fracture in the femur d. Brigette with diarrhea CORRECT ANSWER: B RATIONALE: Anemia is a condition characterized by abnormally low levels of healthy red blood cells or hemoglobin (the component of red blood cells that delivers oxygen to tissues throughout the body). The tissues of the human body need a regular supply of oxygen to stay healthy. Red blood cells, which contain hemoglobin that allows them to deliver oxygen throughout the body, live for only about 120 days. When they die, the iron they contain is returned to the bone marrow and used to create new red blood cells. Anemia develops when heavy bleeding causes significant iron loss or when something happens to slow down the production of red blood cells or to increase the rate at which they are destroyed. OPTIONS A, C and D has no direct effect in the oxygenation of tissues. SOURCE: http://www.answers.com/topic/anemia?cat=health 30. You noted from the lab exams in the chart of Mr. Santos that he has reduced oxygen in the blood. This condition is called: a. Cyanosis b. Hypoxia c. Hypoxemia d. Anemia CORRECT ANSWER: C RATIONALE: Hypoxemia is an abnormal deficiency in the concentration of oxygen in arterial blood (Mosby's Medical Dictionary). OPTION A: Cyanosis-a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood OPTION B: Hypoxia -a condition in which there is a decrease in the oxygen supply to a tissue. OPTION D: Anemia is having less than the normal number of red blood cells or less hemoglobin than normal in the blood. 31. You will do nasopharyngeal suctioning to 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 cheek c. the distance from the tip of the nose to the tip of the ear lobe d. eight to ten inches CORRECT ANSWER: C RATIONALE: Oropharyngeal or nasopharyngeal suctioning removes secretions from the upper respiratory tract. Make an appropriate measure of the depth of the catheter by measuring the distance between the tip of the clients nose and the earlobe, or about 13 cm (5 inches) for an adult. OPTIONS A, B and D are inappropriate th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 1318, 1320 32. While doing nasopharyngeal suctioning on Mr. Abad, the nurse can avoid trauma to the area by: a. Applying 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 inserted with gentle suction CORRECT ANSWER: C RATIONALE: For nasopharyngeal suctioning, without applying the suction, insert the catheter premeasured or recommended distance into either nares and advance it along the floor of the For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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nasal cavity. This avoids the nasal turbinates. Never force the catheter against an obstruction. If one nostril is obstructed, try another. OPTION A: Suction is applied for 5 to 10 seconds while slowly withdrawing the catheter. A suction attempt should last only 10 to 15 seconds. OPTION B is true to prevent infection but not avoiding trauma OPTION D: The catheter is rotated during suction not during the insertion of catheter and no suction is applied during the insertion of the catheter. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 1320 33. 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 CORRECT ANSWER: B RATIONALE: Orthopnea: The inability to breathe easily unless one is sitting up straight or standing erect. OPTION A: Apnea is the temporary cessation of breathing OPTION C: Dyspnea: Difficult or labored breathing; shortness of breath. OPTION D: Abnormally fast breathing. A respiratory rate that is too rapid. SOURCE: http://www.medterms.com/script/main/art.asp?articlekey=5702 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. 34. 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 brachial artery CORRECT ANSWER: D RATIONALE: Pump up the cuff until the sphygmomanometer reads 30 mmHg above the point where the brachial pulse disappeared. OPTION A: Wait 1 to 2 minutes before making further measurements. A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic readings will occur. OPTION C: Wrap the deflated cuff evenly around the upper arm. Locate the brachial artery. Apply the center of the bladder directly over the artery. The bladder inside the cuff must be directly over the artery to be compressed if the reading is to be accurate. For an adult, place the lower border of the cuff approximately 2.5 cm or 1 inch above the antecubital space. OPTION D is inappropriate th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 515-516 35. Chronic Obstructive Pulmonary Disease (COPD) in one of the leading causes of death worldwide and is a preventable disease. The primary cause of COPD is: a. tobacco hack b. bronchitis c. asthma d. cigarette smoking CORRECT ANSWER: D
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RATIONALE: COPD is a chronic lung disease. It has its own symptoms. The most common cause of COPD is known. And it's preventable. Smoking is the primary cause of COPD. It is 10 times more likely that a smoker will get COPD than a nonsmoker. Exposure to secondhand tobacco Cigarette smoke causes COPD by irritating the airways and creating inflammation that narrows the airways, making it more difficult to breathe. Cigarette smoke also causes the cilia to stop working properly so mucus and trapped particles are not cleaned from the airways. As a result, chronic cough and excess mucus production develop, leading to chronic bronchitis. OPTION B: is one of the diseases in COPD OPTION A and C:incorrect SOURCE: http://www.clevelandclinic.org/health/health-info/docs/2400/2416.asp?index=8709 http://www.copdguide.com/copd-is-different.jsp 36. In your health education class for clients with diabetes you teach, them the areas for control Diabetes which include all EXCEPT: a. regular physical activity b. thorough knowledge of foot care c. prevention of infection d. proper nutrition CORRECT ANSWER: B RATIONALE: Option D: In order to maintain a constant blood sugar level, diabetics should ideally eat approximately the same amount of food per day, with a set number of calories at around the same time of day so that blood sugar levels dont fluctuate too much. In addition, healthy snacks should be enjoyed to stop the blood glucose levels from dropping too much in between meals. Meals should never be skipped and the days food should contain a mixture of whole grains, fruits, lean meat or meat substitutes i.e. corn, vegetables and low fat dairy products. OPTION A: In conjunction with a healthy low fat diet, moderate exercise should be taken at least five times a week for around 30 minutes each session. How a diabetic person chooses to exercise will depend to some extent on their initial level of fitness i.e. obese people will not go jogging or cycling for miles at a time, and any exercise routine should only be performed after consulting a doctor. As an individual starts to lose weight then the level of physical activity can be increased accordingly but overdoing it to begin will undoubtedly lead to even bigger problems. OPTION C: Infection may result to hyperglycemia because the body requires more glucose for energy. Thus preventing infection also control diabetes OPTION B: A knowledge on foot care prevents complication of diabetic foot but does not control diabetes itself. SOURCE: http://www.diabeticlive.com/articles/17/1/Controlling-Diabetes-With-Diet-AndExercise/Page1.html 37. You teach your clients the difference between, Type I (IDDM) and Type II (NDDM) Diabetes. Which of the following is true? a. both types of diabetes mellitus clients are all prone to develop 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 (IDDM) is characterized by fasting hyperglycemia d. Type II (IDDM) is characterized by abnormal immune response CORRECT ANSWER: B RATIONALE: While it is said that type 2 diabetes occurs mostly in individuals over 30 years old and the incidence increases with age, we are seeing an alarming number patients with type 2 diabetes who are barely in their teen years. In fact, for the first time in the history of humans, type 2 diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a direct result of poor eating habits, higher body weight, and lack of exercise.Type 1 diabetes was also called insulin dependent diabetes mellitus (IDDM), or juvenile onset diabetes mellitus. In type 1 diabetes, the pancreas undergoes an autoimmune attack by the body itself, and is rendered For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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incapable of making insulin. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Antibodies are proteins in the blood that are part of the body's immune system. The patient with type 1 diabetes must rely on insulin medication for survival. In autoimmune diseases, such as type 1 diabetes, the immune system mistakenly manufactures antibodies and inflammatory cells that are directed against and cause damage to patients' own body tissues. In persons with type 1 diabetes, the beta cells of the pancreas, which are responsible for insulin production, are attacked by the misdirected immune system. It is believed that the tendency to develop abnormal antibodies in type 1 diabetes is, in part, genetically inherited, though the details are not fully understood. OPTION A: ketoacidosis -- mostly in people with type 1 diabetes -- and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) in people with type 2 diabetes or in people at risk for type 2 diabetes. OPTION C:There is no such thing as fasting hyperglycemia OPTION D: Type I is characterized by abnormal immune response SOURCE: http://www.medicinenet.com/diabetes_mellitus/page3.htm 38. Lifestyle-related diseases in general share common risk factors. These are the following except a. physical activity b. smoking c. genetics d. nutrition CORRECT ANSWER: C RATIONALE: A way of life or style of living that reflects the attitudes and values of a person or group. Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Categories of lifestyle generally assessed are physical activity, nutritional practices, stress management and such habits as smoking, alcohol consumption and drug use. OPTION C genetics is the scientific study of heredity. Genetics pertains to humans and all other organisms. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 128 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. 39. 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 CORRECT ANSWER: D RATIONALE: The first priority whenever an accident occurs is to deal with the emergency and ensure that any injuries or illnesses receive prompt medical attention. SOURCE: http://web.princeton.edu/sites/ehs/healthsafetyguide/A2.htm 40. 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 of breathing c. Noel who has lacerations on the arms with mild-bleeding d. Andy whose left ankle swelled and has some abrasions CORRECT ANSWER: B RATIONALE: Respiratory problems and problem with the oxygenation should always be the priority. OPTION A is least priority because it is a psychological need OPTION C is the second OPTION D is the third
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41. 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 CORRECT ANSWER: D RATIONALE: Bleeding from any external wound sites on the victim's body should be controlled to prevent the victim from going into shock which could lead to death if not treated immediately. Elevation - Keeping the wound above the level of the heart will decrease the pressure at the point of injury, and will reduce the bleeding. Direct Pressure - Placing pressure on the wound will constrict the blood vessels manually. After applying pressure for sometime, you can make a pressure bandage around the injury site. The key is to not make this too tight to cut all circulation because this could have direct consequences later on. The bandage should be tight enough to maintain pressure on the wound but not too tight to impede any blood flow. If the skin turns purple-blue or if there is no pulse present at the major pressure pints then the pressure bandage is on too tight. OPTION A does not address the immediate need of the patient OPTION B is incorrect because it may induce more bleeding OPTION C is correct but option D is more specific SOURCE: http://en.wikipedia.org/wiki/Emergency_bleeding_control 42. The nurse applies pressure 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 micro organisms in the air d. Promote hemostasis CORRECT ANSWER: D RATIONALE: Hemostasis is the stoppage of bleeding or hemorrhage. Also, the stoppage of blood flow through a blood vessel or organ of the body Pressure dressing is a nonadherent bandage applied over the incision that is covered by an absorbent layer and a stretchable adhesive. This application is intended to compress dead space and prevent hematoma and seroma formation. SOURCE: http://www.woundsresearch.com/Pressure-dressing 43. 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 CORRECT ANSWER: C RATIONALE: Nurse preparing to send clients home needs to assess the following parameters in their clients: personal and health data, abilities to perform the activities of daily living (ADLs), any physical, cognitive or other functional limitations, caregivers responses and abilities, adequacy of financial resources, community supports, hazards or barriers that the home environment presents and need for health care assistance in the home. Essential information before discharge includes information about medications, dietary, and activity restrictions, signs of complications that need to be reported to the physician, follow-up appointments an telephone numbers, and where supplies can be obtained. OPTION C: The client does not have the direct appointment with the nurse after the discharge. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 114 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. 44. The nurse purpose of your initial nursing interview is to: a. Record pertinent information in the client chart for health team to read b. Assist the client find solutions to 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 CORRECT ANSWER: C RATIONALE: An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluating change, teach, provide support or provide counseling or therapy. Initially during an assessment, the nurse first ask the complaints of the client and the associated symptoms so that initial intervention can be done. It is an umbrella effect. Option C encompasses options A, B and D. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.265 45. 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 few weeks now CORRECT ANSWER: D RATIONALE: To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the clients health status. Data are recorded in a factual manner and not interpreted by the nurse. OPTION D is more complete recording of the patients complaints. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp.274 46. 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 the major food groups with plenty of fluids CORRECT ANSWER: D RATIONALE: Diet planning principles (ABCNMV) 1. Adequacy -Provides sufficient energy and nutrients 2. Balance For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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- Consume a number of different foods in appropriate proportion to each other 3. kCalorie control -Energy balance 4. Nutrient density -Large amount of nutrients in a food with a small amount of calories 5. Moderation -In consuming foods that are not nutrient dense 6. Variety -Consume a variety of foods within and among the food groups OPTION A is inappropriate because the patient is already in vegetable diet OPTION B is limited only in protein and carbohydrates OPTION C is limited to carbohydrates only SOURCE: http://www.usm.edu/~nfs362/chap2.out.PDF 47. 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 she 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 the mother and the baby d. Studies show conclusively that caffeine causes mental retardation CORRECT ANSWER: B RATIONALE: Maternal malnutrition impairs pregnancy outcome, increases maternal mortality and retards early childhood development. 18 million low-birth weight babies are born to undernourished mothers each year. This is a prime cause of infant mortality in developing countries OPTION A, C and D are all limited to effects of caffeine SOURCE: http://www.iaea.org/Publications/Booklets/Malnutrition/four.html 48. 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 of the following EXCEPT: a. Cardiovascular diseases b. Cancer c. Diabetes Mellitus d. Osteoporosis CORRECT ANSWER: D RATIONALE: Your cardiovascular system consists of your heart and all blood vessels throughout your body. Diseases ranging from aneurysms to valve disease are types of cardiovascular disease. You may be born with some types of cardiovascular disease (congenital) or acquire others later on, usually from a lifetime of unhealthy habits, such as smoking, which can damage your arteries and cause atherosclerosis Cigarette smoking causes 87 percent of lung cancer deaths (1). Lung cancer is the leading cause of cancer death in both men and women (3). Smoking is also responsible for most cancers of the larynx, oral cavity and pharynx, esophagus, and bladder. In addition, it is a cause of kidney, pancreatic, cervical, and stomach cancers (2, 4), as well as acute myeloid leukemia (2). OPTION D:Osteoporosis occurs when an imbalance occurs between new bone formation and old bone resorption. The body may fail to form enough new bone, or too much old bone may be reabsorbed, or both. Two essential minerals for normal bone formation are calcium and phosphate. Throughout youth, the body uses these minerals to produce bones. If calcium intake For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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is not sufficient or if the body does not absorb enough calcium from the diet, bone production and bone tissue may suffer. SOURCE: http://www.emedicinehealth.com/osteoporosis/page2_em.htm; http://www.cancer.gov/cancertopics/factsheet/Tobacco/cancer http://www.mayoclinic.com/health/cardiovascular-disease/HB00032/UPDATEAPP=0 Situation 11 - Management of nurse practitioners is done by qualified nursing leaders who have had clinical experience and management experience. 49. An example of a management function of a nurse is: a. Teaching patient do breathing and coughing exercises b. Preparing for a surprise party for a client c. Performing nursing procedures for clients d. Directing and evaluating the staff nurses CORRECT ANSWER: D RATIONALE: Management has a unique purpose and outcome that is needed to maintain a healthy organization. Management functions include planning, organizing, staffing, directing and controlling. According to Kleinman,the basic components of management functions include planning, organizing, delegating, problem solving, evaluating and enforcing policies and procedures. Other options are not correct SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in Nursing. Theory and applications. 5th Edition.pp. 39-41 50. Your head nurse in the unit believes that the staff nurses are not capable of decision making so she makes the decisions for everyone without consulting anybody. This type of leadership is: a. Laissez faire leadership b. Democratic leadership c. Autocratic leadership d. Managerial leadership CORRECT ANSWER: C RATIONALE: Autocratic Leadership Style This is often considered the classical approach. It is one in which the manager retains as much power and decision-making authority as possible. The manager does not consult employees, nor are they allowed to give any input. Employees are expected to obey orders without receiving any explanations. The motivation environment is produced by creating a structured set of rewards and punishments. OPTION A:The laissez-faire leadership style is also known as the hands-off style. It is one in which the manager provides little or no direction and gives employees as much freedom as possible. All authority or power is given to the employees and they must determine goals, make decisions, and resolve problems on their own. OPTION B:The democratic leadership style is also called the participative style as it encourages employees to be a part of the decision making. The democratic manager keeps his or her employees informed about everything that affects their work and shares decision making and problem solving responsibilities. This style requires the leader to be a coach who has the final say, but gathers information from staff members before making a decision OPTION D:A managers style of managing has been a continuing cause of concern to his manager's style is one of the major contributors to the performance and effectiveness of his unit. The desire to define how a manager should conduct himself while working with others has led to investigations into those variables that may affect levels of managerial performance. This article examines, in summary form, investigations by various management authorities on the subject of managerial styles. These investigations have been developed into three theories of managerial style: trait, behavior, and situation. SOURCE: http://www.essortment.com/all/leadershipstyle_rrnq.htm
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http://www.airpower.maxwell.af.mil/airchronicles/aureview/1976/mar-apr/dean.html 51. When the head nurse in your ward plots and approves your work schedules and directs your work, she is demonstrating: a. Responsibility b. Delegation c. Accountability d. Authority CORRECT ANSWER: D RATIONALE: Authority is defined as the legitimate right to direct the work of others. Authority is an integral component of managing. OPTION A: Responsibility is an obligation to complete a task. OPTION B: Delegation is the assignment of authority and responsibility to another person (normally from a manager to a subordinate) to carry out specific activities. However the person who delegated the work remains accountable for the outcome of the delegate work. It allows a subordinate to make decisions, i.e. it is a shift of decision-making authority from one organizational level to a lower one. OPTION C: Accountability is the ability and willingness to assume responsibility for ones actions and accept the consequences of ones behavior. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 477 52. The following tasks can be safely delegated by a nurse to a non-nurse health worker EXCEPT: a. Transfer a client from bed to chair b. Change IV infusions c. Irrigation of a nasogastric tube d. Take vital signs CORRECT ANSWER: B RATIONALE: Delegation is transferring to a competent individual the authority to perform a specific nursing task in a selected situation. The nurse retains the responsibility and the accountability for the delegated tasks. The registered nurse directs care and determines the appropriate utilization of any nursing assistant/nurse aide involved in providing direct patient care. The registered nurse may delegate components of care but does not delegate the nursing process itself. The functions of assessment, planning, evaluation and nursing judgment are pervasive to nursing practice and cannot be delegated. The registered nurse delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures. Tasks that may be delegated to an unlicensed assistive personnel: Taking of vital signs Measuring and recording intake and output Patient transfer and ambulation Postmortem care Bathing Feeding Clean Catheterization Gastrostomy feedings in established settings Attending to safety Performing simple dressing changes Suctioning of chronic tracheotomies Performing basic life support Tasks that may not be delegated to an unlicensed assistive personnel: Assessment For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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Interpretation of data Making a nursing diagnosis Creation of a nursing care plan Evaluation if care effectiveness Care of invasive lines Administering parenteral medications Performing venipuncture Insertion of NGT Client education Performing triage Giving telephone advise Performing sterile procedures SOURCE: Kozier Fundamentals of Nursing. 7th ed. p. 470 53. You made a mistake in giving the medicine to the wrong client. You notify the client's doctor and write an incident report. You are demonstrating: a. Responsibility b. Accountability c. Authority d. Autocracy CORRECT ANSWER: B RATIONALE: Accountability is the ability and willingness to assume responsibility for ones actions and accept the consequences of ones behavior. OPTION A: Responsibility is an obligation to complete a task. OPTION C:Authority is defined as the legitimate right to direct the work of others. Authority is an integral component of managing. OPTION D:Autocracy-government by a single person having unlimited power; despotism.A country or state that is governed by a single person with unlimited power. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 477 Situation 12 - Mr. Dizon, 84 years old, is brought to the .Emergency Room for complaint of hypertension flushed face, severe headache, and nausea. You are doing the initial assessment of vital signs. 54. You are to measure the client's initial blood pressure reading by doing all of the following EXCEPT: a. Take the blood pressure reading on both arms for comparison b. Listen to and identify the phases of Korotkoff's sounds c. Pump the cuff up to around 50 mmHg above the point where the pulse is obliterated d. Observe procedures for infection control CORRECT ANSWER: C RATIONALE: All are correct guidelines in measuring the blood pressure except Option C. The cuff is pumped until the sphygmomanometer reads 30mmHg above the point where the brachial pulse disappeared. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 516 55. A pulse oximeter is attached to Mr. Dizon's finger to: a. Determine if the client's hemoglobin level is low and if he needs blood transfusion b. Check level of client's tissue perfusion c. Measure the efficacy of the client's anti hypertensive medications d. Detect oxygen saturation of arterial blood before symptoms of hypoxemia develops CORRECT ANSWER: D RATIONALE: A pulse oximeter is a noninvasive device that measures a clients arterial blood oxygen saturation by means of a sensor attached to the clients finger, toe, nose, earlobe or
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forehead ( or around the hand or foot of a neonate). The pulse oximeter can detect hypoxemia before clinical signs and symptoms, such as dusky skin color and dusky nailbeds develop. OPTIONS A, B and C are incorrect th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 517 56. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be: a. Inconsistent b. low systolic and high diastolic pressure c. higher than what the reading should be d. lower than what the reading should be CORRECT Answer: C Rationale: When the cuff is too narrow it will give the nurse an erroneously high reading. OPTION A is a result of failure to use the same arm consistently OPTION B is a result of deflating the cuff too quickly OPTION D is a result of using too wide cuff SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 514 57. Through the client's health history, you gather that Mr. Dizon smokes and drinks coffee. When taking the blood pressure of a client who recently smoked or drank coffee, how long should be the nurse wait before taking the client's blood pressure for accurate reading? a. 15 minutes b. 30 minutes c. 1 hour d. 5 minutes CORRECT ANSWER: B RATIONALE: Make sure that the client has not smoked or ingested caffeine within 30 minutes prior to measurement. OPTIONS A,C and D are incorrect th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 515 58. While the client has the pulse oximeter on his fingertip, you notice that the sunlight is shining on the area where the oximeter is. Your action will be to: a. Set and turn on the alarm of the oximeter b. Do nothing since there is no identified problem c. Cover the fingertip sensor with a towel or bedsheet d. Change the location of the sensor every four hours CORRECT ANSWER: C RATIONALE: Cover the sensor with sheet or towel to block large amounts of light from external sources (e.g., sunlight, procedure lamps, or bilirubin lights in the nursery). Large amounts of outside light may be sensed by the photodetector and alter the oxygen saturation value. OPTION A: It signals high and low SaO2 measurements and a high and low pulse rate. It is turned on before leaving the patient. OPTION B is a form of negligence OPTION D: done as part of the monitoring to ensure client safety th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 519
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Situation 13 - The nurse's understanding of ethico-legal responsibilities will guide his/her nursing practice. 59. The principles that -govern right and proper conducts of a person regarding life, biology and the health professions is referred to as: a. Morality b. Religion c. Values d. Bioethics CORRECT ANSWER: D RATIONALE: Bioethics is a branch of applied ethics that studies the philosophical, social, and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and well-being, though it sometimes also treats ethical questions relating to the nonhuman biological environment. OPTION A: The quality of being in accord with standards of right or good conduct. OPTION B: Belief in and reverence for a supernatural power or powers regarded as creator and governor of the universe. OPTION C: Values are considered subjective and vary across people and cultures. Types of values include ethical/moral values, doctrinal/ideological (political, religious) values, social values, and aesthetic values. 60. The purpose of having nurses' code of ethics is: a. Delineate the scope and areas of nursing practice b. Identify nursing action recommended for specific healthcare situations c. To help the public understand professional conduct, expected of nurses d. To define the roles and functions of the health care giver, nurses, clients CORRECT ANSWER: C RATIONALE: The professional code of ethics for Filipino nurses provide direction for the nurses to act morally. It strongly emphasizes the four-fold responsibility of the nurse, the universality of the nursing practice, the scope of the responsibilities to the people they serve, to co-workers, to society and environment and to their profession. OPTION A is The RA 9173 of the Nursing Act of 2002 th SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 Edition.pp. 128-129 61. Potassium chloride (KCL) was ordered by a physician. The nurse administered it by directive push. The patient died instantly of ventricular fibrillation. She is liable for. a. Negligence b. Malpractice c. Battery d. Assault CORRECT ANSWER: A RATIONALE: Negligence is the commission or omission of an act that a reasonable and prudent person would do in a similar situation or would not have done. It is also a misconduct or practice that is below the standard expected of an ordinary, reasonable and prudent person. Such conduct places another person at risk for harm. Both medical and nonmedical professional person can be liable for negligent acts. Below are the specific examples of Negligence: 1. failure to report observations to attending physicians 2. failure to exercise the degree of diligence which the circumstances of the particular case demands. 3. Mistaken Identity 4. wrong medicine, wrong concentration, wrong route, wrong dose.
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5. Defects in the equipment such as stretchers and wheelchairs may lead to falls thus injuring the patient. 6. Errors due to family assistance 7. administration of medicines without the doctors prescription. OPTION B: malpractice in the usual sense implies the idea of improper or unskillful care of a patient by a nurse. Malpractice also denotes stepping beyond ones authority with serious consequences. Malpractice is a term for negligence or carelessness of professional personnel. An example of malpractice is giving of anesthesia of a nurse or prescribing a medicine. OPTION C: Battery is an intentional, unconsented touching of another person. It is, therefore, procedures, he must have given consent to this effect. If consent has not been secured, the person performing the procedure may be liable for battery. OPTION D: assault is the imminent threat of harmful or offensive bodily contact. It is unjustifiable to touch another person, to threat to do so in such circumstances as to cause the other to reasonably believe that it will be carried out. th SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 Edition.pp.. 178, 181 62. You inform the patient about his rights which include the following EXCEPT: a. Right to expect reasonable continuity of care b. Right to consent to or decline to participate in research studies or experiments c. Right to obtain information about another patient d. Right to expect that the records about his care will be treated as confidential CORRECT ANSWER: C RATIONALE: All are rights of the patient except option C. Other patients dont have the right to obtain information about the other patients. SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10th Edition.pp. 358-361 63. The principle states that a person has unconditional worth and has the capacity to determine his own destiny. a. Bioethics b. Justice c. Fidelity d. Autonomy CORRECT ANSWER: D RATIONALE: Autonomy comes from the Greek word autos meaning self and nomos meaning governance. It involves self-determination and freedom to choose and implement ones decision, free from deceit, duress, constraint or coercion. OPTION A:Bioethics is a branch of applied ethics that studies the philosophical, social, and legal issues arising in medicine and the life sciences. It is chiefly concerned with human life and wellbeing, though it sometimes also treats ethical questions relating to the nonhuman biological environment. OPTION B: Justice refers to the right to demand to be treated justly, fairly and equally. OPTION C:Exact correspondence with fact or with a given quality, condition, or event; accuracy. th SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 Edition.pp. 99,103 Situation 14 - Your director of nursing wants to improve the quality of health care offered in the hospital. As a staff nurse in that hospital you know that this entails quality assurance programs. 64. A legislative enactment that serves as a defense to malpractice is the Good Samaritan statute. The following statements are correct, except: a. It protects health care provides from civil liability that may be incurred in stopping to render aid at the scene of an accident. b. It also applies to hospital care given to a client as long it is of an emergency nature For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. Health care professionals may still be sued by an injured victim for gross negligence. d. Health care provides should not charge the patient during an emergency if they want to be covered by the statute. CORRECT ANSWER B RATIONALE:All of the choices, except for B, are correct. In the United States, the Good Samaritan Law has been passed to encourage on-the-spot volunteer first aid in emergency situations by persons with knowledge and skill. A nurse therefore who renders first aid or treatment at the scene of an emergency and who does so within the standard of care, acting in good faith, is relieved of the consequences of the act (Venzon, 124). The Good Samaritan Act does not apply in the hospital, only on On-the-spot situations. SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10th Edition.pp. 124 65. Standards of nursing practice serve as guide for: a. Nursing practice in the different fields of nursing b. Proper nursing approaches and techniques c. Safe nursing care and management d. Evaluation of nursing cared rendered CORRECT ANSWER: C RATIONALE: Establishing and implementing standards of practice are major functions of a professional organization. The standards (a) reflect the values and priorities of the nursing profession, (b) provide direction for professional nursing practice, (c) provide a framework for the evaluation of nursing practice, and (d) define the professions accountability to the public and the client outcomes for which nurses are responsible (Kozier, 9). OPTION A does not refer to Standards OPTION B refers to Manual of Procedure OPTION D refers to Controlling of the management process (Marquis, 28). SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 9 Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in Nursing. th Theory and applications. 5 Edition.pp. 28 66. You are taking care of critically ill client and the doctor in charge calls to order a DNR (do not resuscitate) for the client. Which of the following is the appropriate action when getting DNR order over the phone? a. Have the registered nurse, family spokesperson, nurse supervisor and doctor sign b. Have two nurses validate the phone order, both nurses sign the order and the doctor should sign his order within 24 hours. c. Have the registered nurse, family and doctor sign the order d. Have 1 nurse take the order and sign it and have the doctor sign it within 24 hours CORRECT ANSWER: D RATIONALE: Doctors should limit orders to extreme emergency situations where there is no alternative. Only in an extreme emergency and when no other resident or intern is available should a nurse receive telephone orders. The nurse should read back such order to the physician to make certain the order has been correctly written. Such order should be signed by the physician on his/her next visit within 24 hours. The nurse should sign the name of physician per her own and note the time the order was received. All other options are incorrect th SOURCE: Venzon, Lydia and Venzon, Ronald. Professional Nursing in the Philippines.10 Edition.pp 172-173 67. To ensure the client safety before starting blood transfusion the following are needed before the procedure For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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can be done EXCEPT: a. take baseline vital signs b. blood should be warmed to room temperature for 30 minutes before blood transfusion is administered c. have two nurses verify client identification, blood type, unit number and expiration date of blood d. get a consent signed for blood transfusion CORRECT ANSWER: D RATIONALE: Options A,B and C are correct. It is true that consent is signed before the blood transfusion but its the physicians responsibility to let the patients sign the consent. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 1402 68. Part of standards of care has to do with the use of restraints. Which of the following statements is NOT true? a. Doctor's order for restraints should be signed within 24 hours b. Remove and reapply restraints every two hours c. Check client's pulse, blood pressure and circulation every four hours d. Offer food and toileting every two hours CORRECT ANSWER: C RATIONALE: All options are correct except option C. It is correct to check clients pulse, blood pressure and circulation but it is done simultaneously every 2 hours when you remove the restraints. SOURCE: Kozier & Erb. Fundamentals of Nursing. 689 Situation 15 - During the NUTRITION EDUCATION class discussion a 58 year old man, Mr. Bruno shows increased interest. 69. Mr. Bruno asks what the "normal" allowable salt intake is. Your best response to Mr. Bruno is: a. 1 tsp of salt/day with iodine and sprinkle of MSG b. 5 gms per day or 1 tsp of table salt/day c. 1 tbsp of salt/day with some patis and toyo d. 1 tsp of salt/day but not patis or toyo CORRECT ANSWER: B RATIONALE: A minimum recommendation is proposed by the RDA in the amount of 500 mg/day for adults. SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Nutrition and diet therapy.pp. 70. Your instructions to reduce or limit salt intake include all the following EXCEPT: a. eat natural food with little or no salt added b. limit use of table salt and use condiments instead c. use herbs and spices d. limit intake of preserved or processed food CORRECT ANSWER: B RATIONALE: All are correct except option B because condiments still contains more sodium along with other spices. Tips for Reducing Sodium in Your Diet Buy fresh, plain frozen, or canned "with no salt added" vegetables. Use fresh poultry, fish, and lean meat, rather than canned or processed types. Use herbs, spices, and salt-free seasoning blends in cooking and at the table. Cook rice, pasta, and hot cereals without salt. Cut back on instant or flavored rice, pasta, and cereal mixes, which usually have added salt Choose "convenience" foods that are lower in sodium. Cut back on frozen dinners, pizza, packaged mixes, canned soups or broths, and salad dressings these often have a lot of sodium. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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Rinse canned foods, such as tuna, to remove some sodium. When available, buy low- or reduced-sodium, or no-salt-added versions of foods. Choose ready-to-eat breakfast cereals that are lower in sodium. SOURCE: http://www.nhlbi.nih.gov/hbp/prevent/sodium/tips.htm 71. Which of the following behaviors by a client indicates to the nurse that learning in cognitive domain has taken place? a. Physically demonstrating how to cook low sodium dish b. Actively demonstrating the new skill c. Telling the nurse that he has accepted the illness and its effects on lifestyle d. Explaining the need to have low sodium diet CORRECT ANSWER: D RATIONALE: Learning in the cognitive domain involves the acquisition and use of knowledge mentally or intellectually. OPTION A and B involve learning in the psychomotor domain OPTION C involves learning in the affective domain which involves changing feelings and values toward a positive health behavior. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 448 72. The nurse determines that dietary teaching has been effective when a client states that which of the following food items has the highest sodium content? a. milk b. fresh fruits c. meats d. chocolate pudding CORRECT Answer: D RATIONALE: Processed foods have the highest sodium content. Chocolate pudding is the only option that reflects a processed food item. The other options are of lower sodium content. SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Nutrition and diet therapy.pp. 86 73. The role of the health worker in health education is to: a. report incidence of non-communicable disease to community health center b. educate as many people about warning signs of non-communicable diseases c. focus on smoking cessation projects d. monitor clients with hypertension CORRECT ANSWER: B RATIONALE: Individuals and communities who seek to increase their personal health and selfcare require health education. The trend toward health promotion has created the opportunity for nurses to strengthen the professions influence on health promotion, disseminate information that promotes an educated public and assist individuals and communities to change long-standing health behaviors. As health educator, our main function is to educate the people about illness care, the prevention of problems and the promotion of optimal wellness and well-being. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp.125, 143 Situation 16 - You are assigned to take care of 10 patients during the morning shift. The endorsement includes the IV infusion and medications for these clients. 74. Mr- Felipe, 36 years old is to be given 2700ml of D5RL to infuse for 18 hours starting at 8am. At what rate should the IV fluid be flowing hourly? a. 100 ml/hour b. 210 ml/hour c. 150 ml/hour For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. 90 ml/hour CORRECT ANSWER: C RATIONALE: Milliliters per hour= Total infusion volume/Total infusion time = 2700ml/18hours = 150 ml/hr SOURCE: Kozier & Erb. Fundamentals of Nursing. 1391 75. Mr. Lagro is to receive 1 liter of D5LR to run for 12 hours. The drop factor of the IV infusion set is 10 drops per minute. Approximately, how many drops per minute should the IV is regulated? a. 13-14 drops b. 17-18 drops c. 10-12 drops d. 15-16 drops CORRECT ANSWER: A RATIONALE: Drops per minute= Total infusion volume x drop factor Total of infusion in minutes = 1000 ml x 10 12hr x 60min = 13.89 drops 76. You are to apply a transdermal patch of nitroglycerin to your client. The following important guidelines to observe EXCEPT: a. Apply to clean hairlines of the skin that are not subject to too much wrinkling b. Patches may be applied to distal part of the extremities like forearm c. Change application and site regularly to prevent irritation of the skin d. Wear gloves to avoid any medication of your hand CORRECT ANSWER: B RATIONALE: All of the options are correct except option B. Transdermal dosage forms can be applied to any nonhairy part of the skin except distal parts of arms and legs because absoption wont be maximal at distal sites. SOURCE: Lippincott Williams and Wilkins. Nursing 2006 Drug handbook.26 th Edition.pp. 268 77. You will be applying eye drops to Miss Romualdez. After checking all the necessary information and cleaning the affected eyelid and eyelashes you administer the ophthalmic drops by instilling the eye drops. a. directly onto the cornea b. pressing on the lacrimal duct c. into the outer third of the upper conjunctival sac d. from the inner canthus going towards the side of the eye CORRECT ANSWER: B RATIONALE: Pressing the lacrimal duct prevents the absorption through the tear duct and drainage of the medication. OPTION A: It is not instilled directly in cornea but on the sac formed by lower lid. OPTION C: it should be outer third of lower conjunctival sac OPTION D: it is true in an eye ointment. SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Pharmacology.pp. 580 78. When applying eye ointment, the following guidelines apply EXCEPT: a. squeeze about 2 cm of ointment and gently close but not squeeze eye b. apply ointment from the inner canthus going outward of the affected eye
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c. discard the first bead of the eye ointment before application because the tube likely to expel more than desired amount of ointment d. hold the tube above the conjunctival sac do not let tip touch the conjunctiva CORRECT ANSWER: C Rationale: All are guidelines in administering eye ointment except C. In order not to expel more than the desired amount of the medication, hold the tube of ointment in your hand for a few moments. This will warm the medicine so it will flow easily from the tube. Do not use ointment that has dried out. Or The first bead of ointment from a tube is discarded because it is considered to be contaminated not because it will expel more than the desired amount. SOURCE: Kozier & Erb. Fundamentals of Nursing pp.841; Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Pharmacology.pp. 580; http://www.med.umich.edu/1libr/aha/aha_dropoint_oph.htm Situation 17 - Nursing management is performing leadership functions of governance and decisionmaking within organizations employing nurses. 79. The unit manager is meeting with the director of nursing for the unit managers yearly performance review. The director of nursing states that the unit manager needs to improve leadership skills. In differentiating leadership from management, the nurse manager recognizes that which of the following approaches will apply? a. The manager works more one-on-one with staff b. A leader seeks a higher position on an organizational chart c. A good leader uses managerial principles d. A manager is not required to use leadership principles CORRECT ANSWER: C RATIONALE: A good leader can incorporate managerial theories into practice, whereas a manager does does not necessarily utilize leadership techniques. It is unnecessary to work onon-one with staff unless the need arises. OPTIONS B and D are false statements SOURCE: Hogan, Mary Ann and Hill, Karen.Prentice Hall.Reviews and Rationales series for nursing. Fundamentals of nursing.pp. 90, 104 80. When Mrs. Guevarra, a nurse, delegates aspects of the clients care to the nurse-aide who is an unlicensed staff, Mrs. Guevarra. a. makes the assignment to teach the staff member b. is assigning the responsibility to the aide but not the accountability for those tasks c. does not have to supervise or evaluate the aide d. most know how to perform task delegated CORRECT ANSWER: B RATIONALE: Delegation is the transference of responsibility and authority for the performance of an activity to a competent individual. It is important to note that the nurse is not held legally responsible for the acts of the unlicensed person, but is accountable for the quality of the acts of delegation and has the ultimate responsibility to ensure that proper care is provided. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 470-471 81. A staff nurse is responsible for the care of the assigned client from admission to discharge. When the staff nurse is not on duty, others provide care based on instructions left by the staff nurse. Which type of nursing assignment does this represent? a. Case management b. Team c. Primary For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. Functional CORRECT ANSWER: C RATIONALE: In primary nursing, one nurse is responsible for total care of a number of clients 24 hours a day, 7 days a week. Team nursing provides individualized nursing care to clients by a nursing team lead by a professional nurse. The case manager may not provide direct client care but coordinates health care among numerous healthcare workers. Functional nursing care is organized by task with specific tasks being performed by different nursing personnel rather than one nurse. SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in th Nursing. Theory and applications. 5 Edition.pp.331-336 82. Process of formal negotiations of working conditions between a group of registered nurses and employer is: a. grievance b. arbitration c. collective bargaining d. strike CORRECT ANSWER: C RATIONALE: Collective bargaining is a legal process used by organized employees to negotiate with an employer about wages and related concerns resulting in an employment contract. OPTION B: Arbitration includes procedures for using the services of a third party to settle labor disputes. OPTION A: Grievance is any complaint by an employer or union concerning an aspect of employment OPTION D: Strike is a concerted withholding of labor supply to bring about economic pressure on employers and cause them to grant employee demands. SOURCE: Marquis, Bessie and Huston, Carol. Leadership Roles and Management Functions in th Nursing. Theory and applications. 5 Edition.pp. 556; Tomey, Ann Marriner. Guide to Nursing th Management and Leadership. 7 Edition. pp.138 83. You are attending a certification program on cardiopulmonary resuscitation (CPR) offered and required by the hospital employing you. This is; a. professional course towards credits b. in-service education c. advance training d. continuing education CORRECT ANSWER: B RATIONALE: In-service education program is administered by an employer; it is designed to upgrade the knowledge or skills of employees. Some in-service programs are mandatory such as cardiopulmonary resuscitation and fire safety programs OPTION D: Continuing education refers to formalized experiences designed to enlarge the knowledge or skills of practitioners. th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 26 Situation 18 - There are various developments in health education that the nurse should know about. 84. The nurse is preparing a client for a magnetic resonance imaging (MRI). Which of the following client statements indicates to the nurse that teaching has been successful? a. The dye used in the test will turn my urine green for about 24 hours. b. This procedure will take about 90 minutes to complete. There will be no discomfort. c. I will be put to sleep for this procedure. I will return to my room in two hours. d. The wires that will be attached to my head and chest will not cause me any pain.
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CORRECT ANSWER: B RATIONALE: procedure takes approximately 90 minutes, not painful OPTION A: no dye is used for an MRI OPTION C: client is not anesthetized for this procedure OPTION D:indicates misunderstanding of MRI because no wires are used SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 774 85. In preparing a teaching plan regarding colostomy irrigations, the nurse should include which of the following? a. The colostomy needs to be irrigated at the same time every day b. Irrigate the colostomy after meals to increase peristalsis c. Insert the catheter about 10 inches into the stoma d. The solution should be very warm to increase dilation and flow CORRECT ANSWER: A RATIONALE:Colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination OPTION B: colostomy should be irrigated only once a day OPTION C:catheter should never be inserted more than 4 inches OPTION D:solution should be at body temperature; increasing the temperature does not make irrigation more efficient th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 1250 86. Part of teaching client in health promotion is responsibility for one's health, when Danica states she need to improve her nutritional status this means: a. Goals and interventions to be followed by client are based on nurse's priorities b. Goals and intervention developed by nurse and client should be approved by the doctor c. Nurse will decide goals and, interventions needed to meet client goals d. Client will decide the goals and interventions required to meet her goals CORRECT ANSWER: D RATIONALE: Health promotion plans need to be developed according to the needs, desires and priorities of the client. The client decides on health promotion goals, the activities or interventions to achieve those goals, the frequency and duration of the activities, and the method of evaluation. During the process the nurse acts as a resource person rather than an advisor or counselor. The nurse provides information when asked, emphasizes the importance of small steps to behavioral change and reviews the clients goals and plans to make sure they are realistic, measurable and acceptable to the client. OPTION A: It should be based on clients priorities OPTION D: There is no need for the doctor to approve the goal set by the client OPTION C. The client is the one who will decide. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 133 87. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary prevention is: a. Marriage counseling b. Self-examination for breast cancer c. Teaching complications of diabetes d. Poison control CORRECT ANSWER: A RATIONALE: Marriage counseling is a tertiary prevention. Marriage seminar ir primary prevention and accepting the presence of a problem is a secondary prevention. OPTION B and D are secondary prevention OPTION C is a primary prevention
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88. Mrs. Ostrea has a schedule for Pap smear. She has a strong family history of cervical cancer. This is an example of: a. tertiary prevention b. secondary prevention c. health screening d. primary prevention CORRECT ANSWER: B RATIONALE: health promotion ( health education) and illness prevention ( proper nutrition, regular exercise etc.) are primary prevention; diagnosis and treatment are secondary prevention; and rehabilitation and health restoration are tertiary prevention. SOURCE: Kozier & Erb. Fundamentals of Nursing. 89 Situation 19 - Ronnie has a vehicular accident where he sustained injury to his left ankle. In the Emergency Room, you notice how anxious he looks. 89. You establish rapport with him and to reduce his anxiety you initially a. Take him to the radiology, section for X-ray of affected extremity b. Identify yourself and state your purpose in being with the client c. Talk to the physician for an order of Valium d. Do inspection and palpation to check extent of his injuries CORRECT ANSWER: B RATIONALE: Nurses carry out measures to minimize clients anxiety and stress by providing an atmosphere of warmth and trust and convey a sense of caring and empathy. For example, explain procedures before they are implemented including sensations likely to be experienced during the procedure. OPTION A: you disregard the feeling of the patient could further aggravate anxiety level OPTION C is inappropriate OPTION D: inappropriate , further aggravate anxiety SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 1023-1024 90. While doing your assessment, Ronnie asks you "Do I have a fracture? I don't want to have a cast." The most appropriate nursing response would be: a. "You have to have an X-ray first to know if you have a fracture." b. "Why do you; sound so scared? It is just a cast and it's not painful" c. "You seem to be concerned about being in a cast." d. "Based on my assessment, there doesn't seem to be a fracture." CORRECT ANSWER: C RATIONALE: Option C is reflecting. It is directing ideas, feelings, questions or content back to clients to enable them to explore their own ideas and feelings about a situation. OPTION A ignores the clients feeling OPTION B belittle the clients feeling OPTION D is giving false reassurance Situation 20 - You are taking care of Mrs. Leyba, 66 years old, who is terminally ill with ovarian cancer stage IV. 91. When caring for a dying client you will perform which of the following activities? a. Encourage the client to reach optimal health b. Assist client perform activities of daily living c. Assist the client towards a peaceful death d. Motivate client to gain independence CORRECT ANSWER: C For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Nurses need to ensure that the client is treated with dignity, that is with honor and respect. Dying clients often feel they have lost control over their lives and over life itself. Helping clients die with dignity involves maintaining their humanity, consistent with their values, beliefs and culture. Clients want to be able to manage the events preceding death so they can die peacefully. Nurses can help clients to determine their own physical, psychologic and social priorities. OPTIONS A, B and D are inappropriate SOURCE: Kozier & Erb. Fundamentals of Nursing. 1050 92. The client prepares for eventual death and discusses with the nurse and her family how she would like her funeral to look like and what dress she will use. This client is in the stage of: a. acceptance b. resolution c. denial d. bargaining CORRECT ANSWER: A RATIONALE: The model was introduced by Elizabeth Kbler-Ross in her 1969 book "On Death and Dying". The stages have become well-known as the "Five Stages of Grief". The stages are: 1. Denial: "It can't be happening." 2. Anger: "Why me? It's not fair." 3. Bargaining: "Just let me live to see my children graduate." 4. Depression: "I'm so sad, why bother with anything?" 5. Acceptance: "It's going to be OK." Acceptance-there is a difference between resignation and acceptance. You have to accept the loss, not just try to bear it quietly. Realization that it takes two to make or break a marriage. Realization that the person is gone (in death) that it is not their fault, they didn't leave you on purpose. (even in cases of suicide, often the deceased person, was not in their right frame of mind) Finding the good that can come out of the pain of loss, finding comfort and healing. Our goals turn toward personal growth. Stay with fond memories of person. SOURCE: http://en.wikipedia.org/wiki/K%C3%BCbler-Ross_model Situation 21 - You are a newly hired nurse in a tertiary hospital. You have finished your orientation program recently and you are beginning to assimilate the culture of the profession. 93. Using Benners stages of nursing expertise, you are a beginning nurse practitioner. You will rank yourself as a/an: a. competent nurse b. novice nurse c. proficient nurse d. advanced beginner CORRECT ANSWER: B RATIONALE: Benners model describes five levels of proficiency in nursing-based on the Dreyfus general model of skill acquisition. The five stages, which have implications for teaching and learning, are novice, advanced beginner, competent, proficient, and expert. Benner's Stages of Clinical Competence Stage 1: Novice Beginners have had no experience of the situations in which they are expected to perform. Novices are taught rules to help them perform. The rules are context-free and independent of specific cases; hence the rules tend to be applied universally. The rule-governed behavior typical of the novice is extremely limited and inflexible. As such, novices have no "life experience" in the application of rules. "Just tell me what I need to do and I'll do it."
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Stage 2: Advanced Beginner Advanced beginners are those who can demonstrate marginally acceptable performance, those who have coped with enough real situations to note, or to have pointed out to them by a mentor, the recurring meaningful situational components. These components require prior experience in actual situations for recognition. Principles to guide actions begin to be formulated. The principles are based on experience. Stage 3: Competent Competence, typified by the nurse who has been on the job in the same or similar situations two or three years, develops when the nurse begins to see his or her actions in terms of long-range goals or plans of which he or she is consciously aware. For the competent nurse, a plan establishes a perspective, and the plan is based on considerable conscious, abstract, analytic contemplation of the problem. The conscious, deliberate planning that is characteristic of this skill level helps achieve efficiency and organization. The competent nurse lacks the speed and flexibility of the proficient nurse but does have a feeling of mastery and the ability to cope with and manage the many contingencies of clinical nursing. The competent person does not yet have enough experience to recognize a situation in terms of an overall picture or in terms of which aspects are most salient, most important. Stage 4: Proficient The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects, and performance is guided by maxims. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals. The proficient nurse learns from experience what typical events to expect in a given situation and how plans need to be modified in response to these events. The proficient nurse can now recognize when the expected normal picture does not materialize. This holistic understanding improves the proficient nurse's decision making; it becomes less labored because the nurse now has a perspective on which of the many existing attributes and aspects in the present situation are the important ones. The proficient nurse uses maxims as guides which reflect what would appear to the competent or novice performer as unintelligible nuances of the situation; they can mean one thing at one time and quite another thing later. Once one has a deep understanding of the situation overall, however, the maxim provides direction as to what must be taken into account. Maxims reflect nuances of the situation. Stage 5: The Expert The expert performer no longer relies on an analytic principle (rule, guideline, maxim) to connect her or his understanding of the situation to an appropriate action. The expert nurse, with an enormous background of experience, now has an intuitive grasp of each situation and zeroes in on the accurate region of the problem without wasteful consideration of a large range of unfruitful, alternative diagnoses and solutions. The expert operates from a deep understanding of the total situation. The chess master, for instance, when asked why he or she made a particularly masterful move, will just say: "Because it felt right; it looked good." The performer is no longer aware of features and rules;' his/her performance becomes fluid and flexible and highly proficient. This is not to say that the expert never uses analytic tools. Highly skilled analytic ability is necessary for those situations with which the nurse has had no previous experience. Analytic tools are also necessary for those times when the expert gets a wrong grasp of the situation and then finds that events and behaviors are not occurring as expected When alternative perspectives are not available to the clinician, the only way out of a wrong grasp of the problem is by using analytic problem solving. SOURCE: Kozier & Erb. Fundamentals of Nursing. 7th Edition.pp. 13; http://www.sonoma.edu/users/n/nolan/n312/benner.htm 94. Benners proficient nurse level is different from the other levels in nursing expertise in the context of having: a. the ability to organize and plan activities b. having attained an advanced level of education c. a holistic understanding and perception of the client d. intuitive and analytic ability in new situations For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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CORRECT ANSWER: C RATIONALE: Stage 4: Proficient The proficient performer perceives situations as wholes rather than in terms of chopped up parts or aspects, and performance is guided by maxims. Proficient nurses understand a situation as a whole because they perceive its meaning in terms of long-term goals. The proficient nurse learns from experience what typical events to expect in a given situation and how plans need to be modified in response to these events. The proficient nurse can now recognize when the expected normal picture does not materialize. This holistic understanding improves the proficient nurse's decision making; it becomes less labored because the nurse now has a perspective on which of the many existing attributes and aspects in the present situation are the important ones. The proficient nurse uses maxims as guides which reflect what would appear to the competent or novice performer as unintelligible nuances of the situation; they can mean one thing at one time and quite another thing later. Once one has a deep understanding of the situation overall, however, the maxim provides direction as to what must be taken into account. Maxims reflect nuances of the situation. OPTION A : Stage 3, Competent OPTION D: Stage 5. Expert th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 13; http://www.sonoma.edu/users/n/nolan/n312/benner.htm 95. The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a client. Which of the following results would indicate to the nurse that the tube feeding can begin? a. A small amount of white mucus is aspirated from the NG tube b. The pH of the contents removed from the NG tube is 3 c. No bubbles are seen when the nurse inverts the NG tube in water d. The client says he can feel the NG tube in the back of his throat CORRECT ANSWER: B RATIONALE: Stomach contents are acidic. Research indicates that testing pH is a realiable way to determine location of a feeding tube. OPTION A:may be from lungs OPTION C: not a safe way to check placement OPTION D: not a reliable indication th SOURCE: Kozier & Erb. Fundamentals of Nursing. 7 Edition.pp. 96. The nurse in the outpatient clinic assists with the application of a cast to the left arm of a five-year old girl. After the cast is applied, the nurse should a. petal the edges of the cast to prevent irritation b. elevate the clients left arm on two pillows c. apply cool, humidified air to dry the cast d. ask the client to move her fingers to maintain mobility CORRECT ANSWER: B RATIONALE: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? Option B is correct. It minimizes swelling, elevated for first 24-48 hours, protects from pressure and flattening of cast OPTION A: done when cast is completely dry, prevents crumbling of plaster into cast OPTION C: would delay drying of cast OPTION D: maintaining mobility of fingers not most important after application of cast 97. A nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination? a. Avoid strenuous activity b. Eat more foods with increased bulk For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. Decrease fluid intake to decrease urinary losses d. Use oral laxatives so that a bowel pattern emerges CORRECT ANSWER: B RATIONALE: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?Option B is correct. It is contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis OPTION A: regular exercise program facilitates bowel elimination OPTION C: fluid intake of 1,500 cc/day facilitates bowel elimination OPTION D: laxatives used as last resort because they become habit-forming 98. An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client a. in semi-Fowlers position b. prone, with the head turned to the side c. with the head of the bed elevated 45 and the neck extended d. supine, with the head in the midline position CORRECT ANSWER: A RATIONALE: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? Option A:correctcheck vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm) OPTION B: would limit respiratory excursion and assessment of breathing OPTION C: extension of neck could obstruct airway because tongue falls in back of mouth OPTION D: not best position after procedure 99. The nurse is reviewing procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements? a. It is my responsibility to ensure that the consent form has been signed and is attached to the patients chart. b. It is my responsibility to witness the signature of the patient before surgery is performed. c. It is my responsibility to explain the surgery and ask the patient to sign the consent form. d. It is my responsibility to answer questions that the patient may have before surgery. CORRECT ANSWER: C RATIONALE: Strategy: "Nurse would intervene" indicates that you should look for an incorrect statement.Question is unstated. Read answer choices for clues.Option C: correctphysician should provide explanation and obtain patient's signature OPTION A:describes the nurse's responsibility in obtaining consent OPTION B:signature indicates that the nurse saw the patient sign the form OPTION D:.the nurse should answer questions after the physician has obtain consent 100. For a client with a neurological disorder, which of the following nursing assessments will be MOST helpful in determining subtle changes in the clients level of consciousness? a. Client posturing b. Glasgow coma scale c. Client thinking pattern d. Occurrence of hallucinations CORRECT ANSWER: B RATIONALE: Strategy: Think about each answer choice. Option B:correctGlasgow coma scale score best evaluates changes in a clients level of consciousness by evaluating eye-opening, motor, and verbal responses OPTION A: indicates increased intracranial pressure OPTION C: more appropriate for the psychiatric client OPTION D: more appropriate for the psychiatric client
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Situation 1 - Nurse Minette is an independent Nurse Practitioner following-up referred clients in their respective homes. Here she handles a case of POSTPARTAL 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 CORRECT ANSWER: A RATIONALE: Recommended Schedule of Post partum Care visits: 1st visit 1st week post Partum preferably 3-5 days 2nd visit- 6 weeks post partum SOURCE: DOH: Public Health Nursing in the Philippines. Pp 125 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 CORRECT ANSWER: B RATIONALE: Early ambulation, a good diet with adequate roughage and adequate fluid intake all aid in preventing the problem of constipation. Options A and D are possible answers but in the situation, bed rest causes the constipation. Therefore, in order to prevent this allow the postpartal woman to ambulate. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 644 3. If you were Minette, which of the following actions, would alert you that a new mother is entering a postpartal at taking-hold phase? a. She urges the baby to stay awake so that she can breast-feed him in 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 CORRECT ANSWER: A RATIONALE: Taking hold phase the second phase of the postpartal period where the woman begins to initiate action. The mother is independent and show care for her baby. OPTION B: Taking in phase- the first phase of the postpartal period experienced when the woman is usually 2-3 days postpartum, she is dependent to others and does not show interest in taking care of the baby. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION C: Taking in phase OPTION D: Taking in Phase SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 623 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 the umbilicus c. No longer palpable on her abdomen d. One centimeter above the symphysis pubis CORRECT ANSWER: C RATIONALE: On the first postpartal day, it will be palpable one fingerbreath below the umbilicus; on the second day, two fingerbreadths below the umbilicus; and so on. Because a fingerbreadth is about 1cm, this can be recorded as 1cm below the umbilicus, 2cm below it and so forth. In the average woman by the ninth or tenth day, the uterus will have contracted so much that it is withdrawn into the pelvis and can no longer be detected by abdominal palpation. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 628 4. 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 cal/day b. 500 cal/day c. 200 cal/day d. 1,000 cal/day CORRECT ANSWER: B RATIONALE: A woman who is breast-feeding needs an additional 500 calories (i.e., a 2700-kcal diet) and an additional 500ml of fluid ( this may be from the same source) each day to encourage the production of high quality breast milk. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 641 Situation 2 Nurse Lisa manages her own Reproductive and Childrens Nursing Clinic in Sorsogon and necessarily she attends to health conditions of mothers and children. The following questions pertains to the growing fetus. 5. Obstetrical client Marichu asks how much longer Nurse Lisa will refer to the baby inside her as an embryo. What would be your best explanation? a. Her baby will be a fetus as soon as the placenta forms b. From the time of implantation until 5 to 8 weeks, the baby is an embryo c. After the 20th week of pregnancy, the baby is called a zygote d. This term is used during the time before fertilization CORRECT ANSWER: B RATIONALE: Under fetal development: st Pre embryonic period- the 1 2 weeks after conception Embryonic period- beginning of the third week through the 8 weeks after conception Fetal period- beginning of the 9 th week after conception and ending with birth RD SOURCE: Saunders Comprehensive review for the NCLEX-RN. 3 Edition.pp.253 6. Marichu is worried that her baby will be born with a congenital heart disease. What assessment of a fetus at birth is important to help detect congenital heart defect? a. Determining that the color of the umbilical cord is not green b. Assessing whether the umbilical cord has two arteries and one vein c. Assessing whether the Whartons jelly of the cord has a pH higher than 7.2 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. Measuring the length of the cord to be certain that it is longer than 3 feet CORRECT ANSWER: B RATIONALE: A normal cord contains one vein and two arteries. The absence of the umbilical arteries is associated with congenital heart and kidney anomalies, because the insult that caused the loss of the vessel may have affected other mesoderm germ layer structures as well. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 615-616 7. Additionally, Nurse Lisa would gather more information about Marichus worry about what may threaten the health of her baby. What would Nurse Lisa hope to find? a. Has Marichu been overly anxious about something b. Has Marichu suffered from any communicable/contagious disease at the time of her early stage of pregnancy c. Has Marichu engage in sexual activity during the fetal development state of her child d. Has Marichu engaged in any detrimental activities during the fetal development stage (e.g. smoking, drinking, taking drugs, a bad fall, or attempts to terminate pregnancy.) CORRECT ANSWER: D RATIONALE: During the early time of organogenesis (organ formation) the growing structure is most vulnerable to invasion by teratogens. (any factors that affects the fertilized ovum, embryo, fetus adversely, such as alcohol). It is important to teach women how to minimize their exposure to teratogens during these times OPTION B: A number of infections are not teratogenic to a fetus during pregnancy but are harmful if they are present at the time of birth. OPTION C: Sexual intercourse does not affect fetal development. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 190,290, 94 8. Marichu is scheduled to have an ultrasound examination. What instruction would you give her before her examination? a. You can have medicine for pain for any contraction caused by the test b. Drink at least 3 glassess of fluid before the procedure c. The intravenous fluid infused to dilate your uterus does not hurt the fetus d. Void immediately before the procedure to reduce your bladder size CORRECT ANSWER: B RATIONALE: Before ultrasound, the mother needs to have a full bladder in order for the sound waves to reflect best and the uterus to be held stable. In order to ensure a full bladder, a woman should drink a full glass of water 15 minutes beginning, 90 minutes before the procedure and should not void before the procedure. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 615-616 9. Marichu is scheduled to have an amniocentesis to test for fetal maturity. What instruction would you give her before this procedure? a. The x-ray used to reveal your fetus position has no long term effects b. The intravenous fluid infused to dilate your uterus does not hurt the fetus c. No more amniotic fluid form afterward, which is why only a small amount is removed d. Void immediately before the procedure to reduce your bladder size. CORRECT ANSWER: D RATIONALE: Amniocentesis is the withdrawal of amniotic fluid through the abdominal wall for th th analysis at 14 -16 week of pregnancy. In preparation for amniocentesis, ask the woman to void (to reduce the size of the bladder, thus preventing in advertent puncture). OPTION A: X-ray is not used in amniocentesis OPTION B: Intravenous fluid is not infused to dilate the uterus SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 207 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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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 illness c. Rehabilitation back to health d. Promotion of health CORRECT ANSWER: D RATIONALE:The primary focus of community health nursing practice is on health promotion. The community health nurse by the nature of his/her work has the opportunity and responsibility for evaluating the health status of people and groups and relating them to practice. SOURCE: DOH CHN pp. 17 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 CORRECT ANSWER: D RATIONALE: One of the principles of the Community Health Nursing, the family is the unit of service. SOURCE: DOH CHN pp. 19 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 arid 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 CORRECT ANSWER: A RATIONALE: The process of assessment in community health nursing includes; intensive fact finding, the application of professional judgment in estimating the meaning and importance of these facts to the family and the community, the availability of nursing resources that can be provided, and the degree of change which nursing intervention can be expected to effect. SOURCE:DOH CHN pp. 45 14. In community health nursing it is important to take into account the family health with an equally important need to perform ocular inspection of the areas activities which are powerful elements of: a. evaluation b. assessment c. implementation d. planning CORRECT ANSWER: B RATIONALE: Assessment provides an estimate of degree to which a family, group or community is achieving the level of health possible for them, identify specific deficiencies for guidance needed and estimates the possible effects of the nursing interventions. SOURCE: DOH CHN pp. 43
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15. The initial step in the PLANNING process in order to engage in any nursing project or parties at the community level involves: a. goal-setting b. monitoring c. evaluation of data d. provision of data CORRECT ANSWER: A RATIONALE: The plan for nursing action or care is based on the actual and potential problems that were Identified and prioritized. Planning nursing actions include the following steps: 1. Goal setting- a goal is declaration of purpose or intent that gives essential direction to action. 2. Constructing a Plan of Action: the planning phase of community health nursing process is concerned with choosing from among the possible courses of action, selecting the appropriate types of nursing intervention, identifying appropriate and available resources for care and developing an operational plan 3. Developing an Operational Plan- to develop an operational plan, the community health nurse must establish priorities, phase and coordinate activities. 4. Implementation of Planned Care- In community health nursing, implementation involves various nursing interventions which have been previously set. 5. Evaluation of Care and Services Provided- evaluation is interwoven in every nursing activity and every step of the community health nurses. SOURCE: DOH CHN Page 46-48 16. Transmission of HIV from an Infected Individual to another person occurs: a. Most frequently in nurses with needle sticks 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 CORRECT ANSWER: C RATIONALE: Human Immunodeficiency Virus Causative agent: Retrovirus- Human T-cell lymphotrophic virus 3 (HTLV-3) Mode of transmission: Sexual contact Blood transfusion Contaminated syringes, needles, nipper, razor blades Direct contact of open wound/mucous membrane with contaminated blood, body fluids, semen and vaginal discharges. OPTION D: All neonates born to HIV positive mothers acquire maternal antibody to HIV infection, but not all acquire the infection. rd SOURCE: DOH CHN Page 294; Saunders Comprehensive Review for the NCLEX-RN 3 edition Page 346 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 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. Cephalopelvic disproportion CORRECT ANSWER: D RATIONALE: A disproportion between the size of the normal fetal head and the pelvic diameters. This results in failure to progress in labor. OPTIONS A,B & C does not exist. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 606 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. Toxoplasmosia CORRECT ANSWER: A RATIONALE: If a woman has a primary infection, herpes can be transmitted across the placenta to cause congenital infection in the newborn, if a woman has primary or secondary active lesions in the vagina or on the vulva at the time of birth, herpes infection can be transmitted to the newborn at birth.If no lesion are present vaginal birth is preferable. OPTION B: Human Papilloma Virus= the presence of vulvar lesions appears to have no effect on the fetus during pregnancy, but if they are present in the time of birth and obstruct the birth canal a C/S may be necessary. OPTION C: Hepatitis A not known to be transmitted to the fetus. Hepatitis B&C are spread by exposure to contaminated blood or blood products. OPTION D: Toxoplasmosis is transmitted to the mother through a raw meat or handling of cat litter of infected in the the mother; organism is transmitted to the fetus across the placenta. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 351 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 CORRECT ANSWER: B RATIONALE: A posterior position is suggested by a dysfunctional labor pattern such as a prolonged active active phase, arrested descent, or fetal heart sounds heard best at the lateral sides of the abdomen. A posterior head does not fit the cervix as snugly as one in an anterior portion. Because this increases the risk of umbilical cord prolapse, the position of the fetus is confirmed by vaginal examination or by sonogram. Because the arc of rotation is greater, it is usual for the labor to somewhat prolonged. Because the fetal head rotates against the sacrum, a woman may experience pressure and pain in her lower back due to sacral nerve compression. This sensations may be so intense that she asks for medication for relief, not for her contractions but for the intense back pressure and pain. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 600-601 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 cervical1 pain receptors For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. Prevent cervical lacerations d. Stimulate uterine contractions CORRECT ANSWER: A RATIONALE: Prostaglandin such as Misoprostol (cytotec) are more commonly used method of speeding cervical ripening. Applied to the interior surface of the cervix by a catheter or suppository. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 608 Situation 4 - 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 cannot 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 CORRECT ANSWER: C RATIONALE: Tubal ligation= the fallopian tubes are occluded by cautery, crushing, clamping or blocking and thereby preventing passage of both sperm and ova. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 123 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 CORRECT ANSWER: C RATIONALE: Infertility is said to exist when a pregnancy has not occurred after at least 1 year of engaging in unprotected coitus. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 23. Another client names Lilia is diagnosed as having endometriosis. This condition interferes with the fertility because: a. endometrial implants can block the fallopian tubes b. the uterine cervix becomes inflamed and swollen c. ovaries stop producing adequate estrogen d. pressure on the pituitary leads to decreased FSH levels CORRECT ANSWER: A RATIONALE: Endometriosis refers to the implantation of uterine endometrium or nodules, that have spread from the interior of the uterus to locations outside the uterus. If growths occur in the fallopian tube, tubal obstruction may result or adhesions forming from these growths may displace fallopian tubes away from the ovaries preventing the entrance of ova into the tubes. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 139 24. Lilia is scheduled to have a hysterosalpingogram. 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 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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CORRECT ANSWER: D RATIONALE: Hysterosalpingogram= a radiologic examination of the fallopian tubes using a radiopaque medium, is the most frequently used method of assessing tubal patency. Because the medium is thick, it distends the uterus and tubes slightly, causing momentary painful uterine cramping. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 144 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 CORRECT ANSWER: A RATIONALE: Artificial Insemination is the installation of sperm into the female reproductive tract to aid conception. The sperm can be instilled into the cervix (intracervical insemination) or into the uterus (intrauterine insemination. Donor sperm (artificial insemination by donor or therapeutic donor insemination) can be used. These test can be used if the man has an inadequate sperm count or the woman has a vaginal or cervical factor that interferes with sperm motility. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 148 Situation 5 - 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 +8 deg C CORRECT ANSWER: B RATIONALE: Vaccines are substances very sensitive to various temp. to avoid spoilage and maintain potency, vaccines need to be stored at correct temperature. Below are recommended storage temperatures of EPI vaccines. Types/Form of vaccines Oral Polio (live attenuated) Measles (freeze dried) Least sensitive to Heat DPT/Hep B D Toxoid which is a weakened toxin P Killed bacteria T Toxoid which is a weakend toxin Hep B +2 C to + 8 C ( in the body of the refrigerator) +2 C to + 8 C ( in the body of the refrigerator) Storage Temperature -15C to -25C ( at the freezer) -15C to -25C ( in the body of the refrigerator +2C to +8C (in the body of the refrigerator)
Most Sensitive to Heat
BCG ( freeze dried)
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Tetanus Toxoid
SOURCE: Public health Nursing in the Philippines, Page 151 27. Which of the following vaccines is not done by intramuscular (IM) injection? a.Measles vaccine b.DPT c.Hep B vaccines d.DPT CORRECT ANSWER: A RATIONALE: Measles vaccine give subcutaneous at the outer part of the upper arm OPTION B: DPT= intramuscular given at the upper outer portion of the thigh OPTION C: Hep B vaccine= intramuscular, given at the upper outer portion of the thigh OPTION D: DPT= intramuscular given at the upper outer portion of the thigh SOURCE: Public health Nursing in the Philippines, Page 152 28. According to the new EPI Routine Schedule of immunization, when is Hepa B vaccine first given? a. 6 weeks b. 9 months c. 12 months d. at birth CORRECT ANSWER: D RATIONALIZATION: Hepa B vaccine is first given at birth. Six weeks interval from first dose to second dose and 8 weeks interval from second dose to third dose. An early start of Hep B reduces the chance of being infected and becoming a carrier and prevents liver cirrhosis and liver cancer. SOURCE:PHN pp.149 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 CORRECT ANSWER: B Rationale: Because it is given when the child reaches 9 months of age and the last vaccine to be administered. SOURCE: DOH CHN page 111 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? For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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a. Tetanus toxoid 3 b. Tetanus toxoid 2 c. Tetanus toxoid 1 d. Tetanus toxoid 4 CORRECT ANSWER: D RATIONALE: Tetanus toxoid vaccination for women is important to prevent tetanus in both mother and the baby. TT4 gives 10 years protection for the mother. OPTION A: TT3 gives 5 years protection for the mother OPTION B: TT2 gives 3 years protection for the mother. OPTION C: TT1 gives no protection SOURCE: PHN, Page 150 Situation 6 - 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 specifics, types of information. The following pertains to documentation/records management. 31. This special form used when the patient is admitted to the unit. The nurse completes the information in this records 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 CORRECT ANSWER: B RATIONALE: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. OPTION A: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION C: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. OPTION D: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. SOURCE: Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339 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, postpartum 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
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CORRECT ANSWER: B RATIONALE: Graphic flow sheet- a flow sheet enables nurses to record nursing data quickly and concisely and provides an easy-to-read record of the clients condition over time. OPTION A: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION C: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. OPTION D: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. th SOURCE:Fundamentals of Nursing 7 edition by Barbara Kozier, Page 339 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 CORRECT ANSWER: D RATIONALE: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. OPTION A: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. OPTION B: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. OPTION C: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. SOURCE:Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339 34. This flip-over card is usually kept in a portable file at the Nurses 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 beside 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 CORRECT ANSWER: D RATIONALE: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION A: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required.
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OPTION B: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. OPTION C: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. SOURCE: Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339 35. Most nurses regard this as 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 CORRECT ANSWER: A RATIONALE: Nursing Discharge/ Referral Summary- a discharge note and referral summary are completed when the client is being discharged and transferred to another institution or to a home setting where a visit by a community health nurse is required. OPTION B: Kardex is a widely used, concise method of organizing and recording data about a client making information quickly accessible to all health professionals. OPTION C: Medicine and treatment record- medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route and the nurses signature. OPTION D: AKA Admission Nursing Assessment/ Initial data base/Nursing History or Nursing Assessment. This is completed when the client is admitted to the nursing unit. This forms can be organized according to body systems, functional abilities, health problems and risks. SOURCE: Fundamentals of Nursing 7th edition by Barbara Kozier, Page 339 Situation 7 - Health instructions are essentially given to pregnant mothers. 36. A public health nurse would instruct a pregnant woman to notify the physician immediately if which of the following symptoms occur during pregnancy? a. Presence of dark color in the neck b. Increased vaginal discharge c. Swelling of the face d. Breast tenderness CORRECT ANSWER: C RATIONALE: Swelling of the face is a manifestation of mild preeclampsia. Edema in mild preeclampsia begins to accumulate in the upper part of the body, rather than just the typical ankle edema of pregnancy. OPTION A: Presence of a dark color in the neck is caused by increase in pigmentation, that is caused by melanocyte stimulating hormone which secreted by the pituitary gland. OPTION B: Due to increase in the activity of the epithelial cells results in white vaginal discharge throughout pregnancy OPTION D: Breast tenderness is due to increase stimulation of breast tissue by the high estrogen level in the body. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 427,228,229
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37. A woman who is 9 weeks pregnant comes to the health center with moderate bright red vaginal bleeding. On physical examination, the physician finds the clients cervix 2 cm dilated. Which term best describes the clients condition? a. Missed abortion b. Incomplete abortion c. Inevitable abortion d. Threatened abortion CORRECT ANSWER: C RATIONALE: Occurs if uterine contractions and cervical dilatation occurs. OPTION A: The fetus dies in utero but is not expelled OPTION B: part of the conceptus (usually the fetus) is expelled, but membrane or placenta in retained in the uterus. OPTION D: is manifested by vaginal bleeding, initially beginning as scant bleeding and usually bright red. There may be slight cramping, but no cervical dilatation is present in vaginal exam. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 417 38. In a big government hospital, Nurse Pura is taking care of a woman with a diagnosis of abruptio placenta. What complication of this condition is of most concern to Nurse Pura? a. Urinary tract infection b. Pulmonary embolism c. Hypocalcemia d. Disseminated intravascular coagulation CORRECT ANSWER: D RATIONALE: Abruptio placenta occur when the placenta appears to have been implanted correctly. Suddenly, however, it begins to separate and bleeding results. Conditions such as abruption placenta causes DIC. Disseminated intravascular coagulation occurs when there is such extreme bleeding and so many platelets and fibrin from the general circulation rush to the site that not enough are left in the rest of the body for further clotting. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 417 39. Which of the following findings on a newly delivered womans chart would indicate she is risk for developing postpartum hemorrhage? a. Post-term delivery b. Epidural anesthesia c. Grand multiparity d. Premature rupture of membrane CORRECT ANSWER: C RATIONALE: Multiple gestation distends the uterus beyond average capacity causing uterine atony. Uterine atony or relaxation of the uterus is the most frequent cause of postpartal hemorrhage. OPTION B: Epidural anesthesia causes hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. OPTION D: premature rupture of membrane will cause prolapsed of the cord and uterine infection. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 456-657 40. Mrs. Hacienda Gracia 35 years old postpartum client is at risk of thrombophlebitis. Which of the following nursing interventions decreases her chance of developing postpartum thrombophlebitis? a. breastfeeding the newborn b. early ambulation c. administration of anticoagulant postpartum For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. immobilization and elevation of the lower extremities. CORRECT ANSWER: B RATIONALE: Thrombophlebitis is inflammation with the formation of blood clots. Ambulation and limiting the time a woman remains in obstetric stirrups encourages circulation in the lower extremities, promotes venous return and decreases the possibility of clot formation, helping to prevent thrombophlebitis. OPTION A: will not prevent thrombophlebitis OPTION C: will increase risk of pospartal hemorrhage OPTION D: though elevation of lower extremities promotes venous return, immobilization could increase risk of thrombophlebitis SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 Situation 8 - Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK PREGNANCIES: Particularly women with preexisting of 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 gold 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 CORRECT ANSWER: D RATIONALE: Candidiasis a vaginal infection spread by the fungus, Candida. It results in a thick vaginal discharge that resembles creamcheese and is extremely pruritic. The vagina appears red and irritated. Candidiasis occurs more frequently during pregnancy than normally because of the increased estrogen level present during pregnancy, which causes the vaginal ph to be less acidic. It also occurs less frequently in women being treated with an antibiotic for another infection, in women with gestational diabetes and in women with HIV infection. 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 the placenta and so does not affect a fetus CORRECT ANSWER: D RATIONALE: Heparin has large molecules that cannot pass the placental blood barrier. Therefore it will not affect the baby and is allowed for pregnant mothers. 43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further instruction on prenatal care. Which 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 grown new red blood cells c. I am careful to drink at least eight glasses of fluid everyday d. I understand why folic acid is important for red cell formation CORRECT ANSWER: B RATIONALE: The majority of the red blood cells are irregular or sickle-shaped so cannot carry as much hemoglobin as normally shaped red blood cells. When oxygen tension becomes reduced, as happens at high altitudes, or blood becomes more viscid than usual (dehydration), the cells tend to clump because of the irregular shape. Thus clumping can result in vessel blockage with For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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reduced blood flow of the organs. The cells then will hemolyze reducing the number available and causing a severe anemia. OPTION A: Dehydration can make the blood more viscous causing the cells to clump. OPTION C: Increasing the fluid volume of the circulatory system to lower viscosity are important interventions. OPTION D: Women do need a folic acid supplement to keep the new cells produced from being megaloblastic SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 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 salicylates toxicity c. Newborns develop withdrawal headaches from salicylates d. Salicylates can lead to increased maternal bleeding at childbirth CORRECT ANSWER: D RATIONALE: Women with juvenile rheumatoid arthritis frequently take corticosteroids and nonsteroidal anti-inflammatory drug (NSAID) to prevent joint pain and loss of mobility. Although they should continue to take this medications during pregnancy to prevent joint damage, large amount of salicylates may lead to increase bleeding at birth or prolong pregnancy (salicylates interferes withy prostaglandin synthesis, so labor contractions are not initiated). For this reason, a women is asked to decrease her intake of salicylates approximately 2 weeks before term. OPTION A: Aspirin will not cause deep vein thrombosis after birth because it has an anticoagulant effect that inhibits platelet aggregation. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 370 45. Bernadette received a laceration on her leg from her automotive 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 o f her fatigue d. Healing is limited during pregnancy, so these will not heal until after birth CORRECT ANSWER: B RATIONALE: Laceration (jagged cut) may involve only the skin layer or may penetrate to deeper subcutaneous tissue or tendons. Lacerations generally bleed profusely. Halt bleeding by putting pressure on the edges of the lacerations ( this is difficult to achieve in the lower extremities because venous pressure is greatly increased in pregnancy. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 387-388 Situation 9 - Still in your self-managed Child Health Nursing Clinic, you encounter these cases pertaining to the CARE OF CHILDREN WITH PULMONARY INFECTIONS. 46. Josie brought her 3-rmonths 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 bearing CORRECT ANSWER: B
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RATIONALE: The first thing to do is to assess the patient using the chart on management of child with cough. You determine if this is an initial visit or follow-up visit for this problem. Then you check for danger signs, and ask about the main symptoms: does the child have cough or difficulty breathing?. After assessing you then classify and identify the treatment. SOURCE: IMCI Manual page 2 47. In responding to the care concerns of children with very severe disease, referral to the hospital is of the essence especially if the child manifests which of the following? a. Wheezing b. Stopped bleeding c. Fast breathing d. Difficulty to awaken CORRECT ANSWER: D RATIONALE: Difficulty to awaken is one of the general danger signs and should be refer URGENTLY to hospital. OPTION C: fast breathing is under pneumonia. SOURCE: IMCI Manual Page 2 48. Which of the following is the most important responsibility of a nurse in the prevention of necessary deaths from pneumonia and other severe diseases? a. Giving of antibiotics b. Taking of the temperature of the sick child c. Provision of Careful Assessment d. Weighing of the sick child CORRECT ANSWER: C Rationale: A child with danger signs needs URGENT attention; complete the assessment and any pre-referral treatment so referral is not delayed. Proper assessment would help in classifying the child .and proper treatment could be given. SOURCE: IMCI Manual Page 2 49. A child of 2 months is considered manifesting fast breathing if: a. 50 breaths/min b. below 50 breaths/min c. 50 breaths/minute or more d. 40 breaths/minute or more CORRECT ANSWER: C RATIONALE: If the child is 2 months up to 12 months old, fast breathing is 50 breaths/minute or more OPTION D: 12 months up, 40 breaths/minute or more All other options are incorrect SOURCE: IMCI Manual Page 2 50. Which of the following is the principal focus on 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 CORRECT ANSWER: C For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: The primary focus of the CARI Program is mortality reduction through early detection and antibiotic treatment of pneumonia cases among children between the ages of 0 to less than 5 years old. SOURCE: DOH CHN Page 259 Situation 10 - You are working as a Pediatric Nurse in your own Child Health Nursing Clinic, the following cases pertain to ASSESSMENT AND CARE of THE NEWBORN AT RISK conditions. 50. Theresa, a mother with a 2 year old daughter asks, "at what age can I be able to take the blood pressure of my daughter as a routine procedure since hypertension is common in the family?" Your answer to this is: a. At 2 years you may b. As early as 1 year old c. When she's 3- years old d. When she's 6 years old? CORRECT ANSWER: C Rationale: Blood pressure should be included in the routine physical assessment of all children older than 3 years of age. Offer a good explanation of the procedure, especially to young children, because wrapping their arm and applying pressure can be frightening if they are not prepared for it. Blood pressure is difficult to measure in infants due to mechanical problem. Doppler ultrasound blood pressure recording is especially effective with infants. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 1120 52. You typically gag children to inspect the back of their throat. When is it important NOT to solicit a gag reflex? a. when a girl has a geographic tongue b. when a boy has a possible inguinal hernia c. when a child has symptoms of epiglottitis d. when children are under 5 years of age CORRECT ANSWER: C RATIONALE: Epiglottitis is the inflammation of the epiglottis. If a childs gag reflex is stimulated with a tongue blade, the swollen and inflamed epiglottis can be seen to rise in the back of the throat as a cherry-red structure. It can be so edematous, however gagging procedure causes complete obstruction of the glottis and respiratory failure. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 1252 53. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in labor. What drug is commonly used for this? a. Naloxone (Narcan) b. Morphine Sulfate c. Sodium Chloride d. Penicillin G CORRECT ANSWER: A RATIONALE: Naloxone is a drug used to counter act the effects of opiod overdose, for example heroin or morphine overdose. Naloxone is especially used to counter act life threatening depression of CNS and respiratory system. OPTION B: Morphine is a highly potent opiate analgesic drug and is the principal active agent in opium and For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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the prototypical opiod. OPTION C: Sodium chloride AKA: commom salt, table salt. Is the salt most responsible for the salinity of the ocean and of the extracellular fluid of many multicellular organisms. OPTION D: Penicillin is a group of B-lactam antibiotics used in the treatment of bacterial infections caused by susceptible, usually gram positive organisms. SOURCE: Wikipedia the free encyclopedia 54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature? a. They do not have as many fat stores as other infant's b. They are more active than usual so throw off covers c. Their skin is more susceptible to conduction of cold d. They are preterm so are born relatively small in size CORRECT ANSWER: A th RATIONALE: An infant is small for gestational age if the birth weight is below the 10 percentile on an intrauterine growth curve for that age. Small for gestational age infants are less able to control body temperature than normal newborns because they lack subcutaneous fat. OPTION B: Infant may seem unusually alert and active for that weight. OPTION D: SGA infants may be born preterm (before week 38 gestation) or term ( between week 38 and 34) or post term (past 42 weeks) SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 757-758 55. Baby John develops hyperbilirubinemia, what is a method used to treat hyperbilirubinemia in a newborn? a. Keeping infants in a warm arid dark environment b. Administration of a cardiovascular stimulant c. Gentle exercise to stop muscle breakdown d. Early feeding to speed passage of meconium CORRECT ANSWER: D RATIONALE: Hyperbilirubinemia refers to an excessive level of accumulated bilirubin in the blood and is characterized by jaundice a yellow discoloration of the skin, sclerae and nails.Early initiation of feedings and frequent breast feeding this measures are aimed at Promoting increased intestinal motility, decreasing enterohepatic shunting, and establishing normal bacterial flora in the bowel to effectively enhance the excretion by conjugated bilirubin. OPTION A: Light promotes bilirubin excretion by photo isomerization which alters the structure of bilirubin to a soluble form (luminubin) for easier excretion. SOURCE: Hockenberry, Marilyn J. Wongs essentials of Pediatric Nursing.7th edition.pp.263-264 Situation 11 - You are the nurse in the Out-Patient-Department and during your shift you encountered multiple children's condition. The following questions apply. 56. You assessed a child with visible severe wasting, he has: a. edema b. LBM c. kwashiorkor d. marasmus CORRECT ANSWER: D RATIONALE: Marasmus results from general malnutrition of both calories and protein. It is characterized by gradual wasting and atrophy of body tissues, esp. of subcutaneous fat. The child appears to be very old with flabby and wrinkled skin. OPTION A: edema is the abnormal accumulation of fluid in interstitial spaces of tissues such as in the peritoneal cavity or joint capsules. OPTION B: LBM means lean body mass OPTION C: Kwashiorkor has been defined as primarily a deficiency of protein with an adequate supply of calories. The word kwashiorkor means the sickness the older child gets when the next baby is born, and aptly describes the syndrome that develops in the first child, usually between 1 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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and 4 years of age, when weaned from the breast after the second child is born. Kwashiorkor has thin, wasted extremities and a prominent abdomen from edema (ascites). The edema often masks the severe muscular atrophy, making the child appears debilitated than he/she actually is. The skin is scaly and dry and has areas of depigmentation SOURCE:Hockenberry, Marilyn J. Wongs essentials of Pediatric Nursing.7th edition.pp 373; Mosbys pocket dictionary. 4th ed. 57. Which of the following conditions is NOT true about contraindication to immunization? a. do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1 b. do not give BCG if the child has known hepatitis . c. do not give OPT to a child who has recurrent convulsion or active neurologic disease d. do not give BCG if the child has known AIDS CORRECT ANSWER: B RATIONALE: BCG can be given in a child with hepatitis. OPTION A: Vaccines containing the whole cell pertussis component should not be given to children with an evolving neurological disease. (uncontrolled epilepsy of progressive encephalopathy) OPTION D: Live vaccines like BCG vaccine must not be given to individuals who are immunosuppressed due to malignant disease, (e.g. child with clinical AIDS), therapy with immunosuppressive agents on radiation. SOURCE: PHN.pp.143 58. Which of the following statements about immunization is NOT true? a. A child with diarrhea who is due for OPV should receive the OPV and make extra dose on the next visit b. There is no contraindication to immunization if the child is well enough to go home c. There is no contraindication to immunization if the child is well enough to go home and a child should be immunized in the health center before referrals are both correct d. A child should be immunized in the center before referral CORRECT ANSWER: A RATIONALE: False contraindications to immunizations are children with malnutrition, low grade fever, mild respiratory infections and other minor illnesses and diarrhea should not be considered a contraindication to OPV vaccination. Bur there is no nned to make an extra dose on the next visit. SOURCE: PHN pp. 142 59. A child with visible severe wasting or severe palmar pallor may be classified as: a. moderate malnutrition/anemia b. severe malnutrition/anemia c. not very tow weight no anemia d. anemia/very low weight CORRECT ANSWER: B Rationale: Visible severe wasting , edema of both feet or severe palmar pallor is classified under severe Malnutrition or severe anemia. Treatment includes give Vit. A and refer URGENTLY to hospital. SOURCE: IMCI manual page 6 60. A child who has some palmar pallor can be classified as: a. moderate anemia/normal weight b. severe malnutrition/anemia c. anemia/very low weight d. not very low eight to anemia CORRECT ANSWER: C For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Some palmar pallor and Very low weight for age is classified under Anemia or Very low Weight. SOURCE: IMCI manual page 6 Situation 12 - Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is unsure of the date of her last menstrual period. Leopold's Maneuver is done. The obstetrician told her that she appears to be 20 weeks pregnant. . 61. Nette explains this because the fundus is: a. At the level the umbilicus and the fetal heart can be heard with a fetoscope b. 18 cm, and the baby is just about to move c. is just over the symphysis, and fetal heart cannot be heard d. 28 cm, and fetal heart can be heard with a Doppler CORRECT ANSWER: A RATIONALE: Fundal height is measured to evaluate the fetus gestational age. At 20-22 weeks, the fundus is at the level of umbilicus. OPTION B: 18 weeks-fetal movement can be felt by the mother and the fundus can be found below the umbilicus OPTION C: 12 weeks- at the level of the symphysis pubis OPTION D: 28 weeks- the fundus can be felt between the xyphoid process and the umbilicus SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 226 62. In doing Leopold's maneuver palpation which among the following is NOT considered a good preparation? a. The woman should lie in a supine position with her knees flexed slightly b. The hands of the nurse should be cold so that abdominal muscles would contract and tighten c. Be certain that your hands are warm (by washing them in warm water first if necessary) d. The woman empties her bladder before palpation CORRECT ANSWER: B RATIONALE: It should be wash hands using warm water. Handwashing prevents the spread of possible infection. Using warm water aids in clients comfort and prevents tightening of abdominal muscle. OPTION A: Flexing the knees relaxes the abdominal muscles OPTION D: Doing so promotes comfort and allows for more productive palpation because fetal contour will not obscured by a distended bladder. 63. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs because: a. of high blood pressure b. she is expressing pressure c. the fetus utilizes her glucose stores and leaves her with a low blood glucose d. of the rapid growth of the fetus CORRECT ANSWER: D RATIONALE: Fatigue is extremely common in early pregnancy probably due to increased metabolic requirements. OPTION C: The glucose level of the fetus is about 30mg/100 ml lower than the maternal glucose level. To prevent fetal hypoglycemia, with resultant cell destruction on lack of fetal growth, the maternal glucose level is usually at a higher than normal level during pregnancy. Although, the pancreas secretes an increased level of insulin throughout pregnancy, it appears to be not as effective. With insulin that is less effective, fat stores of the woman are utilizedas well as available glucose. This maintains maternal glucose level at a fairly steady level despite long intervals between meals or days of increased activity. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 238 64. The nurse assesses the woman at 20 weeks gestation and expects the woman to report: For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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a. Spotting related to fetal implantation b. Symptoms of diabetes as human placental lactogen is released c. Feeling fetal kicks d. Nausea and vomiting related HCG production CORRECT ANSWER: C RATIONALE: The fetus can be seen to move on ultrasonography as early as the 11th week, although the mother usually does not feel this movement (quickening) until almost 20 weeks of gestation. (presumptive sign of pregnancy). SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp.222 65. If Mrs. Medina comes to you for check-up on June 2, her EDC is June 11, what do you expect during assessment? a. Fundic ht 2 fingers below xyphoid process, engaged b. Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis c. Cervix open, fundic ht. 2 fingers below xyphoid process, floating. d. Fundic height at least at the level of the xyphoid process, engaged CORRECT ANSWER: A RATIONALE: The fundic height is 2 cm below the xyphoid process. Lightening is a descent of the fetal presenting part into the pelvis, occurs approximately 10-14 days before labor begins. This changes a womans abdominal contour because the uterus becomes lower and more anterior. OPTION B: FH midway between umbilicus and symphysis pubis is 16 weeks gestation OPTION D: FH at the level of the xyphoid process indicates 36 weeks gestation. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 489, 226 Situation 13 - Please continue responding as a professional nurse in varied health situations through the following questions. 66. Which of the following medications would the nurse expect the physician to order for recurrent convulsive seizures of a 10-year old child brought to your clinic? a. Phenobarbital b. Nifedipine c. Butorphanol d. Diazepam CORRECT ANSWER: A RATIONALE: Phenobarbital- 10-30 mcg/ml is indicated as anticonvulsants and for febrile seizures. It acts as barbiturates, probably depresses CNS and increases seizure threshold. OPTION B: Nifedipine is a Calcium channel Blocker, used for angina, dysrhythmias and hypertension OPTION C: Butorphanol tartrate is an opioid analgesic indicated for moderate to severe pain OPTION D: Diazepam is an anxiolytics, indicated for anxiety th SOURCE: Lippincott Williams and Wilkins. Nursing 2006 Drug handbook.26 Edition.pp. 265 67. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring. The nurse is aware that in addition to pregnancy, Rh-negative women would also receive this medication after which of the following? a. Unsuccessful artificial insemination procedure b. Blood transfusion after hemorrhage c. Therapeutic or spontaneous abortion d. Head injury from a car accident CORRECT ANSWER: C For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Any woman who does not receive RhoGAM injection after an induced abortion, miscarriage, ectopic pregnancy and amniocentesis can have had antibody formation begins. OPTIONS A, B & D does not expose the mother to fetal blood so therefore will not cause antibody formation that could cross the placenta and cause red blood cell destruction (hemolysis) of fetal RBC. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp.437-38 68. Which of the following would the nurse include when describing the pathophysiology of gestational diabetes? a. Glucose levels decrease to accommodate fetal growth b. Hypoinsulinemia develops early in the first trimester c. Pregnancy fosters the development of carbohydrate cravings d. There is progressive resistance to the effects of insulin CORRECT ANSWER: D RATIONALE: It is known that gestational diabetes results from inadequate insulin response to carbohydrate and from excessive resistance to insulin or a combination of both may occur. OPTION A: To prevent fetal hypoglycemia, with resultant cell destruction on lack of fetal growth, the maternal glucose level is usually at a higher than normal level during pregnancy. OPTION B: The pancreas increases production of insulin in response to the higher levels of glucocorticoid produced by the adrenal glands. Insulin is less effective than normal, however because estrogen, progesterone and HPL are all antagonist to insulin. Therefore a woman who is diabeteic and taking insulin before pregnancy will need more insulin during pregnancy. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 378 69. When providing prenatal education to a pregnant woman with asthma, which of the following would be important for the nurse to do? a. Demonstrate how to assess her blood glucose b. Teach correct administration of subcutaneous bronchodilators c. Ensure she seeks treatment for any acute exacerbation d. Explain that she should avoid steroids during her pregnancy CORRECT ANSWER: C RATIONALE: Asthma has the potential of reducing the oxygen supply to the fetus if a major attack should occur during pregnancy. OPTION A: Glucose monitoring is not related to asthma; focus on the stream of the question OPTION B: Bronchodilators such as albuterol sulfate, are given orally or as inhalants. OPTION D: Steroids are allowed in patient with asthma during pregnancy. The inhaled corticosteroid beclomethasone are commonly used by women with persistent asthma and are the best choice for pregnant women and those who might become pregnant. SOURCE:Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 368 70. Which of the following conditions would cause an insulin-dependent diabetic client the most difficulty during her pregnancy? a. Rh incompatibility b. Placenta previa c. Hyperemesis gravidarum d. Abruptio placenta CORRECT ANSWER: C Rationale: Hyperemesis gravidarum is nausea and vomiting of pregnancy that is prolonged past week 12 Of pregnancy or is so severe that dehydration, ketonuria and significant weight loss occur within the first 12 weeks of pregnancy. Hyperemesis gravidarum is detrimental in patients with type 1 diabetes because in type 1 DM this can lead to DKA in DKA the blood glucose can reach up to
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800mg/dl, therefore the tendency of the body is to secrete the glucose into the urine (glucosuria) together with the ketones (ketonuria) causing polyuria. Polyuria can cause dehydration. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 320 Situation 14 - One important tool a community health nurse uses in the conduct of his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this vital facility for our practice? 71. The Community/Public Health Bag is: a. a requirement for home visits b. an essential and indispensable equipment of the community health nurse c. contains basic medications and articles used by the community health nurse d. a tool used by the Community health nurse is rendering effective nursing procedure during a home visit CORRECT ANSWER: B RATIONALE: Public health bag is an essential and indispensable equipment of the public health nurse which he/she has to carry along when he/she goes out home visiting. It contains basic medications and articles which are necessary for giving care. OPTION C: an incomplete definition of public health bag OPTION D: Rationale of bag technique SOURCE: DOH CHN pp. 54 72. What is the rationale in the use of bag technique during home visit? a. It helps render effective nursing care to clients or other members of the family b. It saves time and effort of the nurse in the performance of nursing procedures c. It should minimize or prevent the spread of infection from individuals to families d. It should not overshadow concerns for the patient CORRECT ANSWER: A RATIONALE: Options B,C and D are all principles of bag technique SOURCE: DOH CHN pp. 54 73. Which among the following is important in the use of the bag technique during home visit? a. Arrangement of the bag's contents must be convenient to the nurse b. The bag should contain all necessary supplies and equipment ready for use c. Be sure to thoroughly clean your bag especially when exposed to communicable disease cases d. Minimize if not totally prevent the spread of infection CORRECT ANSWER: D RATIONALE: The number 1 principle in bag technique is to minimize if not totally prevent the spread of infection from individuals, families, hence, to the community. OPTIONS A, B and C are all special considerations in the use of bag technique. SOURCE: DOH CHN pp.54 74. This is an important procedure of the nurse during home visits? a. protection of the CHN bag b. arrangement of the contents of the CHN bag c. cleaning of the CHN bag d. proper handwashing CORRECT ANSWER: D RATIONALE: Handwashing is done as frequently as the situation calls for, it helps in minimizing or avoiding contamination of the bag and its contents, because the number 1 principle of ag technique is to prevent spread of infection. OPTION B: the arrangement of content of the bag should be the most convenient to the user to facilitate efficienty and avoid confusion but does not help prevent spread of infection.
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OPTION C: The bag and its contents should be cleaned as often as possible, supplies replaced and ready for use at anytime. OPTION D: The bag and its contents should be well protected from contact with any article in the home of the patients. Consider the bag and its content clean and sterile while any article belonging to the patient as dirty and contaminated. SOURCE: DOH CHN pp. 54-55 75. Which of the following is not found inside the public health bag? a. apron b. test tube holder c. alcohol lamp d. sphygmomanometer and stethoscope CORRECT ANSWER: D RATIONALIZATION: Options A, B and C are contents of public health bag while option D are carried separately. SOURCE: PHN pp. 52 Situation 15 - As a community health nurse, you may realize that the family is faced with a number of health and nursing problems which cannot be taken up all at the same time considering the available resources of both the family and the nurse. The following questions pertain in prioritizing health problems. 76. In identifying and prioritizing health problems of the family in the community setting, the following factors are identified except: a. Nature of the problem b. Cost of resources c. Salience d. Modifiability CORRECT ANSWER: B RATIONALE: Scale for ranking family health problems according to priorities aims to objectivize priority setting. It has 4 criteria: Nature of the problem presented Modifiability of the problem Preventive potential and Salience Option B is not included in scale for ranking family health problems. SOURCE: CHN by Maglaya pp. 61-63 77. According to the factors affecting priority setting, which of the following situations would be classified as a health threat that needs immediate attention? a. G2P1 mother with history of pre-eclampsia b. School age children below normal weight c. Mothers who have no knowledge on caring for the young d. Community with 100 people suffering from scabies CORRECT ANSWER: A RATIONALE: Health threats are conditions that promote disease or injury and prevent people from realizing their health potentials Health deficit occurs when there is a gap between actual and achievable health status Foreseable crisis includes stressful occurrences such as death or illness of a family member. OPTIONS B and D: Health deficit OPTION C: Foreseable crisis SOURCE: DOH CHN pp.44 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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78. A health deficit refers to preventable health problems brought about by lack of knowledge to handle situation. Which of the following is not a health deficit? a. Family size beyond familys resources b. Malnutrition c. Unsanitary waste disposal d. Cases of malaria CORRECT ANSWER: D RATIONALE: refer to # 77 OPTION D is a health threat OPTIONS A, B and C are health deficit SOURCE: DOH CHN pp.44 79. In formulating goals for family health nursing, there are barriers which the nurse has to identify. Which of the following situation is an identified barrier? a. Family accepts the existence of the problem b. Nurse and family develops a working relationship c. Family perceives problem but belittles it. d. Goals set by both family and nurse is attainable CORRECT ANSWER: C RATIONALE: One of the barriers to joint setting between the nurse and the family is the failure of the family on the part to perceive the existence of the problem. In many instances, the problem is seen only by the nurse while the family is perfectly satisfied with the existing situation. SOURCE: CHN by Maglaya pp.71 80. In planning nursing care in the community health setting, the nurse has to consider the different concepts of planning except: a. Planning is a set and standardized and rigid b. Planning is dynamic and continuous c. Planning entails a systematic process d. Planning is futuristic. CORRECT ANSWER: A RATIONALE: The following summarize the concepts of planning; Planning is futuristic Planning is change-oriented Planning is a continuous and dynamic process Planning is flexible Planning is a systematic process SOURCE: CHN by Maglaya pp.71
Situation 16 - You are actively practicing nurse who just finished your Graduate Studies. You earned the value of Research and would like to utilize the knowledge and skills gained in the application of research to nursing service. The following questions apply to research. 81. Which type of research inquiry investigates the issue of human complexity (e.g. understanding the human expertise) a. Logical position b. Naturalistic inquiry c. Positivism For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. Quantitative Research CORRECT ANSWER: B RATIONALE: Naturalistic inquiry is research that focus on how people behave when they are absorbed in genuine life experiences in natural settings. OPTION A: logical positivism= the philosophy underlying the traditional scientific approach OPTION C: positivism is same with logical positivism OPTION D: Quantitative research= the investigation of phenomena that lend themselves to precise measurement and quantifications, after involving a vigorous and controlled design SOURCE: www.uky.edu/cohort/methods 82. Which of the following studies is based on quantitative research? a. A study examining the bereavement process in spouses of clients with terminal cancer b. A study exploring factors influencing weight control behavior c. A study measuring the effects of sleep deprivation on wound healing d. A study examining client's feelings before, during and after a bone marrow aspiration CORRECT ANSWER: C RATIONALE: Quantitative research is the investigation of phenomena that lead themselves to precise measurement and quantifications, often involving a vigorous and controlled design. OPTIONS A, B and D are qualitative research.
SOURCE: http://www.wilderdom.com/research/QualitativeVersusQuantitativeResearch.html 83. Which of the following studies is based on qualitative research? a. A study examining clients reactions to stress after open heart surgery b. A study measuring nutrition and weight, loss/gain in clients with cancer c. A study examining oxygen levels after endotracheal suctioning For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. A study measuring differences in blood pressure before during and after a procedure CORRECT ANSWER: A RATIONALE: refer to # 82 Other options are quantitative research. 84. An 85 year old client in a nursing home tells a nurse, "I signed the papers for that research study because the doctor was so insistent and I want him to continue taking care of me." Which client right is being violated? a. Right of self determination b. Right to privacy and confidentiality c. Right to full disclosure d. Right not to be harmed CORRECT ANSWER: A RATIONALE: The principle of self-determination means that the prospective participants have the right to decide voluntarily whether to participate in a study, without risking any penalty or prejudicial treatment. A persons right to self-determination includes freedom from coercion. OPTION B: Participants have the right to expect that any data they provide will be kept in strictest confidence. OPTION C: Full disclosure means that the researcher has fully describe the nature of the study, the persons right to refuse participation, the researchers responsibilities and the likely risks and benefits. OPTION D: Researchers should strive to minimize all types of harm and discomfort and to achieve in so far as possible a balance between the potential benefits and risk of being aparticipants. SOURCE: Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. th 7 Edition.pp. 143-149 85. "A supposition or system of ideas that is proposed to explain a given phenomenon," best defines: a. a paradigm b. a concept c. a theory d. a conceptual framework CORRECT ANSWER: C RATIONALIZATION: Theory is an abstract generalization that presents a systematic explaination about the relationship among phenomenon. OPTION A: Paradigm is a way of looking at natural phenomena that encompasses a set of philosophical assumptions and that guides ones approach to inquiry. OPTION B: Concept an abstraction based on observation of behaviors or characteristics, (examples stress, pain) OPTION D: Is a group of related ideas, statements, or concepts. SOURCE:Polit, Denise F and Beck, Cheryl Tatano. Nursing research. Principles and Methods. 7th Edition th Kozier & Erb. Fundamentals of Nursing. 7 Edition. Situation 17 - Nurse Michelle works with a Family Nursing Team in Calbayog Province specifically handling a UNICEF Project for Children. The following conditions pertain, to CARE OP THE FAMILIES PRESCHOOLERS. 86. Ronnie asks constant questions. How many does a typical 3-year-old ask in a day's time? a. 1,200 or more b. Less than 50 c. 100-200 d. 300-400
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CORRECT ANSWER: D RATIONALE: A 3-year-old child has a vocabulary of about 900 words. These are used to ask questions constantly up to 400 a day, mostly how and why questions. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 887 87. Ronnie will need to change to a new bed because his baby sister will need Ronnie's old crib, what measure would you suggest that his parents take to help decrease sibling rivalry between Ronnie and his new sister? a. Move him to the new bed before the baby arrives b. Explain that new sisters grow up to become best friends c. Tell him he will have to share with the new baby d. Ask him to get his crib ready for the new baby CORRECT ANSWER: A RATIONALE: Introduction of a new sibling is such a major happening that parents need to take special steps to be certain their preschooler will be prepared. Help parents not to underestimate the significance of a bed to a preschool child. It is security, consistency and home. If the preschooler has been sleeping in a crib that is to be used for the baby, it is usually best if he/she is moved to a bed about 3 months in advance of the birth. The parents might explain, It is time to sleep in a new bed now because youre a big boy. The fact that he is growing up is better reason for such a move than because a new brother/sister wants the old bed. The latter is a direct route to sibling rivalry and jealousy. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 900-901 88. Ronnie's parents want to know how to react to him when he begins to masturbate while watching television, what would you suggest? a. They refuse to allow him to watch television b. They schedule a health check-up for sex-related disease c. They remind him that some activities are private d. They give him "timeout" when this begins CORRECT ANSWER: C RATIONALE: it is common for preschoolers to engage in masturbation while watching TV or being read to or before they fall asleep at night. The frequency of this may increase under stress at night. If observing a child doing this bothers parents, suggest they explain that things are done in some places but not in others. Children can relate to this kind of direction without feeling inhibited, just as they accept the fact that they use a bathroom in private or eat only at table. Calling unnecessary attention to the act can increase anxiety and cause increased not decreased, activity. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp. 902 89. How many words does a typical 12-month-oId infant use? a. About 12 words b. Twenty or more words c. About 50 words d. Two, plus "mama" and "dada" CORRECT ANSWER: D RATIONALE: By ten months an infant masters another word such as bye-bye or no. At 12 months infants can generally say two words besides mama and dada, they use those two words with meaning. SOURCE: Maternal & Child Health Nursing by Adele Pillitteri, 5th edition, Pp 136 90. As a nurse, you reviewed infant safety procedures with Bryan's mother. What are two of the most common types of accidents among infants? For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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a. Aspiration and falls b. Falls and auto accidents c. Poisoning and burns d. Drowning and homicide CORRECT ANSWER: A RATIONALE: Injuries are a major cause of death during infancy, esp. children 6 to 12 months old. According to a recent Canadian survey the top leading causes of injury to infants were falls, ingestion injuries and burns. Constant vigilance, awareness and supervision are essential as the child gains increased locomotor and manipulative skills that are coupled with an unstable curiosity about the environment. th SOURCE: Wongs Essentials of Pediatric Nursing 7 edition Page 346 Situation 18 - Among common conditions found in children especially among poor communities are ear infection/ problems. The following questions apply. 91. A child with ear problem should be assessed for the following EXCEPT: a. is there any fever? b. ear discharge c. if discharge is present for how long? d. ear pain CORRECT ANSWER: A RATIONALE: A child with ear problem should be assessed for? * Is there pain? * Is there ear discharge? If yes for how long? Look , Feel: -Look for the pus draining from the ear -Feel for tender swelling behind the ear SOURCE:IMCI Manual Page 5 92. If the child does not have ear problem, using IMCI, what should you as the nurse do? a. Check for ear discharge b. Check for tender swellings, behind the ear c. Check for ear pain d. Go to the next question, check for malnutrition CORRECT ANSWER: D RATIONALE: A child with no ear infection, no additional treatment is prescribed and advise mother when to return immediately. Then go to the next question and check for malnutrition SOURCE: IMCI Manual Page 5 93. An ear discharge that has been present for more than 14 days can be classified as: a. mastoditis b. chronic ear infection c. acute ear infection d. complicated ear infection CORRECT ANSWER: B RATIONALE: Pus seen draining the ear and discharge is reported for more than 14 days is considered chronic ear infection. Nursing interventions includes: * dry the ear by wicking *follow-up in 5 days *advise mother when to return immediately. OPTION A: mastoiditis manifestation according to IMCI tender swelling behind the ear OPTION C: Acute era infection, there is ear pain, pus is seen draining from the ear, and discharge is reported for less than 14 days. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION D: not found in IMCi SOURCE: IMCI Manual Page 5 94. An ear discharge that has been present for less than 14 days can be classified as: a. chronic ear infection b. mastoditis c. acute ear infection d. complicated ear infection CORRECT ANSWER: A RATIONALE: Manifestation classified as Chronic Ear Infection is pus seen draining from the ear, and discharge reported for less than 14 days. OPTION B: Mastoiditis if there is tender swelling behind the ear OPTION C: if the manifestation is accompanied by Ear Pain then it is classified as Acute ear pain OPTION D: not a classification in IMCI SOURCE: IMCI Manual Page 5 95. If the child has severe classification because of ear problem, what would be the best thing that you as the nurse can do? a. instruct mother when to return immediately b. refer urgently c. give an antibiotic for 5 days d. dry the ear by wicking CORRECT ANSWER: B RATIONALE: Severe classification of ear problem is classified as mastoiditis. Nursing intervention includes: give 1st dose of an appropriate antibiotics give 1st dose of paracetamol for pain refer URGENTLY to hospital SOURCE: IMCI Manual Page Situation 19 - If a child with diarrhea registers one sign in the pink row and one in the yellow; row in the IMCI Chart. 96. We can classify the patient as: a. moderate dehydration b. some dehydration c. no dehydration d. severe dehydration CORRECT ANSWER: D RATIONALE: Any danger sign classify it as severe dehydration. Examples of danger signs are: *abnormally sleepy or difficult to awaken *sunken eyes *not able to drink or drinking poorly *skin pinch goes back slowly SOURCE: IMCI Manual Page 3 97. The child with no dehydration needs home treatment. Which of the following is not included the rules for home treatment in this case: a. continue feeding the child b. give oresol every 4 hours c. know when to return to the health center d. give the child extra fluids For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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CORRECT ANSWER: B RATIONALE: If the child is classified under no dehydration, treatment includes: give fluids and food to treat diarrhea at home give zinc supplements advice mother when to return immediately follow-up in 5 days if not improving SOURCE: IMCI Manual Page 98. A child who has had diarrhea for 14 days but has no sign of dehydration is classified as: a. severe persistent diarrhea b. dysentery c. severe dysentery b. dysentery d. persistent diarrhea CORRECT ANSWER: D RATIONALE: A child with no signs of dehydration is classified under persistent diarrhea. Interventions include: advice the mother on feeding a child who has persistent diarrhea give vit. A follow-up in 5 days advice mother when to return immediately OPTION A: dehydration present OPTION B: signs include blood in the stookl OPTION C; wrong classification SOURCE: IMCI Manual Page 99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back slowly, the classification would be: a. no dehydration b. moderate dehydration c. some dehydration d. severe dehydration CORRECT ANSWER: C RATIONALE: Classification under some dehydration, signs include:Two of the following signs restless, irritable sunken eyes drinks eagerly, thirsty skin pinch goes back very slow OPTION A: No dehydration signs include: not enough signs to classify as some or severe dehydration OPTION B: moderate dehydration- wrong classification OPTION D: Severe dehydration, two of the following signs: abnormally sleepy or difficult to awaken sunken eyes not able to drink or drinking poorly skin pinch goes back slow SOURCE: IMCI manual 100. Carlo has had diarrhea for 5 days. There is no blood in the stool, he is irritable. His eyes are sunken the nurse offers fluid to Carlo and he drinks eagerly. When the nurse pinched the abdomen, it goes back slowly. How will you classify Carlo's illness? a. severe dehydration b. no dehydration For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. some dehydration d. moderate dehydration CORRECT ANSWER: C RATIONALE: The manifestations of the client are of some dehydration. Other manifestation under the classification is restlessness. OPTION A: Two of the following should be manifested in order to be classified as severe dehydration: Abnormally sleepy or difficult to awaken Sunken eyes Skin pinch goes back very slowly OPTION B: if not enough signs to classify as some or severe dehydration. OPTION D: not part of the classification SOURCE: IMCI manual Page 24
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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. Anesthesiologist c. Surgeon d. Nursing aide CORRECT ANSWER: A RATIONALE: The circulating nurse is responsible for the overall running of the OR before, during and after the operative procedure. Also he/she is responsible for the opening of the outer wrapper of sterile supplies that will be used during the operative procedure. OPTION B: The anesthesiologist is the person that administers the anesthetic to the patient. OPTION C: The surgeon is responsible in performing the surgical procedure safely and correctly. OPTION D: The nursing aide is not a part of the surgical team. SOURCE: Barela et. al. Operating Room Technique Instructional Manual 1st Ed. pp. 42-44 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. Who monitors the status of the client like urine output, blood loss while the surgeon performs the surgical procedure? a. Scrub nurse b. Surgeon c. Anesthesiologist d. Circulating nurse CORRECT ANSWER: C RATIONALE:The anesthesiologist or nurse anesthetist maintains the airway, ensures adequate gas exchange, monitors circulation and respiration, estimates blood and fluid loss, infuses blood and fluids, administers medications to maintain hemodynamic stability, and alerts the surgeon immediately to any complication. OPTION A: Scrub nurse organize the surgical equipment and hand the surgeon the appropriate instruments required for the operative procedure. OPTION B: The surgeon heads the surgical team and makes decision about the surgical procedure. OPTION D: the circulating nurse maintains the coordination of all team members. th SOURCE: Black and Hawks. Medical-Surgical Nursing. Volmue 1. 7 ed. p. 284 3. The following are members of the sterile team EXCEPT for one. a. Surgeon b. Surgical Assistant c. Anesthetist d. Scrub nurse
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CORRECT ANSWER: C RATIONALE:Anesthetist is the answer. Sterile team are perioperative caregivers who provide direct care within the sterile field. Nonsterile team are perioperative caregivers who provide direct care from the pheripery of the sterile field and environment. An Anesthetist is a member of the nonsterile team who administers anesthetics during the surgical procedure OPTIONS A, B & D: Sterile members of the surgical team SOURCE: Phillips. p. 50 4. Before blood transfusion, the nurse started an IV infusion as ordered. Which of the following is commonly ordered before BT? a. Sterile water solution b. D5LR c. Dextrose 5% in water d. Normal saline solution CORRECT ANSWER: D RATIONALE:Normal saline solution is the only solution compatible for blood transfusion OPTION A: is not for blood transfusion OPTION B: Solutions containing calcium, such as Ringers lactate may cause clotting. OPTION C: Dextrose may lead to clumping of red blood cells and hemolysis. SOURCES: Timby. Clinical Nursing Procedures. p. 138; Luckmann and Sorensen. Medical Surgical Nursing. 3 rd Ed. p. 1029 Situation 2 - You are assigned in the Orthopedic Ward where clients are complaining of pain in varying degrees upon movement of body parts. 5. 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 CORRECT ANSWER: B RATIONALE: These assessment is a sign of decrease blood flow to the area that may require immediate intervention before complications (e.g. necrosis) may happen. OPTION A: Not alarming to report to physician. Reinforcing of dressing can be done. OPTION C: it is normal because the patient has just undergone a surgery OPTION D: Within normal range 6. There is an order of Demerol 50 mg I.M. now and every 6 hours prn, 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 CORRECT ANSWER: C RATIONALE: Demerol is given at 5pm. If pain is still present, the next dose of this will be 6 hours after at 11 pm. 7. A patient is in pain following surgery. Which of the following instructions should the nurse give to the patient regarding pain management? a. Try to bear the pain as long as you can. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. Pain should be reported in the early stages. c. Higher levels of pain are easier to reduce than lower levels. d. Our goal is to keep you pain free. CORRECT ANSWER: B RATIONALE: Medicating before pain begins will require less medication. Therefore, the nurse should advise the postoperative patient that pain should be reported in the early stages to best manage the pain. OPTION A: Trying to bear as long as possible will only require more medication and/or greater frequency to get the pain under control. OPTION C: Higher levels of pain are not easier to reduce than lower levels. OPTION D: It is not always realistic to expect to keep the patient totally pain free at all times. But through frequent assessment, reassessment and proper intervention, the nurse should be able to manage the patients pain throughout the healing process until pain relief is no longer needed. th SOURCE: CGFNS Qualifying Exam. 5 ed. p. 134 8. When assessing a patient for pain, the nurse observes facial grimacing with movement, and blood pressure and pulse elevation. Which of the following measures should the nurse take next? a. Realize that patient has the right to refuse medication. b. Explain the reasons for taking pain medication. c. Tell the patient to notify the nurse when the pain becomes severe. d. Leave the medication at the bedside in case the patient desires it later. CORRECT ANSWER: B RATIONALE: Regardless of its source, pain that is inadequately treated as harmful has harmful effects beyond the discomforts it causes. Unrelieved pain affects various body systems, including the cardiovascular system, and can initiate the stress response, resulting in increased pulse and BP and a distressed appearance. By providing an explanation such as this, the nurse can help the patient to accept the drugs needed to relieve pain. OPTION A: Patients have the right to refuse therapy. The nurse can play an important role in determining the reason for refusal and should first make that attempt before accepting refusal. OPTION C: A general principle for administering analgesics is to administer them before pain increases in severity. OPTION D: Medications should never be left at the bedside for the patient to take later. th SOURCE: CGFNS Qualifying Exam 5 ed. p. 141 9. 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 CORRECT ANSWER: D RATIONALE: fentanyl (sublimaze) is a narcotic agonist analgesic (Other name: Neuroleptanalgesic) It is 75-100 times more potent than morphine! In very high doses it can cause respiratory depression. Assess respiratory rate to monitor impending signs of respiratory depression. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1, 10th ed. p. 426 Situation 3 Rita just retired from government service and was admitted for pneumonectomy. 10. As the nurse on duty, you should check for the medical clearance of your client for surgery among other pre-op requirements. This clearance primarily covers: a. Stress-coping mechanism of the client For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. Socio-economic status of the client c. Smoking and eating habits of the client d. Cardio-pulmonary system CORRECT ANSWER: D RATIONALE: The goal in preparing any patient for surgery is to ensure a well-functioning cardiovascular system to meet the oxygen, fluid and nutritional needs of the perioperative period. Also a goal for potential surgical patients is optimal respiratory function. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1, 10th ed. p. 403 11. Preoperative tests were done. Particularly, the nurse should assess the lung capacity by checking the: a. Serum creatinine level b. Chest x-ray c. Serum protein levels d. Arterial blood gas CORRECT ANSWER: D RATIONALE: Arterial blood gases provide information about alveolar ventilation, oxygenation, and acid-base balance. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 281 OPTION A: this blood test is essential in the evaluation of renal function OPTION B: chest x-ray identify various abnormalities of the lungs and structures in the thorax, including the heart, great vessels, ribs or diaphragm. OPTION C: this blood test helps diagnose hepatic, gastrointestinal, and renal disease; protein abnormalities; cancer and blood dyscrasias. SOURCE: Gaedeke. Laboratory and Diagnostic Test Handbook 12. The main objective in postoperative pneumonectomy is to: a. Maintain a patent airway b. Provide maximum remaining lung capacity c. Provide early rehabilitation measures d. Recognize early symptoms of complications CORRECT ANSWER: A RATIONALE: Using ABC, airway patency is the priority during postoperative pneumonectomy OPTIONS B, C & D: correct intervention but airway patency is still the priority 13. There is an order of central venous pressure (CVP) reading. As a nurse, you should know that this is a measure observing signs of: a. Hypoxia b. Hypovolemia c. Hypothermia d. Hypoxemia CORRECT ANSWER: B RATIONALE: The CVP is an indirect method of determining right ventricular filing pressure (preload). This makes the CVP a useful hemodynamic parameter to observe when managing an unstable patients fluid volume status. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 678 14. Pulmonary edema is a potential danger that we nurses should monitor in post pneumonectomy. This is usually due to: a. Cardiac output goes to the remaining lung b. Liberal fluid intake c. Rapid infusion of IV fluids For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. Fluid retention due to prolonged bed rest CORRECT ANSWER: A RATIONALE: Pulmonary edema most commonly occurs as a result of increased microvascular pressure from abnormal cardiac function. The backup of blood into the pulmonary vasculature resulting from inadequate left ventricular function causes a increased microvascular pressure, and fluid begin to leak into the interstitial space and alveoli. Other causes of pulmonary edema are hypervolemia or a sudden increase in the intravascular pressure in the lung. One example of this is in the patient who has undergone a pneumonectomy. When one lung has been removed, all the cardiac output then goes to the remaining lung. If the patients fluid status is not monitored closely, pulmonary edema can quickly develop in the post operative period as the patients pulmonary vasculature attempt to adapt. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 542 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 to patient delivery outcome. 15. 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 CORRECT ANSWER: B RATIONALE: Patient safety in the preoperative area is a priority. Using process to verify patient identification, the surgical procedure, and the surgical site maximizes patient safety and allows for early identification and intervention if any discrepancies are identified. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 414 17. In the OR, you will position a patient for TURP in: a. Supine b. Lithotomy c. Semi-fowler d. Trendelenburg CORRECT ANSWER: B RATIONALE: Surgery is performed in lithotomy position - Keep in mind: Functional residual capacity decreases, predisposing patients to atelectasis and hypoxia. Rapid lowering of the legs at the end of the operation acutely decreases venous return and can result in severe hypotension, especially when combined with blood loss during surgery. SOURCE: http://www.rph.wa.gov.au/anaesth/downloads/TURP_Titze.pdf 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 material 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 CORRECT ANSWER: C RATIONALE: Preventing physical injury includes using safety straps and bed rails and not leaving the sedated patient unattended. OPTIONS A & B: does not answer safety question OPTION D: inappropriate SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 435
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19. You refer postoperative patients under general anesthesia to the doctor when he has: a. Cold clammy skin and filiform pulse b. Snoring respiration and rapid pulse c. Accidental removal of the airway d. A drop in blood pressure and rapid pulse CORRECT ANSWER: D RATIONALE: It is the responsibility of the surgeon and the anesthetist or anesthesiologist to monitor and manage complications. However, a nurse plays an important role. Being alert to and reporting changes in vital signs and symptoms of nausea and vomiting, anaphylaxis, hypoxia, hypothermia, malignant hyperthermia and disseminated intravascular coagulation and assisting with their management is an important factor (Smeltzer, 434). The anesthesia provider functions as the guardian of the patient throughout the entire care period, the anesthesia provider manage the patients physiology using the principle of aseptic technique (Phillips, 51). Maintaining the patency of airway is the responsibility of the anesthesia provider, an accidental removal of airway is negligent. SOURCES: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 434 Phillips. p. 51 20. Some different habits and hobbies affect postoperative respiratory function. If your client smokes 3 packs of cigarettes a day for the part 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 CORRECT ANSWER: D RATIONALE: Patients who smoke are encouraged to stop 2 months before surgery. These patients should be counseled to stop smoking at least 24 hours prior to surgery. Research suggest that counseling has a positive effect on the patients smoking behavior 24 hors preceding surgery, helping reduce the potential for adverse effect associated with smoking such as increased airway reactivity, decreased mucocilliary clearance, as well as physiologic changes in the cardiovascular and immune systems. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 403 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 CORRECT ANSWER: C RATIONALE: The duties of the scrub nurse include gathering all equipment for the procedure, preparing all supplies and instruments using sterile technique, maintaining sterility within the sterile field during surgery, handling instruments and supplies during surgery, and cleaning up after the case. During surgery, the scrub nurse maintains an accurate counting of sponges, sharps and instruments on the sterile field and counts the same materials with the circulating nurse before and after the surgery. OPTIONS B & D These are the roles of the anesthesiologist SOURCE: Black and Hawks. Medical-Surgical Nursing. 7th ed. pp. 284-285 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 not leaving the sedated patient For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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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 CORRECT ANSWER: A RATIONALE: Preventing physical injury includes using safety straps and bed rails and not leaving the sedated patient unattended. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 434 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 lessen chance of incision infection? a. Draped b. Pulled c. Clipped d. Shampooed CORRECT ANSWER: D RATIONALE: Immediate preoperative nursing care: Preparing the skin: Explain shower and bathing protocols for the night before the planned surgical procedure. Usually the operative area is cleaned the night before surgery with soap and water or an antimicrobial solution to reduce the number of microbes on the skin. OPTION A: inappropriate OPTION B: inappropriate OPTION C: Electric clippers are used for safe hair removal immediately before the operation if hair must be removed. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 413; Black and Hawks. Medical-Surgical Nursing. 7th ed. p. 277 24. A nurse is assessing the operative site in a client who underwent a breast reconstruction. The nurse is inspecting the flap and the areola of the nipple and notes that the areola is a deep red color around the edge. The nurse takes which action first? a. Document the findings b. Elevate the breast c. Encourage nipple massage d. Notify the physician CORRECT ANSWER: D RATIONALE: Following breast reconstruction, the flap is inspected for color, temperature, and capillary refill. Assessment of the nipple areola is made, and dressings are designed so this area can be observed. An areola that is deep red, purple, dusky, or black around the edge is reported to the physician immediately because this may indicate a decreased blood supply to the area. The nurse would also document the findings once the physician is notified. OPTIONS B & C: are incorrect actions. 25. When performing a surgical dressing change of a clients abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse would do which of the following in the initial care of this wound? a. Leave the incision open to the air to dry the area b. Apply a sterile dressing soaked in povidone-iodine (Betadine) c. Irrigate the wound and apply sterile dressing d. Apply a sterile dressing soaked with normal saline. CORRECT ANSWER: D For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. Dehiscence usually occurs 6-8 days after surgery. The client should be instructed to remain quiet and to avoid coughing and straining. The client should be positioned to prevent further stress on the wound. The nurse must notify the physician after applying a sterile dressing soaked with normal saline. OPTION A: will dry and will be prone to infection if exposed to air OPTION B: Betadine will irritate the tissues rd SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3 ed. 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 CORRECT ANSWER: D RATIONALE: Asthma exacerbations are best managed by early treatment and education of the patient. Quick-acting beta-adrenergic medications are first used to prompt relief of airflow obstruction. OPTION A: This is not a priority OPTION B: Should only be at 2L/min OPTION C: Suctioning the client increases respiratory distress SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. Volume I. p. 592 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 CORRECT ANSWER: A RATIONALE: Classification: Bronchodilator Mechanism of action: relaxes smooth muscle of bronchial airways and pulmonary blood vessels. OPTION B: Expectorants OPTION C: Mucolytic reduces the viscosity of pulmonary secretions. OPTION D: Antitussive suppresses the cough reflex by direct action on the cough center in the medulla. SOURCE: Nursing 2006 Drug handbook 26 th ed. 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 CORRECT ANSWER: D RATIONALE: Asthma is not an infectious disease. Practicing respiratory isolation is a wrong teaching instruction. 29. The asthmatic client asked you what breathing technique he can best practice when asthmatic attack starts. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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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 CORRECT ANSWER: D RATIONALE: Orthopneic position provides maximum lung expansion 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 CORRECT ANSWER: C RATIONALE: Status asthmaticus is severe persistent asthma that does not respond to conventional therapy. The attacks last longer than 24 hours. The basic characteristic of asthma decreases the diameter of the bronchi and is apparent in status asthmaticus. A ventilationperfusion abnormality results in hypoxemia and respiratory alkalosis initially, followed by respiratory acidosis. There is a reduced PaO2 and an initial respiratory alkalosis, with a decreased PaCO2 and an increased pH. As status asthmaticus worsens, the PaCO2 increases and pH falls, reflecting respiratory acidosis. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 595 Situation 7 P. Cruz, 65 years old, was admitted in the hospital because of signs and symptoms of acute MI. You are expected to recognize ECG readings on the cardiac monitor. 31. Which of the following will appear abnormal in the ECG when ischemia and injury occur in the myocardium? a. QRS interval b. ST segment and T wave c. P wave d. PR interval CORRECT ANSWER: B RATIONALE: The first ECG signs of acute MI are from myocardial ischemia and injury. Myocardial injury causes a T wave to become enlarged and symmetric. As the area of injury becomes ischemic, myocardial repolarization is altered and delayed, causing the T wave to invert. The ischemic region may remain depolarized while adjacent areas of the myocardium return to resting state. Myocardial injury also causes ST-segment changes. The injured myocardial cells depolarize normally but repolarize more rapidly than normal cells, causing the ST segment to rise at least 1 mm above the isoelectric line (area between the T wave and the next P wave is used as a reference for isoelectric line) when measured 0.08 seconds after the end of the QRS. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 726 32. From an ECG reading, a QRS complex represents; a. Ventricular depolarization b. Ventricular repolarization c. End of ventricular depolarization d. Atrial depolarization CORRECT ANSWER: A RATIONALE: QRS complex represents ventricular muscle depolarization OPTION B: T wave represents ventricular muscle repolarization OPTION D:P wave represents atrial muscle depolarization For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686 33. Which of the following represents ventricular repolarization? a. T wave b. ST segment c. QRS complex d. PR interval CORRECT ANSWER: A RATIONALE: T wave represents ventricular muscle repolarization OPTION B: ST segment represents early ventricular repolarization OPTION C: QRS complex represents ventricular muscle depolarization OPTION D: PR interval represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686 33. It is important that the nurse measures interval of QRS complex. Which if the following represent the normal interval of QRS complex? a. Greater than .20 sec b. .20 sec c. .10 sec d. .12 sec to .20 sec CORRECT ANSWER: C RATIONALE:The QRS is normally less than 0.12 seconds in duration SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 686 35. Later in the acute phase of MI, which of the following typically appears as the first sign of tissue death? a. ST segment suppression b. Short T wave c. Prolonged PR interval d. Pathologic Q wave CORRECT ANSWER: A RATIONALE:Typically, an evolving acute myocardial infarction will show ST segment elevation on an ECG, which indicate acute, evolving myocardial necrosis. OPTION D the emergence of Q wave may be an indication of worsening ischemia and necrosis. SOURCE: Schumacher & Chernecky. Critical Care and Emergency Nursing. p. 132 Situation 8 - Mrs. Cruz was admitted in the Medical Floor due to pyrosis, dyspepsia and difficulty of swallowing. 36. Based from the symptoms presented, Nurse Yoshi might suspect: a. Esophagitis b. Hiatal hernia c. GERD d. Gastric Ulcer CORRECT ANSWER: C RATIONALE: GERD is the backflow of gastric or duodenal contents into the esophagus caused by incompetent lower esophageal sphincter. Pyrosis or heartburn, dyspepsia and dysphagia are cardinal symptoms. 37. What diagnostic test would confirm the type of problem Mrs. Cruz have? a. Barium enema For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. Barium swallow c. Colonoscopy d. Lower GI series CORRECT ANSWER: B RATIONALE: Barium swallow or upper GI series would confirm GERD. Endoscopy is another diagnostic test. OPTIONS A and D: are the same OPTION C: is incorrect 38. Mrs. Cruz complained of pain and difficulty in swallowing. This term is referred as: a. Odynophagia b. Dysphagia c. Pyrosis d. Dyspepsia CORRECT ANSWER: A RATIONALE: When difficulty of swallowing is accompanied with pain this is now referred as odynophagia OPTION D Dysphagia is difficulty of swallowing alone. 39. To avoid acid reflux, Nurse Yoshi should advice Mrs. Cruz to avoid which type of diet? a. Cola, coffee and tea b. High fat, carbonated and caffeinated beverages c. Beer and green tea d. Lechon paksiw and bicol express CORRECT ANSWER: B RATIONALE: All are correct but OPTION B is the best answer. In patients with GERD, this type of diet must be avoided to avoid backflow of gastric contents. Excessive caffeine reduces the tone of lower esophageal sphincter. Test Taking Skills: look for the umbrella effect 40. Mrs. Cruz body mass index (BMI) is 25. You can categorize her as: a. Normal b. Overweight c. Underweight d. Obese CORRECT ANSWER: B RATIONALE: Mr. Cruz BMI belongs to the overweight category (24 26), malnourished (less than 17), underweight (17 19), normal (20 23), obese (27 30) and morbidly obese (greater than 30). BMI is weight in kilograms divided by height in square meters 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 powder and rings around the stoma c. Clean the area daily with soap and water before applying bag d. Apply talcum powder twice a day CORRECT ANSWER: A RATIONALE: OPTION B: Mild skin irritation may require the use of karaya powder before attaching the pouch.
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OPTION C: Soap acts as a mild abrasive agent to remove enzyme residue from fecal spillage. The nurse advises the patient to protect the peristomal skin by washing the area with gently with a moist, soft cloth and mils soap. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. pp.1062-1063 42. A nurse instructs the patient who had an ileostomy to avoid which of the following foods? a. Potatoes b. Beef c. Popcorn d. Yogurt CORRECT ANSWER: C RATIONALE: Food which can cause a potential obstruction in an ileostomy includes nuts, raisins, popcorn, seeds, chocolate, raw vegetables, celery and corn. OPTIONS A, B & D These foods are not contraindicated for patients who have an ileostomy SOURCE: CGFNS qualifying exam. 5th ed. p. 194 43. The patient who has had an ileostomy says to the nurse, I will have to be isolated for the rest of my life because no one will be able to stand this terrible odor. Which of the following responses by the nurse would most likely be reassuring? a. The odor will gradually become less noticeable. b. I can understand your concern, but remaining in isolation does not reduce the odor. c. There are techniques that can reduce the odor. d. The odor is a normal part of your condition and will not offend people. CORRECT ANSWER: C RATIONALE: There are techniques that the nurse can use to reduce odor of the ileostomy, such as placing charcoal in the ileostomy bag. The charcoal will absorb the odor in the bag. OPTION A the odor does not gradually become less noticeable unless steps are taken to reduce it. OPTION B While it is important to help the patient ventilate, this response does not answer the issue of the odor. OPTION D This statement is not necessarily true. Others may be offended by the odor. Teaching the patient measures that will help to reduce odor will be most beneficial. th SOURCE: CGFNS qualifying exam 5 ed. p. 194 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. Hand the solution 18 inches above the stoma CORRECT ANSWER: A RATIONALE: If cramping occurs, clamp off the tubing and allow the patient to rest before progressing. Painful cramps are often caused by too rapid flow or by too much solution. 300 ml of fluid maybe all that is needed to stimulate evacuation. Volume may be increased with subsequent irrigation to 500, 1000, or 1500ml as needed by the patient for effective results. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. 10 ed. p. 1065 45. The nurse is assessing the colostomy of a client who had an abdominal perineal resection for a bowel tumor. Which of the following assessment findings indicate that the colostomy is beginning to function? a. Blood drainage from the colostomy b. Change the dressing as prescribed c. Absent bowel sounds d. The passage of flatus For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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CORRECT ANSWER: D RATIONALE: Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for the return of peristalsis and listen for bowel sounds and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected in a colostomy. SOURCE: Silvestri. Saunders NCLEX-RN Examination.3rd ed. P. 612 Situation 10 - As a beginner in research, you are aware that sampling is an essential element of the research process. 46. What does a sample group represent? a. Control group b. Study participants c. General population d. Universe CORRECT ANSWER: B RATIONALE: Study participants are the people who are being studied; such study participants comprise the sample. th SOURCE: Polit and Beck. Nursing Research Principles and Methods 7 Ed. p. 26 47. This kind of research gathers data in detail about individual or groups and presented in narrative form, which is a. Case study b. Historical c. Analytical d. Experimental CORRECT ANSWER: A RATIONALE: Case studies are in-depth investigations of a single entity or a small number of entities. The entity may be an individual, family, group, institution, community or other social unit. In case study, researchers obtain a wealth of descriptive information and may examine relationships among different phenomena, or may examine trends over time. OPTION B: Historical research- systematic studies designed to discover facts and relationship about past events Analytical epidemiologic studies are most useful for testing an hypothesized association between human exposure and adverse health effects. OPTIION D: Experimental is a study in which the researcher controls (manipulates) the independent variable and randomly assigns subjects to different conditions. SOURCE: Polit,D.E. and Beck C.T. Nursing Research principles and methods. 7th ed. pp. 259, 716, 718 48. Random sampling ensures that each subject has: a. Been selected systematically b. An equal change of selection c. Been selected based on set criteria d. Characteristics that match other samples CORRECT ANSWER: B RATIONALE: Random sampling is a selection of the sample such that each member of the population has an equal probability of being included. th SOURCE: Polit and Beck. Nursing Research Principles and Methods 7 Ed. p. 730 49. Which of the following sampling methods allows the use of any group of research subject? a. Purposive For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. Convenience c. Snow-bail d. Quota CORRECT ANSWER: B RATIONALE: Convenience sampling selection of the most readily available persons as participants in the study; also known as accidental sampling. OPTION A: Purposive sampling a non-probability sampling method in which the researcher selects participants based on personal judgment about which one will be most representative or informative; also known as judgmental sampling OPTION C: Snowball sampling is the selection of participants through referrals from other participants; also known as network sampling OPTION D: Quota sampling a nonrandom selection of participants in which the researcher prespecifies characteristics of the sample to increase its representative th SOURCE: Polit and Beck. Nursing Research Principles and Methods 7 Ed 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 for you to use in this care? a. Cluster sampling b. Random sampling c. Stratified random sampling d. Systematic sampling CORRECT ANSWER: A RATIONALE: Cluster sampling a form of sampling in which large groupings (clusters) are selected first (e.g. nursing schools) with successive sampling of smaller units (e.g. nursing students) OPTION B: Random sampling the selection of the sample such that each member of the population has an equal probability of being included OPTION C: The random selection of study participants from two or more strata in the population independently OPTION D: Systematic sampling the selection of the study participants such that every nth person (or element) in a sampling frame is chosen th SOURCE: Polit and Beck. Nursing Research Principles and Methods 7 Ed Situation 11 - After an abdominal surgery, the circulating and scrub nurses have critical responsibility about sponge and Instrument count. 51. When is the first sponge/instrument count reported? a. Before closing the subcutaneous layer b. Before peritoneum is closed c. Before initial incision d. Before the fascia is sutured CORRECT ANSWER: C RATIONALE: Counts are performed by two people, usually the circulating nurse and the scrub person, at three different times: 1. Before the initial incision 2. During the surgery 3. Immediately before the incision is closed SOURCE: Black and Hawks. Medical-Surgical Nursing. 7th ed. p. 296 52. What major supportive layer of the abdominal wall must be sutured with long tensile strength such as cotton or nylon or silk suture? a. Fascia For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. Muscle c. Peritoneum d. Skin CORRECT ANSWER: RATIONALE: 53. Like sutures, needles also vary in shape and uses. If you are the scrub nurse for a patient who is prone to keloid formation and has a low threshold of pain, what needle would you prepare? a. Round needle b. Atraumatic needle c. Reverse cutting needle d. Tapered needle CORRECT ANSWER: RATIONALE: OPTION C Reverse cutting: The third cutting edge is on the outer convex curvature of the needle (depth-seeking). These needles are stronger than conventional cutting needles and have a reduced risk of cutting out tissue. The needles are designed for tissue that is tough to penetrate (eg, skin, tendon sheaths, oral mucosa). Reverse-cutting needles are also beneficial in cosmetic and ophthalmic surgery, causing minimal trauma. OPTION D Taper-point (round needle): This type of needle penetrates and passes through tissues by stretching without cutting. A sharp tip at the point flattens to an oval/rectangular shape. The sharpness is determined by taper ratio (8-12:1) and tip angle (20-35). The needle is sharper if it has a higher taper ratio and lower tip angle. The taper-point needle is used for easily penetrated tissues (eg, subcutaneous layers, dura, peritoneum, abdominal viscera) and minimizes potential tearing of fascia. 54. Another alternative "suture" for skin closure is the use of a. Staple b. Therapeutic glue c. Absorbent dressing d. invisible suture CORRECT ANSWER: A RATIONALE: The surgical wound may be closed with sutures, staples and other materials or may be left open to heal by secondary intention. Common skin closures are the following: continuous suture, interrupted suture, staples, skin strips, retention suture and buried suture. th SOURCE: Black and Hawks. Medical-Surgical Nursing. 7 ed. p. 296 55. Like any nursing interventions, counts should be documented. To whom does the scrub nurse report any discrepancy of counts so that immediate and appropriate action in instituted? a. Anesthesiologist b. Surgeon c. OR nurse supervisor d. Circulating nurse CORRECT ANSWER: B RATIONALE: The surgeon is the head of the surgical team and is the one making decisions about the surgery. SOURCE: Black and Hawks. Medical-Surgical Nursing. 7th ed. p. 284 Situation 12 - Knowledge of the drug propantheline bromide [Probanthine] is necessary in treatment of various disorders. 56. What is the action of this drug? For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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a. Increases glandular secretion for clients affected with cystic fibrosis b. Dissolve blockage of the urinary tract due to obstruction of cystine stones c. Reduces secretion of the glandular organ of the body d. Stimulate peristalsis for treatment of constipation and obstruction CORRECT ANSWER: C RATIONALE: Probanthine reduces glandular secretion of the different organs of the body. It is an anticholinergic/antispasmodic drug and still, not approved by the FDA for treatment with various disorders. Probanthine exerts benefits for treatment of severe diaphoresis, Ulcers due to over secretion of HCl, Spasms, PANCREATITS [Please take note] and other conditions of over secretion. SOURCE: Retrieved from pinoybsn.blogspot.com 57. What should the nurse caution the client when using this medication? a. Avoid hazardous activities like driving, operating machineries etc. b. Take the drug on empty stomach c. Take with a full glass of water in treatment of Ulcerative colitis d. I must take double dose if I missed the previous dose CORRECT ANSWER: C RATIONALE: Like other anti-cholinergics/ anti-spasmodics, Probanthine causes dizziness, blurred vision and drowsiness. Patients are advised not to drive, operate heavy machineries etc. Probanthine should be taken with a full glass of water but is contraindicated with inflammatory bowel diseases like ulcerative colitis and Crohns disease. OPTION A: Promoting safety. Probanthine causes dizziness and drowsiness OPTION B: Drug is taken with meals to prevent irritation of the gastric mucosa OPTION D: Client is advised not to take double dose in case the previous dose is missed. SOURCE: Retrieved from pinoybsn.blogspot.com 58. Which of the following drugs are not compatible when taking Probanthine? a. Caffeine b. NSAID c. Acetaminophen d. Alcohol CORRECT ANSWER: D RATIONALE: Probanthine on its own already cause severe dizziness and drowsiness. Addition of alcohol will further depress the CNS and might lead to potentiation of the side effects of probanthine. OPTIONS A, B & C are not contraindicated when taking probanthine EXCEPT when the disease entity itself do not permit intake of such drugs like in Pancreatitis, NSAID is not use. Pain is controlled using probanthine and meperidine (Demerol) in cases of acute pancreatitis. SOURCE: Retrieved from pinoybsn.blogspot.com 59. What should the nurse tell clients when taking Probanthine? a. Avoid hot weathers to prevent heat strokes b. Never swim on a chlorinated pool c. Make sure you limit your fluid intake to 1L a day d. Avoid cold weathers to prevent hypothermia CORRECT ANSWER: A RATIONALE: Probanthine alters the ability of the body to secrete sweat. Telling the client to avoid hot weathers to prevent heat stroke is appropriate. OPTION B: Chlorinated pool is discouraged for patients undergoing skin radiation for skin cancer to prevent breakdown. OPTIONS C & D: Limiting fluid intake and avoiding cold weather are unecessary teachings. SOURCE: Retrieved from pinoybsn.blogspot.com
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60. Which of the following disease would Probanthine exert the much needed action for control or treatment of the disorder? a. Urinary retention b. Peptic Ulcer Disease c. Ulcerative Colitis d. Glaucoma CORRECT ANSWER: B RATIONALE: Probanthine is use in PUD to decrease gastric acid secretion. It is also used in Pancreatitis to rest the pancreas from over secretion of pancreatic enzyme and to prevent pain and spasm. OPTION A: Since this is an anti spasmodic drug, Urinary retention will be a side effect OPTIONS C & D: Probanthine is contraindicated in clients with UC, Glaucoma SOURCE: Retrieved from pinoybsn.blogspot.com Situation 13 - Mrs. Gregorio, age 28, is admitted to the emergency department after a house fire. She has second and third degree burns over approximately 30% of her body surface area (BSA). 61. Which parenteral solution should Mrs. Gregorio receive during the fluid resuscitation phase of her treatment? a. Dextrose 5% in water b. Lactated Ringers solution c. Hypotonic Saline Solution d. 20 mEq of potassium chloride in half-normal saline solution CORRECT ANSWER: B RATIONALE: During fluid resuscitation, a critical part of initial treatment, the burn patient should receivelactated Ringers solution, which has an osmolality of 275 mOsm/kg of water and contains sodium, potassium, calcium and chlorine. This isotonic solution helps maintain adequate intravascular volume after burn injuries, which cause large sodium and water lossess from the intravascular compartment. Lactated Ringers solution must be infused rapidly until the patients hemodynamic status is stable; infusion is continued, usually at 4 ml/kg for each percent of the body surface area (BSA) burned, for the first 24 hours. Dextrose 5% in water is not given for fluid resuscitation because it does not correct electrolyte lossess or increase the intravascular volume. Hypotonic saline solution would cause fluid to move into the cells, causing increased cellular destruction. Supplemental potassium replacement typically is not necessary because serum potassium levels are usually elevated from existing cellular and muscle damage. 62. Which information is not used when the nurse calculates and maintains Mrs. Gregorios IV therapy for fluid resuscitation? a. depth and BSA percentage of burns b. sex and past medical history c. hematocrit and hemoglobin values d. urine output and specific gravity CORRECT ANSWER: B RATIONALE: The patients sex and past medical history would not influence immediate fluid resuscitation. The depth and BSA percentage of burns is the most crucial information for determining the patients fluid requirements; the Rule of Nines helps in calculating these requirements. Hemoconcentration (reflected by increased hematocrit and hemoglobin values), oliguria, increased specific gravity, which indicate a need for fluid, are common in early stages of burn injuries; they result from intravascular depletion as body fluids shift into the intracellular and interstitial compartments. The nurse must carefully monitor urine output and specific gravity to assess for impending renal failure.
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63. Which fluid and electrolyte imbalances are likely to occur in initial stage of Mrs. Gregorios burn injury? a. Interstitial-to-plasma fluid shift and sodium excess b. Plasma-to-interstitial fluid shift and potassium excess c. Interstitial-to- extracellular fluid shift and sodium deficit d. Intracellular-to-intravascular fluid shift and potassium deficit CORRECT ANSWER: B RATIONALE: Plasma to interstitial fluid shift usually occurs during the initial stage of burn injury; this causes leakage through the capillaries, resulting in edema. Because of cellular trauma, potassium is released into the extracellular space, causing hyperkalemia. After the initial stage, which usually lasts approximately 36 hours, the body starts to shift fluid back into the intravascular space, predisposing the patient to circulatory overload; at the same time, large amounts of potassium are excreted in the urine because of the increased intravascular volume. Aldosterone, which reabsorbs sodium and excretes potassium, is released in large quantities in response to dilutional hyponatremia, which develops as intracellular and interstitial fluid shift back into the intravascular compartment. 64. Which laboratory value indicates that Mrs. Gregorios water intake should be restricted? a. Elevated serum sodium level b. Elevated potassium level c. Decrease serum sodium level d. Decrease serum magnesium level CORRECT ANSWER: C RATIONALE: A decrease serum sodium level usually indicates dilutional hyponatremia, or water excess; the patients water intake should be restricted to allow the kidneys to excrete the excess water. The other laboratory values do not reflect changes in water balance. 65. Which treatment objective is not necessary to prevent or minimize further complications? a. Preventing and controlling complications b. Supplying nutritional needs, including replacement fluids and electrolytes c. Encouraging the patient to attain her ideal body weight d. Providing psychological support CORRECT ANSWER: C RATIONALE: Deliberate attempt to lose weight during the early phase of burn therapy would keep the patient in a state of negative nitrogen balance (catabolism); this would further complicate the patients condition because he needs to rebuild tissue. Infection control is necessary to help ensure proper healing. Fluid and electrolyte replacement helps prevent weight loss, catabolism, and the effects of fluid and electrolyte imbalances. The nurse should provide psychological support for the patient; burns commonly have negative effect on the patients body image. Situation 14 - You were on duty at the medical ward when Zeny came in for admission for tiredness, cold intolerance, constipation, and weight gain. Upon examination, the doctor's diagnosis was hypothyroidism. 66. Your independent nursing care for hypothyroidism includes: a. Administer sedative round the clock b. Administer thyroid hormone replacement c. Providing a warm, quiet, and comfortable environment d. Encourage to drink 6-8 glasses of water CORRECT ANSWER: C RATIONALE: The patient with hypothyroidism has intolerance to cold so a warm environment should be provided. OPTION A: inappropriate
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OPTION B: administering medication is a dependent nursing intervention. It requires a doctors order. OPTION D: weight gain develops in hypothyroidism due to a slowed metabolic rate and eventually leads to edema formation. Encouraging drinking 6-8 glasses of water may further aggravate existing edema. 67. As the nurse, you should anticipate to administer which of the following medications to Zeny who is diagnosed to be suffering from hypothyroidism? a. Levothyroxine b. Lidocaine c. Lipitor d. Levophed CORRECT ANSWER: A RATIONALE: Clients with hypothyroidism must receive a lifelong thyroid replacement therapy such as (levothyroxine) Synthroid. th SOURCE: Medical-Surgical Nursing by Black and Hawks 7 ed., p. 1196 Levothyroxine is a replacement for a hormone that is normally produced by your thyroid gland to regulate the body's energy and metabolism. Levothyroxine is given when the thyroid does not produce enough of this hormone on its own. OPTION B: An anesthetic agent OPTION C: Antilipidic agent OPTION D: A dopaminergic agent SOURCE:http://rds.yahoo.com/_ylt=A0oGkibBLd5HUE0BZYlXNyoA;_ylu=X3oDMTBzdGpiOGtyB HNlYwNzYwRjb2xvA3NrMQR2dGlkA0RGUjVfNzM/SIG=137cj1jn9/EXP=1205829441/**http%3a//health.yahoo.com/hormonemedications/levothyroxine/healthwise--d00278a1.html 68. Your appropriate nursing diagnosis for Zeny who is suffering from hypothyroidism would probably include which of the following? a. Activity intolerance related to tiredness associated with disorder b. Risk to injury related to incomplete eyelid closure c. Imbalance nutrition related to hypermetabolism d. Deficient fluid volume related to diarrhea CORRECT ANSWER: A RATIONALE: A client with hypothyroidism usually feels fatigued which commonly leads to the nursing diagnosis activity intolerance related to weakness and apathy secondary to a decreased metabolic rate and resulting in an increased heart rate and shortness of breath with activity OPTION B: Appropriate nursing diagnosis for hyperthyroidism. Exophthalmus is seen in hyperthyroidism OPTION C: Appropriate nursing diagnosis for hyperthyroidism. In hypothyroidism there is hypometabolism not hypermetabolism. OPTION D: Appropriate nursing diagnosis for hyperthyroidism. In hypothyroidism there is constipation not diarrhea th SOURCE: Black and Hawks. Medical-Surgical Nursing. 7 ed. Volume 1. p. 1196 69. Myxedema coma is a life threatening complication of long standing and untreated hypothyroidism with one of the following characteristics. a. Hyperglycemia b. Hypothermia c. Hyperthermia d. Hypoglycemia CORRECT ANSWER: B For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Myxedema Coma describes the most extreme, severe stage of hypothyroidism, in which the patient is hypothermic and unconscious. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 9th ed. p. 1039 70. As a nurse, you know that the most common type of goiter is related to a deficiency in: a. Thyroxine b. Thyrotropin c. Iron d. Iodine CORRECT ANSWER: D RATIONALE: Oversecretion of thyroid hormones is usually associated with an enlarged thyroid gland (goiter). Goiter also commonly occurs with iodine deficiency. The lack of iodine results in low levels of circulating thyroid hormones, which causes increased release of TSH; the elevated TSH causes overproduction of thyroglobulin and hypertrophy of the thyroid gland. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 9th ed. p. 1038 Situation 15 - Mrs. Pichay is admitted to your ward. The MD ordered "Prepared for thoracentesis this pm to remove excess air from the pleural cavity." 71. Which of the following nursing responsibility is essential in Mrs. Pichay who will undergo thoracentesis? a. Support, and reassure client during the procedure b. Ensure that the client has been on NPO for 6 hours c. Determine if client has allergic reaction to local anesthesia d. Ascertain if chest x-rays and other tests have been prescribed and completed CORRECT ANSWER: D RATIONALE: Ascertain in advance that a chest x-ray has been ordered and completed and the consent from has been signed. Posteroanterior and lateral chest x-ray films are used to localize fluid and air in the pleural cavity and t aid in determining the puncture site. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 489 72. Mrs. Pichay who is for thoracentesis is assisted by the nurse to any of the following positions, EXCEPT: a. Straddling a chair with arms and head resting on the back of the chair b. Lying on the unaffected side with the bed elevated 30-40 degrees c. Lying prone with the head of the bed lowered 15-30 degrees d. Sitting on the edge of the bed with her feet supported and arms and head on a padded overhead table CORRECT ANSWER: C RATIONALE: Lying prone with the head of the bed lowered 15-30 degrees will make the fluid settle on the upper areas of the lungs by gravity. In thoracentesis, position the patient comfortably with adequate supports. If possible, place the patient upright or in one of the following positions: Sitting on the edge of the bed with the feet supported and arms ad on a padded over-the bed table Straddling a chair with arms and head resting on the back of the chair lying on the unaffected side with the bed elevated 30 degrees to 45 degrees if unable to assume a sitting position The upright position facilitates the removal of fluid that that usually localized at the base of the chest. A position of comfort helps the patient to relax. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 489 73. During thoracentesis, which of the following nursing intervention will be most crucial? a. Place patient in a quiet and cool room b. Maintain strict aseptic technique For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest d. Apply pressure over the puncture site as soon as the needle is withdrawn CORRECT ANSWER: C RATIONALE: Insertion of needle is painful. Explain the importance of holding still during the procedure. Sudden movement may force the needle through the pleural space and injure the visceral pleura or lung parenchyma. SOURCE: Black and Hawks. Medical-Surgical Nursing. 7th ed. p. 1772 74. To promote lung expansion and prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis? a. Place flat in bed b. Turn on the unaffected side c. Turn on the affected side d. On bed rest CORRECT ANSWER: B RATIONALE: After the procedure the client is usually turned onto the unaffected side for 1 hour to facilitate lung expansion. th SOURCE: Black and Hawks. Medical-Surgical Nursing. 7 ed. p. 1772 75. Chest x-ray was ordered after thoracentesis. When your client asks what the reason for another chest x-ray is, you will explain: a. To rule out pneumothorax b. To rule out any possible perforation c. To decongest d. To rule out any foreign: body CORRECT ANSWER: A RATIONALE: Chest x-ray is obtained after thoracentesis. A chest x-ray verifies tat there is no pneumothorax. SOURCE: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 489 Situation 16 - In the hospital, you are aware that we are helped by the use of a variety of equipment/devices to enhance quality patient care delivery. 76. You are initiating an IV line to your patient, Kyle, 5, who is febrile. What IV administration set will you prepare? a. Blood transfusion set b. Macroset c. Volumetric chamber d. Microset CORRECT ANSWER: D RATIONALE: Microdrip chamber is used if the solution contains potent medication that needs to be titrated, such as in critical care setting or in pediatrics. OPTION A: Transfusion of blood components OPTION B: Macrodrip chamber is used if the solution is thick or is to be infused rapidly. OPTION C: A volumetric chamber is provided with a predetermined volume and is adapted for remote
sensing of the fluid level inside the volumetric chamber.
SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3rd ed. p. 150
77. Kyle is diagnosed to have measles. Your protective personal attire includes? a. Gown b. Eyewear For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. Face mask d. Gloves CORRECT ANSWER: C RATIONALE: Measles is an acute highly communicable infection characterized by fever, rashes and symptoms referable to upper respiratory tract. It is transmitted by droplet infection or direct contact with infected persons, or indirectly through articles freshly soiled with secretions of nose and throat, in some instances, probably airborne. Wearing of face mask can protect the nurse when caring for a client with measles. SOURCE: CHN DOH. p. 241 78. The nurse making rounds discovers D5W infusing a 75 ml/hour. The order for the client states, NS at 75 ml/hour. What is the best action for the nurse to take first? a. Complete the infusion of D5W to avoid waste and then ensure the next bag is correct. b. Slow the infusion and contact the physician for current orders c. Immediately change the infusion to the ordered solution d. Compare an unusual occurrence report and submit it to the supervisor. CORRECT ANSWER: C RATIONALE: The nurses immediate response is to ensure compliance with currently ordered intravenous fluids. OPTIONS A & B: are wrong actions OPTION D: Although an unusual occurrence should be filed, it is not a priority SOURCE: Prentice Hall Reviews and Rationales Series for Nursing: Fluids and Electrolytes. p. 35 79. Before bedtime, you went to ensure Kyle's safety in bed. You will do which of the following: a. Put the lights on b. Put the side rails up c. Test the call system d. Lock the doors CORRECT ANSWER: B RATIONALE: The use of side rails has been a routine practice with the rationale that the side rails serve as a safe and effective means of preventing clients from falling out of bed. OPTION A: inappropriate because the patient is going to sleep. Does not address safety. OPTION C: Does not answer safety in bed concern OPTION D: Locking the door does not provide bed safety SOURCE: Kozier. Fundamentals of Nursing. P. 746 Situation 17 - Tony, 11 years old, has 'kissing tonsils' and is scheduled for tonsillectomy and adenoidectomy or T and A. 80. You are the nurse of Tony who will undergo T and A in the morning. His mother asked you if Tony will be put to sleep. Your teaching will focus based on the understanding that T & A procedure is under what anesthesia: a. Spinal anesthesia b. Anesthesiologist's preference c. Local anesthesia d. General anesthesia CORRECT ANSWER: D RATIONALE: The procedure may be under either local or general anesthesia. If a local anesthetic is used, the procedure is usually done with the person in a sitting position (more common with adults). If general anesthesia is used, the person is placed in dorsal recumbent. SOURCE: Luckmann and Sorensen. Medical Surgical Nursing. Vol. I, p. 719
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81. The nurse is caring for Tony who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? a. Offer ice cream every 2 hours b. Place the child in a supine position c. Allow the child to drink through a straw d. Observe swallowing patterns CORRECT ANSWER: D RATIONALE: Continuous nursing intervention is required in the immediate postoperative and recovery period because of significant risk of hemorrhage. Monitor signs of hemorrhage (frequent swallowing may indicate hemorrhage) OPTION A: Milk and milk products (ice cream and yogurt) may be restricted because they make removal of secretions difficult. OPTION B: In the immediate post operative period, the most comfortable position for the patient is prone with the head turned to the side to allow drainage from the mouth and pharynx OPTION C: may mask bleeding SOURCES: Smeltzer and Bare. Medical-Surgical Nursing. Volume 1. 10th ed. p. 500; Silvestri. rd Saunders NCLEX-RN Examination. 3 ed. p. 416 82. The RR nurse should monitor for the most common postoperative complication of: a. Hemorrhage b. Endotracheal tube perforation c. Esopharyngeal edema d. Epiglottis CORRECT ANSWER: A RATIONALE: Continuous nursing intervention is required in the immediate postoperative and recovery period because of the significant risk of hemorrhage. th SOURCE: Smetzer and Bare. Medical Surgical Nursing. 9 ed. Volume I. p. 408 83. The PACU nurse will maintain postoperative T and A client in what position? a. Supine with neck hyperextended and supported with pillow b. Prone with the head on pillow and tuned to the side c. Semi-Fowler's with neck flexed d. Reverse trendelenburg with extended neck CORRECT ANSWER: B RATIONALE: In the immediate post operative period, the most comfortable position for the patient is prone with the head turned to the side to allow drainage from the mouth and pharynx All other options are incorrect SOURCE: Smetzer and Bare. Medical Surgical Nursing. 9th ed. Volume I. p. 408 84. After tonsillectomy, Tony begins to vomit bright red blood. The most appropriate initial nursing action would be to: a. Administer the prescribed antiemetic b. Turn the child to the side c. Notify the physician d. Maintain an NPO status CORRECT ANSWER: B RATIONALE: After tonsillectomy, if bleeding occurs, the nurse turns the child to the side and then notifies the physician. OPTION A: NPO would be maintained but the initial thing to do is to turn the child to the side OPTION C: should be done right after turning the child to the side OPTION D: antiemetic may be prescribed but the initial thing to do is to turn the child to the side SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3rd ed. p. 420
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Situation 18 - Rudy was diagnosed to have chronic renal failure. Hemodialysis is ordered that an A-V shunt was surgically created. 85. Which of the following action would be of highest priority with regards to the external shunt? a. Avoid taking BP or blood sample from the arm with shunt b. Instruct the client not to exercise the arm with the shunt c. Heparinize the shunt daily d. Change dressing of the shunt daily CORRECT ANSWER: A RATIONALE: When the hemodialysis patient is hospitalized for any reason, care must be taken to protect the vascular access from damage. The nurse assesses the vascular access for patency and takes precautions to ensure that the extremity with the vascular access is not used for blood pressure measurements or for blood specimens; tight dressings, restraints, or jewelry over the vascular access are to be avoided. SOURCE: Smetzer and Bare. Medical Surgical Nursing. 9th ed. Volume II. p 1124 86. Diet therapy for Rudy, who has acute renal failure, is low-protein, low potassium and sodium. The nutrition instruction should include: a. Recommend protein of high biologic value like eggs, poultry and lean meat b. Encourage client to include raw cucumbers, carrot, cabbage, and tomatoes c. Allowing the client cheese, canned foods, and other processed food d. Bananas, cantaloupe, orange and other fresh fruits can be included in the diet CORRECT ANSWER: A RATIONALE: Dietary intervention is necessary with deterioration of renal function and includes careful regulation of protein intake, fluid intake to balance fluid losses, sodium intake to balance sodium losses, and some restriction of potassium. At the same time adequate, adequate caloric intake and vitamin supplementation must be ensured. Protein is restricted because urea, uric acid, and organic acids the breakdown product of dietary and tissue proteins accumulate rapidly in the blood where there is impaired renal clearance. The allowed protein must be of high biologic value (dairy products, eggs, meats). High-biologic-value proteins are those that are complete proteins and supply the essential amino acids necessary for growth and cell repair. OPTION C: with decline in the GFR, the patient is unable to excrete potassium normally. Hyperkalemia may lead to dysrhythmias and cardiac arrest thus potassium is restricted in renal failure. OPTION D: the foods are high in potassium. SOURCE: Smetzer and Bare. Medical Surgical Nursing. 9th ed. Volume II. p. 1148-1154 87. Rudy undergoes hemodialysis for the first time and was scared of disequilibrium syndrome. He asked you how this can be prevented. Your response is: a. Maintain a conducive comfortable and cool environment b. Maintain fluid and electrolyte balance c. Initial hemodialysis shall be done for shorter periods only so as not to rapidly remove the waste from the blood than from the brain d. Maintain aseptic technique throughout the hemodialysis CORRECT ANSWER: C RATIONALE: Dialysis disequilibrium syndrome can occur, particularly during the clients first few dialysis episodes. It is characterized by mental confusion, deterioration of the level of consciousness, headache and seizures. Rapid solute removal from the blood probably caused a relative excess of solutes interstitially or intracellularly. The excess causes cerebral edema, which leads to increased intracranial pressure. Many dialysis centers avoid this complication by firsttime dialyzing for shorter times at a reduced flow rate. SOURCE: Black and Hawks. Medical-Surgical Nursing. Volume 1. 7th ed. p. 961
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88. You are assisted by a nursing aide with the care of the client with renal failure. Which of the following tasks can be delegated to the nursing aide? a. Measuring and recording I and O b. Checking bowel movement c. Health teachings d. Making a nursing diagnosis CORRECT ANSWER:A RATIONALE: Delegation is the transference if responsibility and authority for the performance of an activity to a competent individual. The delegate assumes responsibility for the actual performance of the task or procedure. The delegator retains accountability for the outcome. OPTION B: An assessment should not be delegated OPTION C: Client education should not be delegated OPTION D: Making a nursing diagnosis should not be delegated Tasks that may be delegated to an unlicensed assistive personnel: Taking of vital signs Measuring and recording intake and output Patient transfer and ambulation Postmortem care Bathing Feeding Clean Catheterization Gastrostomy feedings in established settings Attending to safety Performing simple dressing changes Suctioning of chronic tracheotomies Performing basic life support Tasks that may not be delegated to an unlicensed assistive personnel: Assessment Interpretation of data Making a nursing diagnosis Creation of a nursing care plan Evaluation if care effectiveness Care of invasive lines Administering parenteral medications Performing venipuncture Insertion of NGT Client education Performing triage Giving telephone advise Performing sterile procedures SOURCE: Kozier Fundamentals of Nursing. 7th ed. p. 470 89. A renal failure patient was ordered for creatinine clearance. As the nurse you will collect a. 48 hour urine specimen b. First morning urine c. 24 hour urine specimen d. Random urine specimen CORRECT ANSWER: C RATIONALE: The creatinine clearance test is a blood and timed urine specimen that evaluates kidney function. Blood is drawn at the start of the test and the morning of the day that the 24-hour urine specimen collection is complete. SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3rd ed. p. 855 Situation 19 - Fe is experiencing left sharp pain and occasional hematuria. She was advised to undergo IVP by her physician.
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90. Fe was so anxious about the procedure and particularly expressed her low pain threshold. Nursing health instruction will include: a. Assure the client that the pain is associated with the warm sensation during the administration of the dye b. Assure the client that the procedure painless c. Assure the client that contrast medium will be given orally d. Assure the client that x-ray procedure like IVP is only done by experts CORRECT ANSWER: B RATIONALE: The IVP is a painless procedure. You will feel a minor sting as the iodine is injected into your arm. Some patients experience a flush of warmth, a mild itching sensation and a metallic taste in their mouth as the iodine begins to circulate throughout their body. SOURCE: http://www.radiologyinfo.org/en/info.cfm?pg=ivp&bhcp=1#part_seven 91. Before the test priority nursing action would be to: a. Administer an oral preparation of radiopaque dye b. Restrict fluids c. Determine a history of allergies d. Administer a sedative CORRECT ANSWER: C RATIONALE: The iodine-based dye used in IVP can cause allergic reactions such as itching, hives, rash, a tight feeling in the throat, shortness of breath, and bronchospasm. Assessing for allergies is a priority. OPTIONS A, B & D Address implementation; assessment is the priority SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3rd ed. p. 139 92. What will the nurse monitor and instruct the client and significant others post IVP? a. Monitor and report signs and symptoms for delayed allergic reactions b. Observe NPO for 6 hours c. Limit fluid intake d. Monitor intake and output CORRECT ANSWER: A RATIONALE: Post IVP interventions: Monitor vital signs. Instruct the client to drink atleast 1L of fluid unless contraindicated. Assess the venipuncture site for bleeding Monitor urinary output. Monitor for signs of a possible allergic reaction to the dye used during the test. SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3rd ed. p. 855 93. Post IVP, Fe should excrete the contrast medium. You instructed the family to include more vegetables in the diet and a. Increase fluid intake b. Barium enema c. Cleansing enema d. Gastric lavage CORRECT ANSWER: A RATIONALE: Post IVP interventions: Monitor vital signs. Instruct the client to drink atleast 1L of fluid unless contraindicated. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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Assess the venipuncture site for bleeding Monitor urinary output. Monitor for signs of a possible allergic reaction to the dye used during the test. rd SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3 ed. p. 855 94. The IVP reveals that Fe has small renal calculus that can be passed out spontaneously. To increase the chance of passing the stones, you instructed her to force fluids and do which of the following? a. Balanced diet b. Ambulance more c. Strain all urine d. Bed rest CORRECT ANSWER: B RATIONALE: Stasis of urine from obstructions, continent urinary diversion and immobilization increases the risk for development of stones because the crystals in unmoving urine precipitate more readily. OPTION D: may cause stasis of urine SOURCE: Black and Hawks. Medical-Surgical Nursing. Volume 1. 7th ed. p. 884 95. The presence of calculi in the urinary tract is called: a. Cholelithiasis b. Nephrolithiasis c. Ureterolithiasis d. Urolithiasis CORRECT ANSWER: D RATIONALE: OPTION A: Presence of stones in the gallbladder OPTION B: Presence of stones in the kidney OPTION C: Presence of stones in the ureter th SOURCE: Black and Hawks. Medical-Surgical Nursing. Volume 1, 7 ed. p. 1150 Situation 20 - At the medical-surgical ward, the nurse must also be concerned about drug interactions. 96. You have a client with TPN. You know that in TPN, like blood transfusion, there should be no drug incorporation. However, the MD's order read; incorporate insulin to present TPN. Will you follow the order? a. No, because insulin will induce hyperglycemia in patients with TPN b. Yes, because insulin is chemically stable with TPN and can enhance blood glucose level c. No, because insulin is not compatible with TPN d. Yes, because it was ordered by the MD CORRECT ANSWER: B RATIONALE: Insulin may be added to control the blood glucose level because of high concentration of glucose in the TPN. OPTION A: Insulin causes hypoglycemia not hyperglycemia OPTION C: Insulin is compatible with TPN SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3 rd ed. p. 139 97. A patient is receiving Total Parenteral Nutrition secondary to acute pancreatitis. The nurse is about to administer insulin when the patient states, Why am I getting insulin? Im not diabetic. Which of the following responses would be the most appropriate? a. The infection in your pancreas is causing too much insulin to be produced. b. This type of infection stops the production of insulin. c. The TPN solution contains high amount of glucose. d. The TPN solution interferes with the production of insulin. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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CORRECT ANSWER: C RATIONALE: TPN is used to maintain nutritional status and prevent malnutrition when the patient is unable to be fed orally or by tube feeding. Glucose is used to supply energy and caloric needs and usually accounts for 50 70% of the nutrient prescription OPTION A: In pancreatitis, 50% of the patients have a transient hyperglycemia due to the damage to the beta cells. If the pancreas were producing too much insulin, the patient would experience hypoglycemia. Giving additional insulin would not be the correct intervention. OPTION B: 50% of patients with pancreatitis have interference with insulin release from the beta cells, which may cause hyperglycemia. Not all patients exhibit hyperglycemia. OPTION D: TPN does not interfere with the production of insulin. The goal of therapy is to reduce the secretion of pancreatic enzymes, which stops the inflammatory process. The use of TPN meets the patients nutritional needs while the patient is taking nothing by mouth. SOURCE: CGFNS Qualifying Exam 5th ed. p. 119 98. A nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which of the following actions, if performed by the client, indicate a need for further teaching? a. Injects air into NPH insulin vial first b. Injects an amount of air equal to the desired dose of insulin into the vial c. Withdraws the NPH insulin first d. Withdraws the regular insulin first CORRECT ANSWER: C RATIONALE: When preparing a mixture of insulin with another insulin preparation, draw the regular insulin into the syringe first. This sequence will avoid contaminating the vial of regular insulin with the insulin of another type. OPTIONS A, B & D correct method of preparing NPH and regular insulin rd SOURCE: Silvestri. Saunders NCLEX-RN Examination. 3 ed. p. 139 99. A pregnant client takes an-over-the-counter (OTC) iron preparation, drug data lists the drug is Pregnancy Category A. the nurse teaches the client which of the following pieces of information? a. To stop the medication during pregnancy b. To immediately report to the physician that she has taken the drug while pregnant c. That his medication is classified as safe to use during pregnancy d. There may be staining of the babys first teeth from this medication CORRECT ANSWER: C RATIONALE: Pregnancy Category A is assigned to drugs that have not shown to have adverse effects on the fetal development. OPTION A: Incorrect information since this medication is safe during pregnancy OPTION B: Unnecessary to report since this medication is safe to use during pregnancy OPTION D: Incorrect information SOURCE: Prentice Hall Reviews and Rationales Series for Nursing: Pharmacology. p. 21 100. In insulin administration, it should be understood that our body normally releases insulin according to our blood glucose level. When is insulin and glucose level highest? a. After excitement b. After a good night's rest c. After an exercise d. After ingestion of food CORRECT ANSWER: D RATIONALE: Insulin is released after ingestion and absorption of carbohydrates SOURCE: th Black and Hawks. Medical-Surgical Nursing. Volume 1. 7 ed. p. 1150 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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Situation 1 - Because of the serious consequences of severe burns management requires a multi disciplinary approach. You have important responsibilities as a nurse. 1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burst 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 CORRECT ANSWER: A RATIONALE: Stop, drop and roll is a simple fire safety technique taught to children, emergency services personnel and industrial workers as a component of health and safety training. Primarily, it is a method to extinguish a fire on a person's clothes or hair without, or in addition to, the use of conventional firefighting equipment. In addition to extinguishing the fire, stop, drop and roll is an effective psychological tool, providing those in a fire situation, particularly children, with a routine that can be used to focus on in order to avoid panic. Stop, drop and roll consists of three components. Stop - The fire victim must stop still. Ceasing any movement which may fan the flames or hamper those attempting to put the fire out. Drop - The fire victim must 'drop' to the ground, lying down if possible. Roll - The fire victim must roll on the ground in an effort to extinguish the fire by depriving it of oxygen. If the victim is on a rug or one is nearby, they can roll the rug around themselves to further extinguish the flame. The effectiveness of stop, drop and roll may be further enhanced by combining it with other firefighting techniques,including the use of a fire extinguisher, dousing with water, or fire beating. 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 Sergio's breathing CORRECT ANSWER: D RATIONALE: Thermal burns are caused by exposure to flames, hot liquids, steam or hot objects. Like this one, 1st priority should go to the assessment of breathing if there are no airway problems, possibility of inhalation of the smoke from the flames may cause smoke poisoning from by products of combustion. A localized inflammatory reaction may occur, causing a decrease in bronchial ciliary action and a decrease in surfactant. A compromised breathing may later on lead to respiratory complications. Assess for mucosal edema in the airways, after several hours, sloughing of the tracheobronchial epithelium may occur, and hemorrhagic bronchitis may develop, ARDS can result.(Source: Saunders Comprehensive Review for the NCLEX-RN exam 3rd Edition, p. 545) OPTION A: covering Sergio with a warm blanket will not benefit the situation since it can only increase heat and compromise comfort that should be provided for Sergio.
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OPTION B: Although giving sips of water may help in the drying of the mucosa of the patient, it is first essential to assess the airway and breathing of the patient as mucosal edema may be present and sips of water may result to aspiration. OPTION C: Calculating the extent of the burn may be done after assessment of the ABCs which is very essential in providing care to the patient. 3. Sergio is brought to the Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness bums on his trunk, right upper extremities ad right lower extremities. His wife asks what that means. Your most accurate response would be: a. Structures beneath the skin are damaged b. Dermis is partially damaged c. Epidermis and dermis are both damaged d. Epidermis is damaged CORRECT ANSWER: D RATIONALE: Superficial partial thickness: These burns are superficial with injury to the epidermis. These are first-degree burns and are characterized by erythema, edema, and pain; slight fluid loss, especially if less than 15% of the body is involved. Superficial partial-thickness burns heal spontaneously within 2-3 weeks, usually without scarring. Injured area is sensitive to cold air. Grafts may be used if healing process is prolonged. rd SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 edition,p. 544) OPTION A: is true for Deep Full-thickness burns as it involves injury to the muscle and bone. OPTION B: is true for Deep Partial-thickness burns as it involves the epidermis and superficial dermis causing erythema, pain, vesicles with oozing; fluid loss slight to moderate. OPTION C: is true for Full-thickness (3 rd Degree) burn affects the epidermis, entire dermis and at times the subcutaneous tissue, resulting in charred or pearly white, dry skin and absence of pain; fluid loss usually severe, especially if more than 2% of body surface is involved. th (SOURCE: Mosby Comprehensive Review of Nursing for the NCLEX-RN exam 18 edition, p. 169.) 4. During the first 24 hours after thermal injury, you should assess Sergio for a. hypokalemia and hypernatremia b. hypokalemia and hyponatremia c. hyperkalemia and hyponatremia d. hyperkalemia and Hypernatremia CORRECT ANSWER: C RATIONALE: Hyperkalemia can also result from injury to muscle or other tissues. Since most of the potassium in the body is contained in muscle, a severe trauma that crushes muscle cells results in an immediate increase in the concentration of potassium in the blood. Hyperkalemia result from severe burns for the 1st 24 hours. Hyponatremia in burns occur due to low plasma osmolarity. (SOURCE: Silvestri Saunders Online Review Course,Fluid and Electrolyte Imbalance, p. 18) 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 b. Hypervolemia c. Metabolic acidosis d. Renal failure . CORRECT ANSWER: A RATIONALE: Rarely do burn-injured clients suffer neurologic damage. The client with a major burn injury is most often awake and alert on admission to the hospital. If alteration in level of For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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consciousness manifests, the client may be suffering from hypoxemia or hypovolemia and needs further assessment for identifying the origin of these changes. It is most often related to impaired perfusion to the brain, hypoxia/hypoxemia (as in a closed space fire), inhalation injury (as from exposure to asphyxiate or other toxic materials from the fire). Major burn injuries that may cause severe fluid loss can lead to a decrease in blood pressure, causing decreased cerebral perfusion, followed by impaired oxygenation to the brain. Neurologic manifestations may include headache, dizziness, memory loss, confusion or loss of consciousness, disorientation, visual changes, hallucinations, combativeness and coma. (SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1441 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 implications. 6. You are on night duty in the surgical ward. One of our patients Martin is prisoner who sustained an abdominal gunshot wound. He is being guarded by policemen 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 hurt Martin. He denied the matter. Which among the following activities will you do first? a. Write an incident report b. Call security officer and report the incident c. Call your nurse supervisor and report the incident: d. Call the physician on duty CORRECT ANSWER: A RATIONALE: The incident report is used as a means of identifying risk situations and improving client care. Specific documentation guidelines are followed in completion of the incident report. The criterias to formulating an incident report are as follows: Accidental omission of ordered therapies Circumstances that led to injury or a risk for client injury Client falls Medication administration errors Needlestick injuries Procedure-related or equipment-related accidents A visitor having symptoms of an illness rd (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 edition, p. 57) 7. The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that the: a. error will result in suspension b. incident report is a method of promoting quality care and risk management c. incident will be reported to the board of nursing d. incident will be documented in the personnel file. CORRECT ANSWER: B RATIONALE: Documentation of unusual occurrences, incidents, and accidents and the nursing actions taken as a result of the occurrence is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks present. Based on the information provided in the question, the nurses error will not result in suspension nor will it be documented in the personnel file. The situation and the error presented in the question are not a reason for notifying the board of nursing. rd (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 edition, p. 62)
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8. The nurse hears a client call for help. The nurse hurries down the hallway to the clients room and finds the client lying on the floor. The nurse performs a thorough assessment and assists the client back to bed. The nurse notifies the physician of the incident and completes an incident report. Which of the following would the nurse document on the incident report? a. the client was found lying on the floor b. the client climbed over the side rails c. the client fell out of bed d. the client became restless and tired to get out of bed CORRECT ANSWER: A RATIONALE: The incident report should contain the clients name, age, and diagnosis. The report should contain a factual description of the incident, any injury experienced by those involved, and the outcome of the situation. Option A is the only option that describes the facts as observed by the nurse. Options B, C, and D are interpretations of the situation and not factual data as observed by the nurse. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 63) 9. You are on duty in the medical ward. The mother of your patient who is also a nurse came running to the nurse station and informed you that Fiolo went into cardiopulmonary arrest. Which among the following will you do first? 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 CORRECT ANSWER: D RATIONALE: The purpose of primary assessment in cardiopulmonary arrest is to immediately identify any client problem that poses a threat, what could have caused the arrest. Airway clearance and breathing should be assured before anything else after which, immediate interventions such as CPR and advanced life support must be instituted to aid in preserving the clients life. OPTIONS A-C: these are the following interventions that are done after a primary assessment of the ABCs had been made. (SOURCE: Med.-Surg. Nursing by Black and Hawk, 7 th edition, vol.2, p.2485) 10. A client is brought to the emergency medical services after being hit by a car. The name of the client is not known. The client has sustained a severe head injury, multiple fractures, and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action? a. call the police to identify the client and locate the family b. obtain a court order for the surgical procedure. c. ask the emergency medical services team to sign the informed consent d. transport the victim to the operating room for surgery CORRECT ANSWER: D RATIONALE: Generally, in only 2 instances is an informed consent of an adult client not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining an informed consent would result in injury or death o the client. The 2 nd instance is when the client waives the right to give informed consent. OPTION 2, will delay emergency treatment and option 3 is inappropriate. Although option 1 may be pursued, it is not the best action.
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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 CORRECT ANSWER: C RATIONALE: Early detection through routine screening is the key to decreasing mortality. It is recommended that people with an average risk for colon cancer be screened annually for digital rectal examinations and Fecal occult blood tests begin at 40 years of age withy sigmoidoscopy every 3-5 years beginning at 50 years of age. 12. To confirm his impression of colorectal cancer, Larry will require which diagnostic study? a. carcinoembryonic antigen b. incisional biopsy of the colon c. stool hematologic test d. abdominal computed tomography (CT) test CORRECT ANSWER: B Rationale: Incisional biopsy; a selected part of the lesion is removed. This form of biopsy is commonly completed During endoscopic examination. The Frozen Method procedure is used to assess for malignant cells from tissue samples. Frozen sections are used for rapid microscopic diagnosis. A thin slice of tissue is cut from the frozen specimen and examined. The procedure requires 10-15 minutes. The pathologist can determine whether malignancy is present and whether the entire tumor has been removed by looking for a margin of tumor-free tissue. SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, Vol.1, p. 106) 13. The following are risk factors for colorectal cancer, EXCEPT: a. inflammatory bowels b. low fat, high fiber diet c. smoking d. genetic factors-familial adenomatous polyposis CORRECT ANSWER: B RATIONALE: Epidemiologic studies indicate that diet may be a major factor in the development of cancer of the large bowel. Studies on bulk in stool and the rate of transit of fecal matter have so far given mixed results. Some researchers propose that metabolic and bacterial end products are carcinogenic and that constipation allows a longer contact with the bowel wall, thus raising the probability that cancer will develop. Increasing fiber in the diet may reduce exposure to carcinogens by speeding stool transit through the intestines. th (SOURCE: Med-Surg. Nsg Black and Hawk 7 edition, Vol.1 p. 831) 14. Symptoms associated with cancer of the colon include: a. constipation, ascites and mucus in the stool b. diarrhea, heartburn and eructation c. blood in the stools, anemia, and pencil-shaped, stools d. anorexia, hematemesis, and increased peristalsis CORRECT ANSWER: C RATIONALE: Symptoms include the following: Blood in stools, anorexia, vomiting, and weight loss, malaise, Anemia, abnormal stools. Ascending colon tumor: Diarrhea, Descending Colon tumor: constipation or some diarrhea, or flat, ribbon-like stool resulting from a partial obstruction. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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Rectal Tumor: alternating constipation and diarrhea, guarding or abdominal distention, abdominal mass (a late sign), Cachexia (a late sign). (source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p.592) 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 CORRECT ANSWER: B RATIONALE: Sulfasuxidine/sulfadiazine is a type of Sulfa drug, primarily for the treatment of asymptomatic mengococcal carrier, can be used as alternative for penicillin in rheumatic fever. Neomycin, kanamycin sulfate, erythromycin, & succinylsulfathiazole (Sulfasuxidine) are used preoperatively to reduce bacterial number in the GI tract. (Source: Nursing Drug Handbook 2006, 26 th Edition, p. 131) Sulfasuxidine and other antiseptics and antibiotics, as prescribed to decrease the bacterial content of the colon to reduce the risk of infection from the surgical procedure. rd (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 edition, p. 592) Situation 4 - ENTEROSTOMAL THERAPY is now considered especially 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 close and contamination is no longer a danger d. The stool starts to become formed, around the 7th postoperative day CORRECT ANSWER: C RATIONALE: Carefully assess the clients physical condition, emotional and mental attitudes toward the colostomy before attempting to teach ostomy self-care. Pace the teaching to the clients level of acceptance of the colostomy and ability to manage it. Teach the client how to apply the pouch to the stoma correctly. The client first should be taught how to examine the stoma. A healthy stoma and abdominal incision is a very good indicator that client is now ready for ostomy care teaching. th (SOURCE: Med-Surg. Nsg. by Black and Hawk, 7 edition, vol.1, p. 837) 17. When preparing to teach Fermin how to irrigate his 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. After breakfast d. After Fermin accepts alteration in body image CORRECT ANSWER: C RATIONALE: A suitable time for the irrigation is selected that is compatible with the patients posthospital pattern of activity (preferably after a meal). Irrigation should be performed at the same time each day. (SOURCE: Brunner and Suddarths Med. Surg. Nursing, 10th Edition Vol. 1, p. 1064) 18. When observing a rectum demonstration of 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. Hands the irrigating bag on the bathroom door doth hook during fluid insertion c. Discontinues the insertion of fluid after only 500 ml of fluid had been insertion d. Clamps off the flow of fluid when feeling uncomfortable CORRECT ANSWER: C For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Although 300 mL of fluid may be all that is needed to stimulate evacuation, Volume may be increased with subsequent irrigations to 500, 1000, up to 1, 500 mL as needed by the patient for effective results. Allow tepid fluid to enter the colon slowly. If cramping occurs, clamp off the tubing and allow the patient to rest before progressing. Water should flow in over 5 to 10 minute period. (SOURCE: Brunner and Suddarths Med. Surg. Nursing, 10th Edition Vol. 1, p. 1064) 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 tube into the stoma." b. If I notice 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 irrigation." CORRECT ANSWER: A Rationale: Any difficulty in the insertion of the irrigating tube into the stoma may mean an obstruction to the system. 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 foods that are easily digested and absorbed by my large intestine." 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." CORRECT ANSWER: A RATIONALE: As such there is no specific diet plan for Ostomy patients. The main point is that you should be able to tolerate the food you are eating. Still certain foods you need to avoid or include in your diet so as to maintain a good health after Ostomy. Below is the list of food you need to keep in consideration: Food resulting in thickened stools (Low-Fiber): Applesauce, Peanut butter, boiled milk, Tapioca, Rice, Cheese, Bananas, and Pretzels. Food resulting in soft stools (High Fiber): Red wine, Beer, Coffee, Prune juice, Fresh vegetables, Fruits and Food with high fiber content. Foods resulting in incomplete digestion: Broccoli, Cabbage, Raw carrots, Raw onions, Pineapple, Beans, Spinach, Potato skins, Corn, Coconut, Celery, Whole grains, Nuts, Raisins, Popcorn, Raw fruits, Chinese vegetables, Seeds and Skins. Foods causing odor: Cabbage, Beans, Asparagus, Onions, Garlic, Eggs, Fish, Alcohol and Vitamins. Foods causing gas: Raw apple, Cabbage, Broccoli, Onions, Turnip, Corn, Nuts, Milk, Beer, Carbonated beverages, iced beverages and Chewing gums. Foods causing diarrhea: Fried foods, highly spicy food, Legumes, Grape juice, Apple juice, Prune juice, Green beans, Spinach, Raw fruits, Cabbage and Milk. SOURCE: Ostomy Nutrition Guide booklet page 1-5 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 CORRECT ANSWER: C
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RATIONALE: Assessment actions to check for signs of extended pneumothorax or hemothorax should be performed such as palpating surrounding areas for crepitus. It may also be an indication for a chest tube complication known as subcutaneous emphysema. Subcutaneous emphysema occurs when air gets into tissues under the skin covering the chest wall or neck. This can happen due to stabbing, gun shot wounds, other penetrations, or blunt trauma. Air can also be found in between skin layers on the arms and legs during certain infections, including gas gangrene. Subcutaneous emphysema can often be seen as a smooth bulging of the skin. When a health care provider feels (palpates) the skin, it produces an unusual crackling sensation as the gas is pushed through the tissue. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN, 3 rd edition, p. 242) 22. Fanny came in from PACK 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 CORRECT ANSWER: A RATIONALE: Thrombophlebitis is a condition in which a clot forms in a vessel wall as a result of the inflammation of the vessel wall. It has 3 Types: Superficial, Femoral, and Pelvic. Assessment findings for a developing Superficial Thrombophlebitis are tenderness and pain in the affected lower extremity. Also includes the following symptoms: warm and pinkish red color over the thrombus area, palpable thrombus that feels bumpy and hard. (SOURCE: Saunders rd Comprehensive Review for the NCLEX-RN exam, 3 Edition, p.329) 23. To prevent recurrent attacks on Terry who has acute glomerulonephritis, 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 CORRECT ANSWER: A RATIONALE: One of the causes of Glomerulonephritis is a history of pharyngitis or tonsillitis 2 3 weeks before symptoms. Usually a streptococcal infection may precede it. It is very important to seek treatment for respiratory infections existing to stop the progress of the disease. And it is usually with untreated respiratory infections (Group A -hemolytic streptococcus) that this sequelae develop. OPTION B: Taking showers instead of tub baths is a measure to prevent bacteria from entering the urethra, however is indicated for UTI. OPTION C: Some fluid restrictions are observed for Glomerulonephritis but it is more of an intervention rather than a preventive measure for recurrence. OPTION D: Avoiding physical activity is also an intervention for Glomerulonephritis. 24. Herbert has 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 CORRECT ANSWER: D RATIONALE: If the patient verbalizes his concerns regarding dislodgement it would mean then that the patient has not been well educated about the process of having a laryngectomy. It is stated that the patient is now for discharge and it is expected that by this time the patient should be having all the information he has to know regarding the laryngectomy. Preoperative teaching is For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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done so that patient will be able to correct misconceptions and fears about the reason for having the surgery, nature of the surgical procedure. Postoperatively, the nurse reviews equipment and treatments for care with the patient, patients family. It means that after essential information and teaching had been offered, patient still lack the knowledge and confidence to carry out self care and important procedure considerations. (SOURCE: Brunner and Suddarths Textbook of Medical Surgical Nursing 10 th Edition, p. 510511) 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 CORRECT ANSWER: A RATIONALE: After surgery, the vital signs are checked frequently. Oxygen is administered via a mechanical ventilator, nasal cannula, or mask for as long as necessary. A reduction in lung capacity requires a period of physiologic adjustment, and fluids may be given at a low hourly rate to prevent fluid overload and pulmonary edema. OPTION B and C: ventilation exchange may also be important as it is the goal of the surgery to promote a better gas exchange and oxygenation. Chest Tube drainage is already a precursor of the surgery as it is needed to facilitate recuperation of lung expansion functions and avoid further complications such as pneumothorax and hemothorax. OPTION D: Blood replacement is a standing order in cases that bleeding problem may arise within the surgical procedure. (SOURCE: Brunner and Suddarths Textbook of Med.-Surg. Nursing 10th edition, vol.1 p. 628) 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 gamma globulin." d. "A vaccine has been developed for this type of hepatitis" CORRECT ANSWER: D RATIONALE: Gamma Globulins contain the antibody immunoglobulins IgM, IgG, IgA, IgD, and IgE, which are essential in the bodys defense against microorganisms. Household and personal contacts of clients with HAV should be given immune globulin (gamma globulin [Gammar] passive) is helpful prophylaxis both before and after exposure. However a specific vaccine had been developed for Hepatitis A which is the inactivated hepatitis A vaccine (active), which is given two doses of at least 6 months apart for persons who reside in a community that has a high rate of hepatitis A virus infection, who are at risk because of foreign travel, or who have chronic liver th disease. (SOURCE: Med.-Surg. Nsg. By Black and Hawk, 7 edition, vol.1, p. 427, Vol.2 p. 2241) 27. Voltaire develops a nosocomial respiratory tract infection. He asks you what that means. 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."
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CORRECT ANSWER: A RATIONALE: Nosocomial Infections also are referred to as hospital-acquired infections. Such infections are infections acquired in a hospital or other health care facility that were not present or incubating at the time of a clients admission. The hospital environment provides exposure to a variety of virulent organisms that the client has not been exposed to in the past; therefore the client has not developed resistance to these organisms. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd edition, p. 180) 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 CORRECT ANSWER: D RATIONALE: It is most important to watch out for signs of infection because a patient in TPN is most prone to infection because of an open venous access that can be easily contaminated; furthermore, microorganisms can easily find its way to enter the body through the bloodstream. A strict aseptic technique must be used because the TPN solution has a high concentration of glucose, which is a medium for bacterial growth. Signs of an infection are as follows: Chills, elevated WBC count, erythema or drainage at the insertion site, and fever. Assess IV site for redness, swelling, tenderness, or drainage. Change IV tubing every 24 hours or according to agency protocol. If signs of infection occur at the site, the following must be done: IV line must be removed and restarted at a different site Remove the tip of the IV catheter and send it to the laboratory for culture Prepare the client for blood cultures
29. A solution used to treat Pseudomonas wound infection is: a. Dakin's solution b. Half-strength hydrogen peroxide c. Acetic acid d. Betadine CORRECT ANSWER: C RATIONALE: Acetic Acid is effective for irrigating, cleansing, and packing wounds infected by Pseudomonas Aeruginosa. Healthy skin surrounding the wound must be protected with a petroleum barrier because acetic acid excoriates the skin. (Source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p. 566)The use of acetic acid to treat Pseudomonas aeruginosa in superficial wounds dates back to 1916 when it was discovered that a 1% solution applied to war wounds led to elimination of this organism then called Bacillus pyocyaneas. In 1992 a prospective study involving the use of 5% acetic acid was undertaken in 9 patients. No patients complained of discomfort after the soaks which were applied daily. Two wounds lost Pseudomonas species within 2 days and a further four within one week. Only one patient remained contaminated after three weeks. Following eradication of the organism, healing occurred rapidly. Milner-S;Acetic acid to treat Pseudomonas aeruginosa in superficial wounds and burns - (letter);The Lancet;Vol 340 (1992):61. It is possible the application of acetic acid may confer other benefits to the healing process as well as the removal of bacteria. Acidification of a wound would also increase the pO2 and reduces the histotoxicity of ammonia which may be present (Ammonia is less toxic in an acid environment). OPTION A: Dakins Solution or more commonly known as Bleach is a chloride solution that loosens, dissolves, and deodorizes necrotic tissue and blood clots. The solution must not be in contact with healing or normal tissue. OPTION B: Half strength hydrogen peroxide is a 3% solution has effervescent action that releases gas and breaks up necrotic tissue. However, it is not used to pack wounds because it decomposes too rapidly. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION D: Betadine is a brand name of povidone-iodine which is a water-soluble complex of iodine with polyvinylpyrrolidone (PVP), with from 9.0% to 12.0% available iodine, calculated on a dry basis[1].It is used in hospitals for cleansing and disinfecting the skin, preparing the skin preoperatively and treating infections susceptible to iodine.It works through disruption of pathogen cell walls. 30. Which of the following is most reliable in diagnosing a wound infection? a. Culture and sensitivity b. Purulent drainage from a wound c. WBC count of 20,000/pL d. Gram stain testing CORRECT ANSWER: D RATIONALE: The Gram-Stain is the most important of all bacteriologic differential stains to diagnose a wound infection. It divides bacteria into two physiologic groups: Gram and Gram + organisms, thus determining the type of medication to be given to the patient. Infectious diseases or processes can be diagnosed by detection of an immunologic response specific to an infecting agent in a patients serum. Normal humans produce both IgM ( first-response antibodies) and IgG (antibodies that may persist long after an infection) to most pathogens. (Frances Fischbachs A manual of Laboratory and Diagnostic Tests 7th edition, p. 500) 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 and an I.V. infusion was started. As a nurse assigned to Wendy what will he your priority goal? a. Prevent skin breakdown b. Preserve muscle function c. Promote urinary elimination d. Maintain a patent airway CORRECT ANSWER: D RATIONALE: In a pt. that has a GCS of 6, it is very essential that airway must be maintained since deficient O2 delivery to the brain can cause irreversible brain damage in only 6 minutes. Taking into consideration the ABCs of emergency and medical management Airway must be established first followed by Breathing, and last is circulation. If patient have already manifestations of brain injury, patient may fail to initiate his own breathing and thus airway patency can be compromised resulting to a more severe condition. (SOURCE: Brunner and Suddarths Textbook of Medical Surgical Nursing Vol.1 10th Edition, p. 201-202) 32. Knowing that for a comatose patient hearing is the best 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 CORRECT ANSWER: D RATIONALE: It is important to get the attention of the client before beginning to speak despite its inability to respond or to react, nurse must move close to the client and speak slowly and clearly, talking in lower tones is advised as shouting may not help and may only disturb other clients inside the unit. Source: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd Edition, p. 910-911) For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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33. Which among the following interventions should you consider as the highest priority when caring for June who has hemiparersis secondary to stroke? a. Place June on an upright lateral position b. Perform range of motion exercises c. Apply antiembolic stocking d. Use hand rolls or pillows for support CORRECT ANSWER: B RATIONALE: Hemiparesis is the partial paralysis of one side of the body. It is generally caused by lesions of the corticospinal tract, which runs down from the cortical neurons of the frontal lobe to the motor neurons of the spinal cord) and is responsible for the movements of the muscles of the body and its limbs. ROM exercises are the highest priority of all the interventions because for a patient with hemiparesis, rehabilitation and restoration of functional capability is very important. ROM exercises may be done with assistance or guidance of a physical therapist and a rehabilitation nurse. Exercise when performed correctly assists in maintaining and building muscle strength, maintaining joint function, preventing deformity, stimulating circulation, developing endurance and promoting relaxation. Some disabilites, such as spinal cord injury, acute brain injury, and other conditions that cause muscle weakness or hemiparesis require extended periods in the recumbent position, thus may be assisted to an alternative 90-degree position such as a reclining wheelchair with elevated leg rests. th (SOURCE: Brunner and Suddarths textbook for Medical Surgical Nursing Vol.1, 10 edition, p.163) 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 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 CORRECT ANSWER: C RATIONALE: Prior to surgery it is important that medical management be maintained, includes: maintaining cerebral perfusion pressure, controlling ICP, minimizing effects of vasospasm. The client with intracranial aneurysm is at great risk for the development of increased ICP. (Normal ICP 0-15mmHg). A therapeutic nursing management is to decrease environmental stimuli which can increase ICP. Dim all lights Speak softly Touch gently and only when needed Space all interventions Limit noxious stimuli such as suctioning to only as needed
OPTIONS A, B and D are distractive and are examples of environmental stimuli that may th aggravate the condition of the patient.(Source: Med.-Surg. Nsg. By Black and Hawk 7 edition Vol.2, p.2095) 35. When performing a neurological 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 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. has received a significant brain injury CORRECT ANSWER: D RATIONALE: Fixed, Dilated pupils (unilateral or bilateral) or midposition fixed pupils indicate an upper midbrain involvement of brain injury. . (SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition Vol.2,p. 2055) 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 surface area c. Decreased anterior-posterior chest diameter d. Hyperventilation CORRECT ANSWER: B RATIONALE: A 70-year-old expends 70% of the total elastic work of breathing on the chest wall compared with 40% for a 20-year-old. While there is great variation between individual and genders, there are age-related decrements of respiratory muscle strength and endurance of approximately 20% by the age of 70 years. Beginning in early adulthood, there is a progressive enlargement of the alveolar ducts and respiratory bronchioles. The effect of the enlargement of the terminal respiratory units is a decrease of functional alveolar surface area by 15% by the age of 70 years. The decrease in alveolar surface area reduces alveolar surface tension with consequential negative effect on alveolar gas exchange and forced expiratory flow. 37. The older patient is at higher risk for in incontinence because of: a. dilated urethra b. increased glomerular filtration rate c. diuretic use d. decreased bladder capacity CORRECT ANSWER: D RATIONALE: Aging causes a number of changes in urinary tract physiology, all of which can affect continence. These changes include: A decrease in bladder elasticity, which decreases bladder capacity and requires the older adult to void more frequently A decrease in the strength of the detrusor muscle, resulting in incomplete bladder emptying An increase in spontaneous detrusor muscle contractions A decrease in the ability to postpone urination A decrease in urethral closing pressure 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 CORRECT ANSWER: B RATIONALE : Visual information is of particular importance to maintaining balance. The visual systems most involved are the optokinetic and pursuit systems. The optokinetic system is the motor impulse responsible for moving the eyes when the head moves, so that the field of vision remains clear. The pursuit system allows a person to focus on a moving object while the head remains stationary. Both of these systems feed information about the person's position relative to For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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the surroundings to the brainstem. A specific type of eye movement called nystagmus, which is repetitive jerky movements of the eye, most often in the horizontal direction, may cause dizziness. Nystagmus may indicate that neurologic signals from the optokinetic or pursuit systems are not in agreement with the other balance information received by the brain. If the eyes do not move in parallel or if the upper eyelid covers more than a tiny portion of the iris, note the conditions as abnormal findings. (SOURCE: Med.-Surg. Nsg. by Black and Hawk 7th edition, vol.2, p. 1924) 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 CORRECT ANSWER: C RATIONALE: A classical manifestation of Myocardial ischemia is angina that can develop quickly or slowly. Some ignore the chest pain, thinking that it will go away or that it is indigestion. Its location is usually retrosternal or slightly to the left of the sternum, as reported by 90% of incidents. The pain usually radiates to the left shoulder and upper arm and may then travel down the inner aspect of the left arm to the elbow, wrist, and 4th-5th finger. (SOURCE: Med.-Surg. Nsg. By Black and Hawk 7th edition, vol.2, p.1703) 40. The nurse is providing medication instructions to an older adult who is taking digoxin (Lanoxin) daily. The nurse bears in mind that which age-related body changes could place the client at risk for digoxin toxicity? a. decreased cough efficiency and decreased vital capacity b. decreased lean body mass and decreased glomerular filtration rate c. decreased salivation and decreased gastrointestinal motility d. decreased muscle strength and loss of bone density CORRECT ANSWER: B RATIONALE: The older client is at risk for medication toxicity because of decreased lean body mass and age-associated decreased glomerular filtration rate. Although options A, C and D identify age-related changes that occur in the older client, they are not associated specifically with this risk. rd (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 edition, p. 394) Situation 9 - A "disaster" is a large-scale emergencyeven 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 program and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all type 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 properly from natural hazards and the effect"? a. Recovery b. Mitigation c. Response d. Preparedness CORRECT ANSWER: B RATIONALE: Mitigation - actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of one
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Involves determining community hazards and risks (actual and potential threats) for the occurrence of a disaster Involves identifying available community resources and community-health personnel Involves determining the resources available for care of infants, older clients, the disabled, and those with chronic health problems Recovery: Includes actions taken to return to normal after the disaster. Includes prevention of debilitating effects and restoration of personal, economic, and environmental health and stability to the community Response: Involves putting disaster-planning services into action and enumerating the actions needed to save lives and prevent further damage. Primary concerns include the safety and physical and mental health of both the victims and the members of the disaster-response team Preparedness: Includes plans for rescue, evacuation, and care of disaster victims Includes plans for training disaster personnel and gathering resources, equipment, and other materials needed for dealing with the disaster Includes identification of specific responsibilities for various disaster-response personnel Establishes a community disaster plan and an effective public-communication system Involves setting up an emergency medical system and a plan for its activation Includes checking proper functioning of emergency equipment Involves making anticipatory provisions and setting up a location for distribution of food, water, clothing, shelter, other supplies, and medicine Includes checking supplies on a regular basis and replenishing those that have become outdated Includes practicing community disaster plans (mock-disaster drills) SOURCE: Saunders Comprehensive Review for the NCLEX-RN Exam, 3 Edition, p. 73-74) 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 CORRECT ANSWER: A RATIONALE: Tertiary prevention combats the complications of disaster. Primary prevention of disaster is possible through technical, organizational and judicial means Secondary prevention implies the optimal management of disaster itself. Aggregate care 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 will 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
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CORRECT ANSWER: D RATIONALE: Green Tag: are reserved for the "walking wounded" who will need medical care at some point, after more critical injuries have been treated. They will require a doctor's care in several hours or days but not immediately, may wait for a number of hours or be told to go home and come back the next day (examples: broken bones without compound fractures, many soft tissue injuries). Option A:Yellow Tag: Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under "normal" circumstances). OPTION B: Red Tag: They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment. OPTION C: Black Tag: They are so severely injured that they will die of their injuries, possibly in hours or days (large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical crisis that they are unlikely to survive given the care available (cardiac arrest, septic shock, severe head or chest wounds); they should be taken to a holding area and given painkillers as required to reduce suffering. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 rd Edition p.75) 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 CORRECT ANSWER: D RATIONALE: Urgent Category are conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living. Usually victim must be treated within 30-60 minutes. These are patients who have a trauma score of 10 or 11 and can wait for a short time before transport to definitive medical attention. Some examples of conditions that can be treated at urgent care include: accidents and falls, broken bones, breathing difficulties, severe abdominal pain, bleeding/cuts, high fever and vomiting/diarrhea/dehydration. Immediate - are used to label those who cannot survive without immediate treatment but who have a chance of survival. patients who have a trauma score of 3 to 10 (RTS) and need immediate attention. they need advanced medical care at once or within 1 hour. These people are in critical condition and would die without immediate assistance. They require immediate surgery or other life-saving intervention, and have first priority for surgical teams or transport to advanced facilities; they "cannot wait" but are likely to survive with immediate treatment. Examples: Talking, not walking (severe distress with dyspnea, twitching, and/or nausea and vomiting);moderate-to-severe effects in two or more systems (eg, respiratory, gastrointestinal, muscular);circulation intact Emergent Clients with life-threatening injuries, who need immediate attention and continuous evaluation, yet have a high probability of survival once their condition is stabilized. Examples: clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, or acute neurological deficits and those who have sustained chemical splashes to the eye. Non-acute Clients with local injuries who do not have immediate complications and who can wait several hours for medical treatment; these clients require evaluation every 1 to 2 hours thereafter. Examples: clients with minor lacerations, sprains, or cold symptom (SOURCE:Saunders Comprehensive Review for the NCLEX-RN exam 3rd edition, p.74-75) 45. Which of the following terms refer to a process by which the individual receives education about recognition
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of stress reactions and management strategies for handling stress which may be instituted after a disaster? a. Critical incident stress management b. Follow-up c. Debriefing d. Defusion CORRECT ANSWER: A RATIONALE: It is an adaptive short term helping process that focuses solely on an immediate and identifiable problem to enable the individual/s affected to return to their daily routine(s) more quickly and with a lessened likelihood of experiencing post-traumatic stress disorder. Critical Incident Stress Management is designed to help people deal with their trauma one incident at a time by allowing the individual to talk about the incident when it happens without judgment or criticism. Follow-up can be held weeks or months later if needed to address any unresolved issues Debriefings are usually the second level of intervention for those directly affected by the incident and often the first for those not directly involved. Defusings are limited only to individuals directly involved in the incident and are often done informally, sometimes at the scene. They are designed to assist individuals in coping in the short term and address immediate needs 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 line 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 CORRECT ANSWER: D RATIONALE: Blood or bodily fluids emanating from ANY person shall be treated cautiously. Gloves shall be worn when cleaning up blood spills or other bodily fluid spills. These spills shall be disinfected with a ten percent bleach solution or an approved cleansing solution. Bleach primarily is used to disinfect blood spills on various surfaces, they are composed of various chemical components one of which is Sodium Hypochlorite. A 1 in 5 dilution of household bleach with water (1 part bleach to 4 parts water) is effective against many bacteria and some viruses, and is often the disinfectant of choice in cleaning surfaces in hospitals. The solution is corrosive, and needs to be thoroughly removed afterwards, so the bleach disinfection is sometimes followed by an ethanol disinfection. 47. The nurse manager has implemented a change in the method of the nursing delivery system from functional team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following would be the best approach in dealing with the nursing assistant? a. ignore the resistance b. exert coercion with the nursing assistant. c. provide a positive reward system for the nursing assistant d. confront the nursing assistant to encourage verbalization of feelings regarding the change. CORRECT ANSWER: D RATIONALE: Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option A will not address the problem. Option B may produce additional resistance. Option C may provide problem solving measures. rd (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 edition, p.78) For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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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 CORRECT ANSWER: C RATIONALE: Learning need is a desire or a requirement to know something that is presently unknown to the learner. A comprehensive assessment of learning needs incorporates data from the nursing history and physical assessment and addresses the clients support system. It also considers client characteristics that may influence the learning process: readiness to learn, motivation to learn, and reading or comprehension level, for example. Assessment of learning need is done first before developing a teaching plan. OPTION D may be done at later part of learning. 49. The nurse is working in a long-term care facility and is administering medications to assigned clients. A client refuses to take the prescribed medication, and the nurse threatens the client and tells the client that if the medication is not taken orally, then restraints will be applied and the medication will be given by injection. This statement by the nurse constitutes which legal tort? a. invasion of privacy b. negligence c. assault d.battery CORRECT ANSWER: C RATIONALE: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with ones body. Negligence involves actions below the standards of care. Invasion of privacy occurs with unreasonable intrusion into the individuals private affairs. rd (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3 edition, p.64) 50. The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? a. a clients family attending a diabetic teaching session b. canceling physical therapy sessions on the weekend c. normal vital signs and absence of wound infection in a postoperative client d. a client demonstrating accurate medication administration following teaching CORRECT ANSWER: B RATIONALE: Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken. (SOURCE: Saunders Comprehensive Review for the NCLEX-RN exam, 3rd edition, p.76)
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Situation 11 - One of the realities that we are confronted with is mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying. 51. Nurse Fay is assigned to client Irma. Irma is terminally ill she speaks to Nurse Fay in confidence. Nurse Fay now feels that Irma's family could be helpful if they knew what Irma has told her. What should Nurse Fay do first? a. Tell the physician who in turn could tell the family b. Obtain Irma's permission to share the information with the family c. Tell Irma that she has to tell her family what she told you d. Make an appointment to discuss the situation with the family CORRECT ANS: C RATIONALE: The nurse may feel conflict because the nurse wants the client to share important information but is unsure about making such promise. The information may be important to the health or safety of the client or others. Let the client decide whether to share the information or not. th (SOURCE: Foundations of Psychiatric Mental Health Nursing, 4 edition; Elizabeth M. Varcarolis; pp.246) The family is the primary system to which a person belongs, and in most cases, it is the most powerful system to which a person may ever belong. Birth, puberty, marriage, and death are all considered to be family experiences. The family can be the source of love or hate, pride or shame, security or insecurity. OPTIONS: A Wrong delegation B & C Let the client decide whether to share the information or not. 52. Nurse Nathalie Angie is assigned to client Ruby. Ruby who has been told she has terminal cancer turns away and refuses to respond to Nurse Nathalie Angie. Nurse Nathalie Angie can best help her by: a. Coming back periodically and indicating your availability if she would like you to sit with her b. Insisting that Ruby should talk with you because it is not good to keep everything inside c. Leaving her alone because she is uncooperative and unpleasant to be with d. Encouraging her to be physically active as possible CORRECT ANS: A RATIONALE: Therapeutic Communication Technique: Offering Self making one self available. It is important that this offer is unconditional, that is, the client doesnot have to respond verbally to get the nurses attention. (Source: nd Psychiatric Mental Health Nursing, 2 edition; Sheila L. Videbeck; pp. 117) Silence Absence of verbal communication, which provides time for the client to put thoughts into words, regain composure, or continue talking. Nurse says nothing but continues to maintain eye contact and conveys interest. (Source: Psychiatric Mental Health Nursing, 2 nd edition; Sheila L. Videbeck; pp. 118) OTHER OPTIONS: B Non therapeutic communication Technique ( Disapproving ) C Judgemental D Giving advise implies that only the nurse knows what is best for the client. 53. Eddy who is terminally ill and recognizes that he is in the process of losing, everything and everybody he loves, is depressed. Which of the following would best help him during depression? a. Arrange for visitors who might cheer him b. Sit down and talk with him for a while c. Encourage him to look at the brighter side of things d. Sit silently with him CORRECT ANS: D For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Silence often encourages the client to verbalize, provided that it is interested and expectant. Silence gives the client time to organize thoughts, direct the topic of interaction, or focus on issues that are most important. Much non verbal behavior takes place during silence, and the nurse needs to be aware of the client and his or her own nonverbal behavior. (Source: Psychiatric Mental Health Nursing; Shiela L. Videbeck; pp.118) OPTION A Not the job of the nurse. OPTION B Must be comfortable sitting with the client in silence. Let the client know you are available to converse but do not require the client to talk. OPTION C Non-therapeutic Communication Technique: Making stereotyped comments Such comments are of no value in the nurse client relationship. Any automatic responses will lack the nurses consideration or thoughtfulness. 54. Which of the following statements would best indicate that Chun Lee; who is dying has accepted this impending death? a. "I'm ready to die." b. "I have resigned myself to dying" c. "What's the use"? d: "I'm giving up" CORRECT ANS: A RATIONALE: Concrete message. Implies acceptance literally. Acceptance occurs when the person shows evidence of coming to terms with death. ( Source: Psychiatric Mental Health Nursing 2nd edition; Shiela Videbeck; pp. 241) OPTIONS B, C Implies Denial; Shock and disbelief towards loss and or dying. OPTION D Implies Anger; maybe expressed towards God, relative, friends, or health care providers. 55. Piola, 90 years old has planned ahead for her-death-philosophically, socially, financially and emotionally. This is recognized as: a. Acceptance that death is inevitable b Avoidance of the true sedation c. Denial with planning for continued life d. Awareness that death will soon occur CORRECT ANS: D RATIONALE: In this age the patient is aware that death will soon occur. Look at the statement. OPTIONS A,B and C Destructors Situation 12 - Brain tumor, whether malignant or benign, has serious management implications nurse, you should be able to understand the consequences of the disease and the treatment. 56. Nurse Farrah Faye is caring for Conrad who has a brain tumor and Increased Intracranial Pressure (ICP). Which intervention should Nurse Farrah Faye include in her plan to reduce ICP? a. Administer bowel Softener b. Position Conrad with his head turned toward the side of the tumor c. Provide sensory stimulation d. Encourage coughing and deep breathing CORRECT ANS: A RATIONALE: Bowel softener promotes bowel evacuation without straining / Valsalvas maneuver th because it increases ICP. (Source: Medical Surgical Nursing 7 Edition; pp 2201). Straining during coughing, movement in bed or moving bowels increases ICP. ( Source: Medical Surgical Nursing 7th editon; Black and Hawks; pp. 2089) OPTION B Positioning the client with his head towards the side of the tumor increases pressure on the tumor and increases or produces pain. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION C Noise and frequent interruptions may decrease needed sleep and alter ability to cope. OPTION D Coughing increases ICP. 57. Nurse Glaiza Mae helps in positioning patient Conrad. Keeping Conrad's head and neck in alignment results in: a. increased intrathoracic pressure b. increased venous outflow c. decreased venous outflow d. increased intra abdominal pressure CORRECT ANS: B RATIONALE: Maintaining head and neck in neutral alignment facilitates drainage and reduces edema. (SOURCE: Medical Surgical Nursing 7 edition; pp. 2089) OPTION A Not related. OPTION C Opposite of the correct ans. OPTION D Increased abdominal pressure could lead to increase ICP. 58. Which of the following activities may increase intracranial pressure (ICP)? a. Raising the head of the bed b. Manual hyperventilation c. Use of osmotic Diuretics d. Valsava's maneuver CORRECT ANS: D RATIONALE: Straining during coughing, movement in bed, moving bowels or Valsalva Maneuver increases ICP. ( SOURCE: Medical Surgical Nursing 7th editon; Black and Hawks; pp. 2089) OPTION A Facilitates venous drainage from the brain. OPTION B Hyperventilation had been recommended as the primary treatment of head injured clients because carbon dioxide causes cerebral blood vessels to dilate. By manually hyperventilating or increasing the ventilator settings to cause hyperventilation, a hypocarbic (low carbon dioxide) blood level is created. A partial pressure of C02 (PaC02) level between 30 and 35 mmHg results in vasoconstriction of the cerebral blood vessels, leading to decreased blood flow thus decreased ICP. OPTION C Osmotic diuretics such as Mannitol, is used to expand immediately the volume of plasma that increases blood flow and oxygen delivery. Mannitol has a delayed effect of creating an osmotic gradient and pulls fluid out of the cells, creating diuresis over the following hours. Thus reduces cerebral edema. 59. After Nurse Ma. Erma assessed Conrad, she suspected increased ICP.Her most appropriate respiratory goal is to: a. maintain partial pressure of arterial 02 (Pa02) above 80 mmHg b. lower arterial pH c. prevent respiratory alkalosis d. promote C02 elimination CORRECT ANS: D RATIONALE: Hyperventilation had been recommended as the primary treatment of head injured clients because carbon dioxide causes cerebral blood vessels to dilate. By manually hyperventilating or increasing the ventilator settings to cause hyperventilation, a hypocarbic (low carbon dioxide) blood level is created. A partial pressure of C02 (PaC02) level between 30 and 35 mmHg results in vasoconstriction of the cerebral blood vessels, leading to decreased blood flow thus decreased ICP. ( Source: Medical Surgical Nursing 7th editon; Black and Hawks; pp. 2089)
th
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OPTION A - An increased ICP has an increased need for oxygen and glucose because of an increased metabolic rate. The PaO2 must be kept between 90 and 100mmHg. OPTION B - Inadequate oxygenation also forces brain cells to produce energy using anaerobic metabolism, which produces lactic acid and lowers pH, also dilating blood vessels and exacerbating the problem. OPTION Respiratory Alkalosis can lead to Decreased intracranial pressure (secondary to cerebral vasoconstriction), preventing 60. Conrad underwent craniotomy. As his nurse; you know that drainage on a craniotomy dressing must be measured and marked, which findings should you report immediately to the surgeon? a. Foul-smelling drainage b. yellowish drainage c. Greenish drainage d. Bloody drainage CORRECT ANS: A RATIONALE: Foul smelling and purulent drainage indicates wound infection. The client may also have fever, malaise, anorexia, and leukocytosis. Notify surgeon of any suspected wound infection. ( Source: Medical Surgical Nursing 7th editon; Black and Hawks; pp. 307) OPTIONS B & C Not common. OPTION D Common in the first 24 hrs of post-surgery When to Call Your Doctor If you experience any of the following: A temperature that exceeds 101 F An incision that shows signs of infection, such as redness, swelling, pain, or drainage. If you are taking an anticonvulsant, and notice drowsiness, balance problems, or rashes. Decreased alertness, increased drowsiness, weakness of arms or legs, increased headaches, vomiting, or severe neck pain that prevents lowering your chin toward the chest. 61. Which of the following instructions should Nurse Julie Lorraine provide to a patient who has diabetes and hypertrophic lipodystrophy? a. Rotate insulin injection sites b. Inject insulin at the edge of the affected area c. Withhold injection of insulin until the area heals d. Use a longer needle to administer the insulin CORRECT ANS: A RATIONALE: Hypertrophic lipodystrophy occurs when the same injection sites are used frequently. The patient should rotate insulin injection sites and avoid using the affected area for six months. This will allow the thickened subcutaneous tissue to regress. (Source: Medical Surgical Nursing; Novak and Broom) OPTION B Injecting at the edge of the affected area could result in erratic absorption of the insulin. OPTION C Withholding insulin for any length of time without a specific physician order is illegal. Since the site could take up to six months to heal, the patient would certainly go into diabetic ketoacidosis and die without appropriate intervention. OPTION D Since insulin is injected into subcutaneous tissue, a longer needle would bypass this tissue and alter the absorption rate of the insulin. Also, only regular insulin can be given via the intramuscular route. This is done when immediate action is desired. 62. The registered nurses signature as a witness on an informed consent indicates that the patient a. has been informed regarding the procedure. b. was medicated for pain before the consent was signed. c. can describe how the procedure will be done. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. voluntarily agreed to having the procedure performed. CORRECT ANS: A RATIONALE: In order for an informed consent to be valid, three basic criteria must be met. The patients decision must be voluntary, the patient must be informed, and the patient must be competent to understand the information and alternatives. The registered nurses signature as a witness indicates these criteria were met. OPTION B for informed consent to be valid, it must be obtained before the administration of the patients preoperative medication. OPTION C The patient needs only to understand the information and alternatives, not describe the procedure. OPTION D Making a voluntary decision to have a procedure performed is only part of an informed consent. 63. Nurse Aileen is assessing a patient with hypovolemic shock, which of the following manifestations would Nurse Aileen most likely see first? a. Nervousness and apprehension b. Decreased urinary output c. Systolic blood pressure below 90 mmHg d. Hypoventilation and tachycardia CORRECT ANS: A RATIONALE: Early hypoxic and hypocapnic changes result in restlessness, confusion, lethargy and mental cloudiness. (Source: CGFNS guide 5th edition; pp 58) OPTION B Decreased urinary output is a clinical manifestation of hypovolemic shock, but occurs later than nervousness and apprehension. OPTION C During the compensatory stage pf shock, the blood pressure is adequate to perfuse the vital organs. The systolic blood pressure does not drop below 90 mmHg until the progressive stage of shock. OPTION D The heart rate is is increased and the depth of ventilation is increased in the early stages of shock to compensate for the lactic acid produced due to anaerobic metabolism. 64. Staff nurses, Allen and Mary Jane, learn that a patient they have been caring for during the last few weeks Has just been diagnosed with tuberculosis. When the nurses express concern about contracting tuberculosis themselves, the charge nurses response should be based on which of the following statements? a. Tuberculosis is not highly infectious when standard precautions are followed. b. The Mantoux test is used to confirm diagnosis of tuberculosis. c. Tuberculosis is easily treated with a short course of antibiotics. d. Vaccination with Bacillus Calmette Guerin (BCG) will be used to immunize the nurses against infection. CORRECT ANS: A RATIONALE: The infectious stage of tuberculosis declines immediately after effective chemotherapy. The risk of infectious tuberculosis is much higher for persons who are immunosuppressed. Patients need to be taught to cover their mouth when coughing, because tuberculosis is spread by droplets. (SOURCE: CGFNS guide 5th edition; pp. 59) OPTION B For a definite diagnosis of TB, a positive sputum culture is necessary. A Mantoux test identifies individuals exposed to Mycobacterium tuberculosis. This test does not differentiate between active and dormant infection. OPTION C Antimycobacterial therapy is usually prescribed for six to nine months. Short term use of antibiotics is not effective chemotherapy. OPTION D BCG strengthens the bodys immune system. 65. To which of the following nursing diagnosis would a nurse manager give priority when an impaired nurse returns to work? For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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a. Ineffective individual coping b. Situational low self-esteem c. Growth and development; altered d. Ineffective family coping; compromised CORRECT ANS: A RATIONALE: The impaired nurse has difficulty in coping with stress and has abused substances as a means to reduce stress and anxiety. The nurse manager should closely monitor the recovering nurses ability to manage stress and utilize effective coping methods. Recognizing the use of ineffective coping is a priority concern. (Source: CGFNS guide 5th edition; pp 77) OPTION B Situational low self-esteem is defined as negative self-appraisal in a person with previous positive self-evaluation. Individuals who abuse substances have experience low selfesteem and a negative self concept. Over a long period of time, therefore, a recovering nurses low self-esteem is not related specifically to returning to work. OPTION C Altered growth and development is identified as a predisposing factor that is associated with substance abuse disorders but is not relevant diagnosis for the recovering nurse. OPTION D The diagnosis of ineffective family coping compromised, is inappropriate in this situation and in relation to the role of the nurse manager. 66. A woman who is dependent on alcohol is admitted to the detoxification unit. The answer to which of the following question is essential for the nurse to obtain from the patient immediately? a. How does her husband react to her problem? b. When did she have her last drink? c. How old she was when she began to drink? d. What did she eat in the past four hours? CORRECT ANS: B RATIONALE: Alcohol withdrawal begins within four to six hours of cessation of, or reduction in, heavy and prolonged alcohol use. By knowing when the patient had her last drink, the nurse can th anticipate withdrawal symptoms and intervene inappropriately. ( Source: CGFNS guide 5 edition; pp 165) OPTION A This information will be use when the individual begins counseling. If the patient has a husband who enables her drinking, it will be much more difficult for her to quit. OPTION C Knowing how old the patient was when she started drinking provides information on the length of her addiction. However, it is not a question that needs to be asked immediately. OPTION D The nurse should be aware of what the patient has eaten prior to admission since food may slow down the absorption of alcohol and thereby delay withdrawal. However, the most essential assessment for the nurse to make is determining when the patient had her last drink. 67. A patient seems unconcerned about the sudden loss of vision in both eyes. Physical examination fails to reveal a physical cause for this problem. Which of the following terms should the nurse use to describe this phenomenon when charting the behavior? a. La belle indifference b. Malingering c. Hypochondria d. Confabulation CORRECT ANS: A RATIONALE: An inappropriate lack of concern about difficulties despite their apparent severity is called la belle indifference. This phenomenon is often seen in patients with conversion disorders th and is unconscious in nature. (SOURCE: CGFNS guide 5 edition; pp 269) OPTION B Malingering is a conscious effort to deceive others, often for personal gain, by pretending physical symptoms. OPTION C Hypochondria is an excessive preoccupation with an imaginary illness, even though there are no signs or organic changes. Although there is no organic cause for blindness, the patient is not excessively preoccupied with the illness. OPTION D Confabulation is the detailed fabrication of a story to make up for memory loss. The purpose of confabulation is to maintain self esteem. It is often seen in dementias. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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68. Nurse May is assigned to patient with PTSD. Which of the following observations would be most definitive when Nurse May is assessing a patient with posttraumatic stress disorder? a. Substance abuse b. Aggression c. Flashbacks d. Depression CORRECT ANS: C RATIONALE: Criteria for the diagnosis of PTSD include acting or feeling as if the traumatic event th were recurring. This phenomenon is termed flashback. (Source: CGFNS Guide 5 edition; pp 175) OPTIONs A, B & D Aggression, Substance abuse and depression are commonly seen as concurrent behaviors in PTSD patients who have limited coping skills for dealing with the anxiety caused by the trauma. 69. Disulfiram (Antabuse) is prescribed for a patient. Which of the following comments, if made by the patient, would indicate correct understanding of the action of this medication? a. Ill drink fruit juice at social gatherings b. Ill take my pulse four times a day c. Ill lie down for half an hour after I take the pill d. Ill take an antacid before my antabuse CORRECT ANS: A RATIONALE: The patient needs to be aware that ingesting any substances containing alcohol can trigger the alcohol disulfiram reaction. This reaction can include hypotension, severe nausea and vomiting, flushing, throbbing headache and respiratory difficulty. (Source: CGFNS Guide 5 th edition; pp. 263) OPTIONS B & C Antabuse, by itself, produces transient effects that usually disappear within two weeks such as, drowsiness, fatigue, impotence, headache, acne and metallic after taste. It is not necessary to monitor the pulse rate four times a day or to rest after taking the drug. OPTION D Antacids interfere with the absorption of medications and should not be taken with antabuse. 70. Which of the following arterial blood gas levels would nurse expect to observe when monitoring a patient who has metabolic alkalosis? a. pH, 7.50; pCO2, 38 mmHg; HC03, 30mEq b. pH, 7.30; pCO2, 56 mmHg; HCO3, 24 mEq c. pH, 7.38; pCO2, 42 mmHg; HCO3, 25 mEq d. pH, 7.26; pCO2, 37 mmHg; HCO3, 18 mEq CORRECT ANS: A RATIONALE: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma bicarbonate concentration. The normal blood pH is 7.35 7.45; the normal pCO2 is 38-42 mmHg; and the normal bicarbonate level is 24 26 mEq /L. (Source: CGFNS guide 5 th edition; pp. 362) OPTION B This arterial blood gas indicates respiratory acidosis. OPTION C This is a normal arterial blood gas OPTION D This arterial blood gas indicates metabolic acidosis. 71. While Jayvee, a burn patient is being transferred by Nurse Vicky from the burn unit to the operating room, the IV bottle fell on Jayvees head. He sustained a laceration on his forehead. Nurse Vicky was proven guilty of negligence. Which of the following did nurse Vicky fail to do? a. Hold the IV bottle b. Check the IV stand c. Place the IV stand on the foot part of the stretcher d. Restrain Jayvee
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CORRECT ANS: A RATIONALE: Negligence the commission of an act that a prudent person would not have done or the omission of the duty that a prudent person would have fulfilled, resulting in injury or harm th to another person. (Source: Mosbys pocket Dictionary 4 edition; pp. 844). Appropriate and proper check up of the IV stand prior to transferring the patient would guarantee security of the IV bottle. OPTION A Always support or hold the client rather than the equipment. (Source: Fundamentals th of Nursing 7 edition, Kozier et al; pp.1091) OPTION C Doesnt guarantee the security of the bottle during transfer. OPTION D Improper. Needs doctors order and patients and or folks approval. 72. Nurse Krystel is caring for client Olga. Olga is receiving D5W 1 liter regulated at 30 drops/min to be consumed in 8 hrs. It was started at 8am. At 10 am her relative informed Nurse Krystel that the bottle is empty. Which of the following will Nurse Krystel do first? a. Refer to nurse manager b. Assess Olga and check level of fluid left in the bottle c. Discontinue IV and assess Olga d. Replace the IV fluid with prescribed follow-up CORRECT ANS: B Assessment is the first step in the nursing process. It involves getting the facts. Collect, organize, validate and recording the clients data. Before Referring to nurse manager and Replacing prescribed IV fluid, assessment should be done first.( Kosier, B., Fundamentals of Nursing Concept, Process and Practice) 73. When Nurse Lynchen Jeanne volunteers to work in a hospital setting and she commits a mistake, who is legally responsible? a. Volunteer nurse, hospital and the nurse in charge b. The professional organization which the volunteer nurse represents c. Hospital d. Volunteer nurse because there is no employer employee relationship CORRECT ANSWER: A RATIONALE: Doctrine of Respondeat Superior Means let the master answer for the acts of the subordinate. Under this doctrine, the liability is expanded to include the master as well as the employee and not a shift of liability from the subordinate to the master. Therefore, when a person, through his negligence, injures another, he remains fully responsible. This doctrine applies only to those acions performed by the employee within the scope of his employment. (Source: Professional Nursing in the Philippines 10 th edition; Venzon & Venzon; pp164) 74. Nurse Mark Lawrence is reviewing the laboratory results of Clare who has rheumatoid arthritis. Which laboratory result should the nurse expect to find? a. Increased platelet count b. Altered blood urea nitrogen (BUN) and creatinine levels c. Electrolyte imbalance d. Elevated erythrocyte sedimentation rate (ESR) CORRECT ANS: D RATIONALE: Elevated Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP) levels are typical of active disease, with the CRP being more definitive indicator of inflammation. OPTION A - Increased platelet counts (thrombocytosis) may be seen in individuals who show no significant medical problems, while others may have a more significant blood problem called myeloproliferative disorder. Some, although they have an increased number of platelets, may have a tendency to bleed due to the lack of stickiness of the platelets; in others, the platelets retain their stickiness but, because they are increased in number, tend to stick to each other, forming clumps that can block a blood vessel and cause damage, including death (thromboembolism). For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION B - The most common cause of an elevated BUN, azotemia, is poor kidney function, although a serum creatinine level is a somewhat more specific measure of renal function. OPTION C - There are many causes for an electrolyte imbalance. Causes for an electrolyte imbalance may include: Loss of body fluids from prolonged vomiting. Inadequate diet and lack of vitamins. Malabsorption and hormonal or endocrine disorders. Kidney disorders. Medications such as; Chemo drugs, Diuretics, Antibiotics and corticosteroids. 75. Nurse Joseph T. accidentally administer 40 mg of Propanolol (Inderal) to a client instead of 10 mg. Although the client exhibits no adverse reactions to the larger dose, Nurse Joseph T should: a. Complete an incident report b. Call the hospital attorney c. Inform the clients family d. Do nothing because the clients condition is stable CORRECT ANS: A RATIONALE: An incident report (also called unusual occurrence report) is an agency record of an accident or unusual occurrence. Incident reports are used to make all facts available to agency personnel, to contribute to statistical data about accidents or incidents, and to help personnel prevent future incidents or accidents. All accidents are usually reported on incident forms. The nurse includes the following in an incident report: Identify the client by name, initials, and hospital or identification number. Give the date, time and place of the incident. Describe the facts of the incident. Avoid any conclusions or blame. Describe the incident as you saw it even if your impressions differ from those of the others. Incorporate the clients account of the incident. State the clients comments by using direct quotes. Identify witnesses to the incident. Identify any equipment by number and any medication by name and dosage. The person who identifies that the incident occurred should complete the incident report. This may not be the same person actually involved with the incident. When an accident occurs, the nurse should first assess the client and intervene to prevent injury. If a client is injured, nurses must take steps to protect the client, themselves, and their employer. (Source: Fundamentals of Nursing 7th edition, Kozier et al; pp.61-62) OPTIONS B & C Premature actions. OPTION D Guilty of Negligence. Situation 13 Nurses Denice and Cynthia are going to participate in a Cancer Consciousness Week. They are assigned to take charge of the women to make them aware of cancer, most especially cervical cancer. They reviewed their manifestations and management. 76. The following are risk factors for cervical Cancer EXCEPT: a. immunosuppressive therapy b. sex at an early age, multiple partners, exposure to socially transmitted diseases, male partner's sexual habits c. viral agents like the Human Papilloma Virus d. smoking CORRECT ANS: A RATIONALE: Not included among the risk factors. OPTIONS B, C & D are all risk factors of cervical cancer. Human papilloma virus (HPV) is the leading cause of cervical cancer. Other factors are Low socioeconomic status, Untreated chronic cervicitis,STDs and Having a sexual partner with a history of penile or prostate cancer. ( th SOURCE: Medical Surgical Nursing 7 edition; Black and Hawks; pp 1072) 77. Late signs and symptoms of cervical cancer include the following EXCEPT: For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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a. urinary/bowel changes b. pain in pelvis, leg of flank c. uterine bleeding d. lymph edema of lower extremities CORRECT ANS: D RATIONALE: Lymphedema develops in clients with missing or impaired lymphatic system. Trauma, neoplasms, filariasis, inflammation, surgical excisions, or high doses of radiation are factors that develops lymphedema. ( Source: Medical Surgical Nursing 7th edition; Black and Hawks; pp 1543) OPTION A Late manifestations. Together with pressure on the bowel, bladder or both. Bladder iiritation, Rectal discharge manifestation of ureteral obstruction and heavy aching abdominal pain. OPTION B Pain is late manifestation. It usually becomes a difficult problem with the onset of cachexia, or general wasting syndrome. OPTION C - Vaginal discharges and bleeding especially after intercourse are late manifestations as well. ( SOURCE: Medical Surgical Nursing 7th edition; Black and Hawks; pp 1074) 78. When a total hysterectomy is performed due to cancer of the cervix, which of the following organs are removed? a. the uterus, cervix, fallopian tubes and one ovary b. the uterus, cervix, and two-thirds of the vagina c. the uterus, cervix, tubes and ovaries d. the uterus and cervix CORRECT ANS: D RATIONALE: Removal of the uterus and the cervix. Can be performed either abdominally or vaginally. th ( SOURCE: Medical Surgical Nursing 7 edition; Black and Hawks; pp 1074) OPTION A Total hysterectomy with unilateral salpingo-oophorectomy. (TAUSO) OPTION B Radical Hysterectomy OPTION C Total Hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) ***Panhysterectomy Removal uterus, cervix, fallopian tube except the ovary. 79. A client with cervical cancer is being treated with a radioactive cervical implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that: a. Overnight stays by family members is against hospital policy. b. There is no need for him to stay because staffing is adequate. c. His wife will rest much better knowing that he is at home. d. Visitation is limited to 30 minutes when the implant is in place. CORRECT ANSWER D RATIONALE:Clients with radium implants should have close contact limited to 30 minutes per visit. The general rule is limiting time spent exposed to radium, putting distance between people and the radium source, and using lead to shield against the radium. Teaching the family member these principles is extremely important. Answers A, B, and C are not empathetic and do not address the question; therefore, they are incorrect. 80. A client with bladder cancer is being treated with iridium seed implants. The nurse's discharge teaching should include telling the client to: a. Strain his urine b. Increase his fluid intake c. Report urinary frequency d. Avoid prolonged sitting CORRECT ANSWER A
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RATIONALE: Iridium seeds can be expelled during urination, so the client should be taught to strain his urine and report to the doctor if any of the seeds are expelled. Increasing fluids, reporting urinary frequency, and avoiding prolonged sitting are not necessary; therefore, answers B, C, and D are incorrect. Situation 14 - Mr. Muscle, age 63, is admitted to the hospital with a diagnosis of Congestive Heart Failure (CHF). The physicians orders include 500 mg of chlorothiazide (Diuril) P.O. twice daily and 0.25 mg of Digoxin (Lanoxin) P.O. daily. 81. Assessment of Mr. Muscle would most likely reveal: a. Crushing chest pain unrelieved by rest or nitroglycerin ( Nitro-Bid) b. Diaphoresis with cool, clammy skin c. Distended neck veins and dependent pitting edema d. Fever and elevated white blood cell count. CORRECT ANS: C RATIONALE: Congestive Heart Failure (CHF) increases systematic venous pressure, causing distended neck veins. Increased blood volume in the venous system changes capillary membrane permeability, allowing plasma to enter interstitial tissues. OPTIONS A & B Crushing chest pain unrelieved by rest or nitroglycerin and diaphoresis with cool clammy skin are common symptoms of MI secondary to coronary artery occlusion. OPTION D Fever and elevated WBC count are common signs of pericarditis. 81. Mr. Muscle is in the acute phase of left ventricular heart failure. To alleviate his symptoms, the nurse should place him in: a. The dorsal recumbent position with elevated feet to reduce edema. b. An upright position to promote chest expansion. c. The low-fowlers position with elevated knees to slow the return of blood to the heart. d. The left lateral sims position to promote emptying to ride side of the heart. CORRECT ANS: B RATIONALE: In left ventricular failure, the left ventricle cannot pump the necessary blood volume of oxygenated blood coming from the lungs, resulting in lung congestion. An upright position allows full chest expansion, which help relieves dyspnea. OPTION A The dorsal recumbent position decreases ventilation; elevating the feet increases blood flow to the heart, putting a greater work load on it. OPTION C The low fowlers position with elevated knees may cause pooling of blood in the abdominal area, which may lead to increased ascites and poor diaphragmatic contractions. OPTION D The left lateral sims position has not been proven more effective in emptying to the right side of the heart; besides an increase in the amount of blood pumped from the right ventricle into the pulmonary circulation would only worsen the patients condition. 83. Nurse Charm administers chlorothiazide. This drug should alleviate Mr. Muscles symptoms by: a. Reducing circulatory volume through dieresis b. Strengthening the force of ventricular contractions c. Reducing the rate of metabolism and the bodys need for oxygen d. Slowing the rate of heart contractions. CORRECT ANS: A RATIONALE: Chlorothiazide (Diuril) is a diuretic that acts on the distal tubules to increase the excretion of water, sodium, chloride, and potassium; this lowers the circulatory volume and alleviates the patients symptoms. OPTIONS B & D Digoxin (Lanoxin) strengthens the force of ventricular contractions and slows the heart rate. OPTION C Chlorothiazide does not affect the metabolic rate.
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84. Mr. Muscle is placed on a strict low-sodium, high potassium diet. Which lunch menu is most appropriate for him? a. Bologna sandwich on low-sodium bread, carrot sticks, orange, and skim milk. b. Tuna fish, noodle and vegetable casserole, banana and coffee. c. Boiled egg sandwich on low-sodium toast; lettuce, tomato, onion salad; banana; skim milk. d. Chicken sandwich on low sodium bread, celery sticks, apple, and tea with lemon. CORRECT ANS: C RATIONALE: This meal is low in sodium, has an item high in potassium (banana) and includes foods from all four basic groups. OPTIONS A,B & D Bologna, Carrot sticks, tuna fish, and celery sticks all have high sodium content; Coffee and tea provide no nutrition. 85. When assessing Mr. Muscle for sign and symptoms of digoxin toxicity, the nurse should watch for all of the following except: a. Bradycardia, tachycardia, begimeny, ectopic beats, and pulse deficits. b. Anorexia, nausea and vomiting, diarrhea, and abdominal pain. c. Headache, double or blurred vision, drowsiness, confusion, restlessness, and muscle weakness. d. Abdominal distention, weakness, paralysis, apathy, depression and hallucinations CORRECT ANS: D RATIONALE: Abdominal distention, weakness, paralysis, apathy, depression, and hallucinations are signs of potassium and calcium overdose, not digoxin toxicity OPTION A Cardiovascular symptoms of Digoxin toxicity OPTION B GI symptoms of digoxin toxicity OPTION C Neurologic symptoms of digoxin toxicity Situation 15 - Mr.Pakyaw has had a persistent cough for about 4 months. One week ago, he noted blood in his sputum. He is admitted in the hospital for diagnostic testing. The physician orders a bronchoscopy. 86. Immediately after the bronchoscopy, the nurse should withhold food and fluid until Mr. Pakyaws gag reflex returns, to prevent: a. Aspiration b. Abdominal distention c. Dyspnea d. Dyspepsia CORRECT ANS: A RATIONALE: After a bronchoscopy, the gag reflex must be present to prevent aspiration of food or fluid into the lungs. OPTIONS A, B & C are not related to the presence of the gag reflex 87. Mr Pakyaw is diagnosed with lung cancer. The physician orders various pulmonary function tests, including measurements of forced vital capacity and forced expiratory volume. The test results are used before surgery to: a. Evaluate the spread of the disease b. Estimate the amount of anesthesia needed for surgery c. Determine the amount of lung tissue to be removed d. Calculate whether the contemplated surgery will leave enough functioning lung tissue CORRECT ANS: D RATIONALE: Pulmonary function tests, which measure lung volume and capacity, help identify the degree of respiratory disability. The results indicate whether enough functioning lung tissue will be intact after surgery to compensate for the removal of the diseased tissue.
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OPTIONS A, B & C Pulmonary function tests are not used to evaluate the spread of the disease, estimate the amount of anesthesia needed for the surgery, or determine how much tissue needs to be removed. 88. After lobectomy, Mr. Pakyaw is returned to the unit with chest tubes in place. The nurse assigns a nursing diagnosis of Impaired gas exchange related to lung alterations after surgery. With this diagnosis, the expected outcome is that the patient will: a. Report less chest pain b. Assume a semi-fowlers position c. Request pain medication frequently d. Exhibit a respiratory rate of less than 20 breaths / minute without dyspnea CORRECT ANS: D RATIONALE: A normal respiratory rate (less than 20 breaths / minute) without dyspnea indicates probable lung expansion and effective chest tube functioning. OPTIONS A & C Reporting chest pain and requesting pain medication frequently would be more appropriate patient outcomes for a nursing diagnosis of Pain related to lung impairment and chest surgery. OPTION B Assuming a semifowlers position, which facilitates breathing, may indicate that gas exchange is still impaired. 89. Mr. Pakyaw will undergo radiation therapy on an outpatient basis to treat the lung cancer. When teaching Mr. Pakyaw about skin care, the nurse should encourage him to: a. Use skin lotions and powders on the irradiated area b. Avoid washing off the marks placed on his skin to guide radiation therapy c. Wear constrictive clothing d. Massage the irradiated area to increase circulation CORRECT ANS: B RATIONALE: If the patient washes off the marks placed on the skin to guide radiation therapy, the areas must be reassessed and remarked a time consuming tasks. OPTION A Skin lotions and powders are contraindicated because they may irritate the skin in the irradiated area. OPTION C The patient should avoid wearing constrictive clothing, which decrease circulatory circulation. OPTION D Massaging an area alredy tender fromradiation can cause irritation and pain. 90. Mr. Pakyaws wife, Chenny, is concerned about his poor appetite and weight loss. Nurse Erika explains to her that radiation treatment, anxiety, and the disease itself can cause anorexia in cancer patients. Nurse Erika should encourage Mr. Pakyaw to: a. Limit activity before and after meals b. Force fluids c. Eat high calorie foods d. Eat hot meat dishes with special sauces CORRECT ANS: C Because Mr. Pakyaws loss of appetite causes him to eat less than normal, he should make every mouthful count by eating high calorie foods. OPTION A moderate activity increases persons appetite. OPTION B Forcing fluids typically causes a feeling of fullness; this would further reduce the patients appetite and nutritional intake.
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OPTION D He should avoid hot meat dishes, which commonly cause a metallic taste in the patient receiving radiation therapy. Situation 16 - Mrs.Dyangga, age 53, has been experiencing bone pain, recurrent infections and abdominal pain for the past 5 years. After ordering a battery of tests, including x-ray studies, the physician diagnoses Multiple Myeloma. 91. The physician orders administration of melphalan (Alkeran) for Mrs. Dyangga because this drug causes pancytopenia, the nurse should assess the patient for: a. Alopecia b. Skin pigmentation changes c. Thrombophlebitis d. Decreased WBC count CORRECT ANS: D RATIONALE: Pancytopenia refers to depression in all the bloods cellular elements; the patient on Melphalan (Alkeran) therapy would probably have a reduced WBC count. OPTIONs A & C Temporary alopecia and mild thrombophlebitis at the infusion site are adverse effects of melphalan therapy, but they are not related to pancytopenia. OPTION B Skin pigmentation is governed by melanocytes, which are controlled by pituitary gland; because melphalan affects bone marrow production of blood cells, the drug would cause skin pigmentation changes. 92. Nursing care for Mrs. Dyangga should include: a. Giving 2,000 ml of fluids daily b. Giving more than 3,000 ml of fluid daily c. Restricting fluid intake to equal the patients insensible fluid loss d. Encouraging increased intake of fluids, particularly milk CORRECT ANS: B RATIONALE: The daily fluid intake of the patient with multiple myeloma should be 3,000 to 4,000 ml. Multiple myelomas cause bone destruction and high calcium in bloodstream, and excess plasma cells produce high globulin levels; a high fluid intake helps dilute the calcium overload and prevent protein from precipitating in the renal tubules. OPTION A Less than advised fluid intake. OPTION C restricting fluid intake would increase the risk of renal stones OPTION D Milk would increase the patients blood calcium level, possibly contributing to calcium excretion in the urine. Situation 17 - Nurse Lucille is caring for Madame L, age 59, in the hospital with tentative diagnosis of stage III B Hodgkins disease. 93. Which assessment finding strongly indicates Hodgkins disease? a. Night sweats b. Enlarged lymph nodes c. Reed-Sternberg cells d. Hepatomegaly CORRECT ANS: C RATIONALE: Reed- Sternberg cells proliferate in the patient with Hodgkins disease, replacing other cellular elements found in the lymph nodes. OPTIONS A & B Night sweats and enlarged lymph nodes occur with hodgkins disease, but they may be caused by other diseases. OPTION Hepatomegaly occurs with other conditions, such as cirrhosis, but not with Hodgkins disease. 94. The usual drug therapy for the patient with stage III B Hodgkins disease is called MOPP. The O in MOPP For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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stands for: a. Prednisone (Orasone) b. Vincristine (Oncovin) c. Oxacillin (Bactocill) d. Oxamniquine (Vansil) CORRECT ANS: B RATIONALE: The O in MOPP stands for Vincristine (Oncovin). The patient with stage III B Hodgkins Disease receives a cyclic drug combination of mechlorethamine (Mustargen), vincristine (Oncovin), procarbazine (Matulane), and prednisone (Orasone); these drugs are given for 14 days, with 14 days rest between cycles. OPTION A P in MOPP therapy OPTION C Oxacillin (Bactocil) is an antibiotic OPTION D Oamniquine (Vansil) is an antihelmintic 95. Which nursing intervention is most effective in relieving nausea and vomiting associated with MOPP therapy? a. Administering an antiemetic simultaneously with the drug b. Encouraging the patient to drink hot liquids, such as coffee or tea c. Giving an antiemetic 1 to 3 hours before MOPP administration d. Provide frequent oral hygiene CORRECT ANS: C RATIONALE: The best intervention for relieving Nausea and Vomiting from MOPP therapy is to administer an antiemetic 1 to 3 hours before starting therapy; this gives the antiemetic time to take effect. OPTION An antiemetic administered simultaneously with MOPP therapy may not be as effective. OPTION B The patient should not drink hot liquids; they appear to contribute to nausea. OPTION D Frequent oral hygiene may reduce stomatitis, but it does not relieve nausea 96. A patient who has sustained a fracture of femur is at risk for which of the following complications in the immediate post-fracture period? a. Electrolyte imbalance b. Fat embolus c. Fluid Volume deficit d. Disuse Syndrome CORRECT ANS: B RATIONALE: Complications of fractures include infection, compartment syndrome, venous thrombosis and fat embolism. (Source: CGFNS study guide 5 th edition; pp 323) OPTION A & C Electrolyte imbalance and fluid volume deficit may occur post-surgery but they are not evident in the immediate post-fracture period. OPTION Disuse Syndrome may occur late into the post fracture period but is not seen immediately. 97. A patient who has a long leg cast says to Nurse Hazel, My thigh is itching under the cast. To provide relief, Nurse Hazel should? a. teach patient guided imagery techniques. b. apply heat to the cast at the site of the itching. c. elevate the patients affected leg on pillows d. encourage the patient to move his/her toes. CORRECT ANS: A
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RATIONALE: Itching under the cast can be extremely uncomfortable. The patient may be tempted to slip an object under the cast to scratch. This is a dangerous practice because of the possibility of breakage and / or skin irritation. Guided imagery is a way to help patients distract themselves from their pain and may produce relaxation response. (Source: CGFNS study guide 5th edition; pp 324) OPTION B Heat increases itching due to vasodilation. OPTION C Elevation prevents dependent edema. OPTION D Inability to move the toes indicates compression. The cast may be too tight if the patient is unable to move his / her toes. 98. Nurse Cherry is caring for a patient who is receiving litium carbonate (Eskalith). Prior to administration of the next dose, Nurse Cherry finds that the patients lithiumblood level is 1.6 mEq /dL. Which of the following actions should Nurse Cherry take first? a. Call the patients physician b. Withhold the dose c. Take the patients Vital signs d. Repeat the blood lithium level CORRECT ANS: B RATIONALE: The first step a nurse should take when a blood lithium level is 1.6 mEq/ dL or th above is to withhold the lithium dose. (Source: CGFNS study guide 5 edition; pp 324) OPTION A The physician should be called to re-evaluate the dose after the nurse has the results of a redrawn lithium level. OPTION C Vital signs may be helpful in assessing if the patient is dehydrated, which can cause an increase in lithium levels. However this should be the initial action by the nurse. OPTION D The nurse should recheck the lithium level after withholding the dose of lithium. 99. Which of the following goals would be given priority in the care plan of a two year old child who has acute gastroenteritis? a. Promote hydration. b. Reduce lethargy c. Preserve skin integrity d. Maintain comfort CORRECT ANS: A RATIONALE: Therapeutic management of acute diarrheal disease ( acute gastroenteritis) is directed at correcting the fluid and electrolyte imbalance and preventing or treating malnutrition. Major goals are assessment of fluid and electrolyte imbalance, re-hydration, maintenance fluid therapy, and reintroduction of an adequate diet. (SOURCE: CGFNS study guide 5th edition; pp 384) OPTION B Lethargy, defined as abnormal drowsiness or stupor, can be caused by high fevers, dehydration and electrolyte imbalances. While the child with acute gastroenteritis may become lethargic, the correction of the fluid and electrolyte imbalance is the priority. OPTION C A patient goal should be to promote skin integrity, since frequent stools will cause irritation to the skin. However this should not be the priority goal. OPTION D A patient goal should be to promote comfort and relieve stress; however, the primary goal for patient is hydration 100. A priority nursing intervention for the care of a terminally ill patient diagnosed with metastatic cancer is a. Maintaining bowel function b. Alleviating and relieving pain c. Preventing respiratory arrest d. managing chemotherapy. CORRECT ANS: B For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Individuals with cancer pain have a right to obtain optimal pain relief. Nurse caring for terminally ill patient with metastatic cancer have an ethical obligation to provide pain relief. A goal is to assist the patient to achieve as comfortable a death as possible. (Source: CGFNS study th guide 5 edition; pp 89) OPTION A While constipation may be a problem secondary to pain medications, it is not the priority intervention in the terminally ill patient. OPTION C A goal in the care of a terminally ill cancer patient is not to prolong life, but to provide comfort. Preventing respiratory arrest would prolong life. OPTION D Many terminally ill patients no longer receive chemotherapy. Managing chemotherapy is the role of oncologist.
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Situation 1 - Jimmy developed his 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 present problem d. help the client to communicate CORRECT ANSWER: C RATIONALE: Crisis Intervention is an active but temporary entry into the life situation of an individual, a family or a group during a period of stress. It includes assessment, planning of therapeutic intervention, implementation of therapeutic intervention and evaluation. Since the client has already conceptualized his own problem, there is no need for assessment anymore. Helping him cope with present problem is already planning of therapeutic intervention. OPTION A- There is no need helping the client find meaning in his experience because as stated, he is already aware of his own problem OPTION B- Planning of alternatives is wrong because the client hasnt cope with his problem yet. He hasnt developed any coping strategies yet. OPTION D- There is no need to let the client verbalize and/or communicate because he has already verbalized that he needs to handle his nervousness. SOURCE: Shives, Psychiatric-Mental health Nursing, 5th ed, pp166-168 2. The nurse is guided that Jimmy is aware of his concerns of the "here and now" when he crossed out which item from his "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. physiological indices of anxiety CORRECT ANSWER: C RATIONALE: Crisis Intervention deals with the here and now, Gestalt therapy. It emphasizes identifying the persons feelings and thoughts in the here and now. Therapists often use gestalt therapy to increase clients self-awareness, focusing on the present. Early signs of anxiety dont deal with the here and now because the client is already manifesting signs of anxiety. An early sign of anxiety is a part of assessment process. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 rd ed, p 59 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 CORRECT ANSWER: B For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: A severely anxious person has trouble thinking and reasoning. They cant complete a task. The range of perception is reduced, anxiety interferes with effective functioning. OPTION A- In panic the ability to concentrate is disrupted, the individual may experience terror or confusion or unable to speak or move. They cant communicate verbally and may be suicidal. OPTION C-In Moderate Anxiety, the perception becomes narrower; concentration is increased and able to ignore distractions in dealing with problems. Moderately anxious person has difficulty concentrating independently. OPTION D- In Mild anxiety, the client is more alert, more aware of environment. It helps the person focus attention to learn, solve problems, think, act, feel and protect himself. SOURCE: Videbeck, Psychiatric Mental health Nursing, 3rd ed, 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 identifies as anxious CORRECT ANSWER: A RATIONALE: Contacting the staff every time he feels anxious is still being dependent to the staff nurses of his self-care OPTION B, C, and Dimplies independence 5. The nurse notes effectiveness of Interventions in using subjective and objective data in the: a. initial plans or order b. database c. problem list d. progress notes CORRECT ANSWER: D RATIONALE: A progress note is a chart entry made by all health professionals involved in a clients care. It is in the progress notes that the nurse notes the effectiveness of interventions. OPTION AOPTION B- includes the nursing assessment, the physicians history, social and family data and the results of the physical examination and baseline diagnostic tests. OPTION C- derived from database. It is usually kept at the front of the chart and serves as an index to the numbered entries in the progress notes. SOURCE: Kozier, Fundamentals of Nursing, 7th ed, pp 331-332 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 a depth study of one boy is a: a. case study b. longitudinal study c. cross-sectional study d. evaluative study CORRECT ANSWER: A RATIONALE: Case study involves an in-depth, longitudinal examination of a single instance or event: a case, rather than using large samples and following a rigid protocol to examine a limited number of variables. OPTION B- Longitudinal study is a correlational research that involves repeated studies observations of the same items over a long period of time. It studies developmental ternds over a long period of time. OPTION C-Cross-sectional study is a study design in which data are collected at one point in time; sometimes used to infer change over time when data are collected from different age or developmental groups
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OPTION D- Evaluative study is a research that investigates how well a program, practice or policy is working SOURCE: Polit and Beck, Nursing Research, 7th ed, pp 712, 715 717, 723 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. Audio and interpretation c. Audio-visual recording d. Verbal narrative account CORRECT ANSWER: C RATIONALE: Process recordings are written records of segment from the nurse-client session that reflects closely as possible the verbal and non-verbal behaviors of both client and nurse. It is usually best of the student can write notes verbatim in a private area immediately after the interaction has taken place. Nurses record their words and clients words, identify whether the responses are therapeutic, and recall their emotions at that time. OPTIONS A, B & D- all are part of process recording SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 245 8. Which of these does NOT happen in a descriptive study? a. Describing relationship among variables b. Exploration of relationships between two or more phenomena c. Manipulation of phenomenon in real life context d. Manipulation of a variable CORRECT ANSWER: D RATIONALE: Descriptive research is a nonexperimental study. The purpose of it is to observe, describe, and document aspects of a situation as it naturally occurs and sometimes to serve as a starting point for hypothesis generation or theory development. The aim of this study is to describe relationship among variables. Neither of the variables could be experimentally manipulated. OPTIONS A, B, C- all happens in a descriptive study SOURCE: Polit and Beck, Nursing Research, 7th ed, pp 192, 195 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 CORRECT ANSWER: C RATIONALE: The primary role of caregiver is the primary role of the nurse. The provision of care to patients that combines both the art and the science of nursing in meeting all the aspect of well being. OPTION A- the researcher participates as a member of the group and observes the group at the same time in data collection OPTION B-the researcher observes a particular group and records behaviors or activities OPTION D- in advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes. Advocacy is the process of acting in the clients behalf when he or she cannot do so. SOURCE: Polit et al, Nursing Research, 7th ed, pp 726, 727 and Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 104 10. To ensure reliability of the study, the investigator analysis and interpretations were: a. subjected to statistical treatment b. correlated with a list coping behaviors For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. subjected to an inter-observe agreement d. scored and compared standard criteria CORRECT ANSWER: A RATIONALE: Statistical treatment is a process of using statistical tools such as mode of central tendency, mean, median to test the reliability of the study. You need to quantify first the data obtained before you can say that the study is reliable. Situation 3 - During the morning endorsement, the outgoing nurse informed the nursing staff that Regina, 5 years old, was given Flurazepam (Dalmane) 15 mg 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?" CORRECT ANSWER: A RATIONALE: Asking open-ended questions, leads or invite the client to explore (elaborate, clarify, describe, compare or illustrate) thoughts or feelings. It enables the nurse to examine important ideas, experiences and encourages communication OPTIONS B & C-it is a closed ended question. It closes an interview rapidly. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 116,118 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 provides her a checklist b. Provide a drug literature and explain its contents 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 CORRECT ANSWER: D RATIONALE: The main purpose is to provide health teaching to the client. Communicating helpful information to the client about the drug she is taking. Asking her what time she would like to watch the informative video least communicate attention to her needs about her medicine because you are giving the client the option to say no to the activity. Although it is an informative video, yet as a nurse, health teaching is our primary responsibility. We must be responsible for the learning of our clients. OPTIONS A,B, CCommunicates attention and care for her needs about her medicine. It is part of health teaching. 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 CORRECT ANSWER: D RATIONALE: In mutual inquiry, the nurse involves the patient in determining the facts of his/her situation wherein the patient will be able to understand her involvement in a certain experience. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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Often just helping the client explore his/her perceptions of a problem stimulates potential solutions in the clients mind. Clients participation is effective in finding meaningful solutions to problems. OPTIONS A, B, C- pertains to goals of crisis intervention SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 rd ed, p 122 14. 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 an advice form 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." CORRECT ANSWER: D RATIONALE: Sleeping pills are hypnotics. Hypnotics are effective in treating transient insomnia, but when used over the long-term, patients run the risk of developing dependence on the drug itself. Hypnotics can worsen existing sleep disturbances when they induce dug dependency insomnia, for once the drug is discontinued, the individual then have rebound insomnia and nightmares. OPTION A- taking the medicine with caution is a must OPTION B and C- shows understanding of the special instructions given to her SOURCE: Varcaloris, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 892 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 CORRECT ANSWER: A RATIONALE: The nurse should make an agreement or contract with the client. Teaching plans are signed by the patient if she/he is able to understand fully the health teaching given to her. Any documents can also serve legal purposes. OPTION B- She may not able to recall everything OPTION C- Written agreement is more formal compared to verbal agreement OPTION D- The husband has nothing to do with the medications. The patient itself must understand the precautions of her medications 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 CORRECT ANSWER: D RATIONALE: Therapists ability to convey an essential interest in the client has been found to be more important than position, appearance, reputation, clinical experience, training and theoretical knowledge. Skilled use of communication techniques helps the nurse understand and empathize with the clients experience. It helps in facilitating the clients expression of emotions. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p112 17. The premise that an individuals behavior and affect are largely determined by the attitudes and assumptions one has developed about the world underlies: 09394837323
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a. modeling b. milieu therapy c. cognitive therapy d. psychoanalytic psychotherapy CORRECT ANSWER: C RATIONALE: Cognitive theory uses cognitive therapy that is an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders. Cognitive theory believes that individuals affect and behavior are largely determined by the way in which they are structure the world. OPTION A- In modeling the therapist provides a role model for specific identified behaviors, and the client learns through imitation. OPTION B- Describe the use of the total environment to treat disturbed children. A comfortable, secure environment is created in which psychotic children were helped to form a new world. OPTION D- Uses many of the tools of psychoanalysis, such as free association, dream analysis, transference and counter transference, but the therapist is much more involved and interacts with the client more freely. th SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4 ed, pp 38, 39, 42, 43 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 CORRECT ANSWER: B RATIONALE: Intervention is any act performed to prevent harming of a patient or to improve the mental, emotional or physical function of a person OPTION A- act of watching carefully and attentively OPTION C- an agreement of the listener with certain elements of the patients communication OPTION D- a structured, recursive process where two or more people work together toward a common goaltypically an intellectual endeavor SOURCE: Mosby, Mosbys Pocket Dictionary, 4th ed, pp 671, 880, 1328 19. All of the following response 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 CORRECT ANSWER: D RATIONALE: Congruence signifies genuineness, or self-awareness of ones feelings as they arise within the relationship, and the ability to communicate them when appropriate. It is conveyed by actions such as not hiding behind the role of nurse, listening to and communicating with others without distorting their message and being clear and concrete in communications with clients. Congruence connotes the ability to use therapeutic communication tools in an appropriately spontaneous manner, rather than rigidly or in a parrot-like fashion. OPTION A- although it is also communicating with clients, it is not the most direct violation of the concept of using therapeutic communication in an appropriately spontaneous manner OPTION B- not directly connected with communicating with the client OPTION C- tolerating behavior is more on behavioral approach rather than communication SOURCE: Varcaloris, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 223 20. The mentally ill person demonstrating a child-like behavior responds positively to the nurse who is warm and caring. This demonstration of the nurse's role as: a. counselor For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. parent surrogate c. therapist d. socializing agent CORRECT ANSWER: B RATIONALE: When a client exhibits child-like behavior or when a nurse is required to provide personal care, the nurse may be tempted to assume the parental role. OPTION A- deals with human development concerns through support, consultation, evaluation, research OPTION C- person with special skills. More on a professional level of a relationship between client and nurse OPTION D- people and groups that influence our self-concept, emotions, attitudes, and behavior SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, p 100 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 one relationship would be b. during the working phase c. towards the end of the relationship d. at the start of the relationship CORRECT ANSWER: D RATIONALE: Termination begins in the orientation phase or at the start of the relationship. The date of the termination phase should be clear from beginning to keep the client aware, less dependent on the nurse and avoid developing a relationship more than that of a professional relationship. Also, to prevent separation anxiety. OPTION A- you should not wait for the client to ask you how long your relationship would be. It is your obligation as a nurse to inform him. OPTION B- in the working phase, the nurse and client together identify and explore areas in the clients life that are causing problems OPTION C- Feelings are aroused in both the client and the nurse with regard to the experience they have had. If you will tell the client that you will terminate your nurse-patient relationship towards the end of the relationship, it would be difficult for the client to accept it and you might awaken the unresolved feelings of abandonment or loneliness, or feelings of being rejected by others. SOURCE: Varcaloris, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 232-235 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." CORRECT ANSWER: A RATIONALE: You are making your patient build a trusting relationship with you. Confidentiality means allowing only those involved in the patients care to have access to any information that the patient divulges. The nurse must define the boundaries of confidentiality to the patient. The nurse is clear that only members of the health care team will have access to patient data. The team must have the data to care for the patient in the best manner possible. OPTIONS B, C, D- it is non therapeutic to agree with the client. When the nurse agrees with the client, there is no opportunity for the client to change his/her mind without being wrong SOURCE: Videbeck, Psychiatric Mental Health Nursing 2nd ed, p 99 23. When the nurse respects the client's self-disclosure, this is a gauge for the nurse's: a. trustworthiness For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. loyalty c. integrity d. professionalism CORRECT ANSWER: A RATIONALE: Nurse-client relationship requires trust. Trust builds when the client is confident in the nurse and the nurses presence conveys integrity and reliability. Trust develops when the client believes that the nurse will be consistent in his/her words and actions and respects the clients self-disclosure, providing confidentiality. OPTION B- it is a feeling of devotion, duty or attachment to somebody or something OPTION C- the quality of possessing and steadfastly adhering to high moral principles or professional standards OPTION D- character expected of a member of a highly trained profession SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 91 24. Building trust is important in: a. orientation phase of the relationship b. the problem identification subphase of the relationship c. all phases of the relationship d. the exploitation phase CORRECT ANSWER: A RATIONALE: It is during the orientation phase that the nurse begins to build trust with the client. It is the nurses responsibility to establish a therapeutic environment that fosters trust and understanding. The nurse should share appropriate information about himself/herself OPTION B- part of the working phase, wherein client identifies the issues or concerns causing the problem OPTION D- during this phase the nurse guides the client to examine feelings and responses and develop better coping skills and a more positive self-image; part of the working phase SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, pp 93, 97 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 psychiatric 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 CORRECT ANSWER: A RATIONALE: Confidentiality is important during nurse-client interaction. No information will be discussed outside the health care team. Only if information may be harmful for the client or others, information may be related to the other nurses and the attending physician and only information that will be helpful in assisting the client toward recovery will be provided to others. The attending psychiatrist or doctor will be informed regarding every concern of the patient, for he will be the one who will decide about certain things pertaining to the concern of the client. OPTION B- Social workers are secondary workers after the doctors. OPTION C- Nurses must know that every decision is made by the attending physician. Before doing anything about the concern of the patient, consult first. OPTION D- Asking the client what is the purpose is not necessary because you already have the information that he has not been visited by relatives for almost a month. SOURCE: Shives, Basic concepts of Psychiatric Mental Health Nursing, 5 th ed, p 133 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
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26. The past history of Camila would most probably reveal that her premorbid personality is: a. schizoid b. extrovert c. ambivert d. cycloid CORRECT ANSWER: A RATIONALE: A schizoid personality is characterized by a persistent pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings. They are aloof and indifferent, appearing emotionally cold, uncaring or unfeeling (Videbeck, 352). OPTION B- An extrovert is a person who is energized by being around other people. Extroverts tend to "fade" when alone and can easily become bored without other people around. When given the chance, an extrovert will talk with someone else rather than sit alone and think (about.com). OPTION C- Ambiverts are the ones who fall between the two extremes of introversion and extroversion, possessing some tendencies of each. They have a well-balanced personality (yahoo.com). OPTION D- A cycloid personality is a person who tends to have periods of marked swings of mood, but within normal limits. 27. Which of the following are considered the negative sign of schizophrenia? a. Anhedonia, Restricted range of feelings, Catatonia b. Delusions, hallucinations, disordered thinking c. Ambivalence, Associative looseness, hallucinations d. Alogia, Echopraxia, Ideas of reference CORRECT ANSWER: A RATIONALE: Schizophrenia has positive and negative symptoms. Positive or hard symptoms include ambivalence, associative looseness, delusions, echopraxia, flight of ideas, hallucinations, ideas of reference and preservation. Negative symptoms are alogia, anhedonia, apathy, blunted affect, catatonia, flat affect, lack of volition OPTION B- positive symptoms OPTION C- positive symptoms OPTION D- alogia is a negative symptom, while the other two are positive symptoms SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, p 276 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 CORRECT ANSWER: B RATIONALE: Interpersonal theorists suggested that schizophrenia resulted from dysfunctional relationships in early life and adolescence. Therapists also believed that schizophrenia results from dysfunctional parenting or family dynamics. OPTION C- anti social personality disorder SOURCE: Videbeck, Psychiatric Mental Health Nursing 3rd ed p 278 29. Schizophrenia is best described as a disorder characterized by: a. Disturbed relationship related to an inability to communicate and think clearly b. Severe mood swings and periods of low to high activity c. Multiple personalities, one of which is more destructive than the others d. Auditory and visual hallucinations CORRECT ANSWER: A
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RATIONALE: Schizophrenia can best be described as one of a group of psychotic reactions characterized by disturbances in an individuals relationship with people and an inability to communicate and think clearly OPTION B- Severe mood swings and periods of low to high activity are typical of bipolar disorder OPTION C- Multiple personality, which is sometimes confused with schizophrenia, is a dissociative disorder, not a psychotic illness OPTION D- Many schizophrenic patients have auditory, not visual hallucinations. Visual hallucinations are more common in organic or toxic disorder 30. Schizophrenia is a/an: a. anxiety disorder b. neurosis c. psychosis d. personality disorder CORRECT ANSWER: C RATIONALE: Psychosis is a mental disorder of organic and emotional origin, and schizophrenia is an organic disease with underlying physical brain pathology. Biologic theories of schizophrenia focus on genetic factors, neuroanatomic and neurochemical factors OPTION A- disorder in which anxiety is the most prominent feature OPTION B- mental disorder in which the symptoms are distressing to the person, reality testing is intact OPTION D- diagnosed when personality traits become inflexible and maladaptive and significantly interfere with how a person functions in society or cause the person emotional distress SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2nd ed, pp 299, 375 and Mosby, Mosbys Pocket , 4th ed, pp 93, 856 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, minimized receiving visitors at home and no longer bothers to answer telephone calls because of deterioration of her 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 part CORRECT ANSWER: C RATIONALE: It is not easy for older clients to experience a slowing of their mental and physical reactions and be unable to do anything about it or to look on younger people perform their job and assume their role. Various emotional and behavioral reactions occur as people undergo physiologic changes of the aging process. These reactions include anxiety, frustration, fear depression, intolerance, loneliness, decreased independence, decreased productivity and low self-esteem. OPTION A- experienced by ages 60-65 during retirement stage OPTION B- a defense mechanism used by elder people in trying to establish a comfortable routine after retirement SOURCE: Shives, Psychiatric-Mental Health Nursing, 5th ed, pp 593-594 32. A nursing diagnosis for Salome is: a. sensory deprivation b. social isolation c. cognitive impairment d. ego despair For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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CORRECT ANSWER: A RATIONALE: Salome is observed to be demanding and speaking louder than usual due to deterioration of her hearing. 33. The nurse will assist Salome and her daughter to plan a goal which is: 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 CORRECT ANSWER: A RATIONALE: aging necessitates adjustment to different roles, relationships, responsibilities, changes in self-image, independence and changes in physical, emotional, mental and spiritual aspects of life. OPTION B- let her adjust to the situation first before you make her participate in conversation and other social situations OPTION C- just a matter of acceptance, no action involved SOURCE: Videbeck, Psychiatric Nursing Care Plans, 7th ed, p 18 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 CORRECT ANSWER: D RATIONALE: Allowing her to take her meals alone is like depriving her of care and treatment she deserves. It will make her feel more sad and alone OPTIONS A, B, C- Communicating with the hearing impaired includes: a.) when speaking, always face the person directly as possible b.) make sure your face is as clear as possible. Locate yourself so that your face is well lighted c.) speak slowly and distinctly and use short and simple sentences SOURCE: Smeltzer, S.C. Medical-Surgical Nursing, 9 th ed, p 1588 35. Salome was fitted a hearing aid. She understood the proper use and wear of this device when she ways 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 CORRECT ANSWER: D RATIONALE: Hearing aid programming software and real ear measurement equipment allow the hearing aids to be individually customized to optimize the hearing aid fitting for the child and to assure the speech signal is delivered at the most appropriate listening levels. The goal of digital hearing aids is to deliver soft sounds at an audible level. Hearing aids should be turned on to a minimal level to avoid feedback. 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 For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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d. xenophobia CORRECT ANSWER: C RATIONALE: Agoraphobia involves intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing, or in which help might not be available if a panic attack occurred. OPTION A- Acrophobia is the fear of high places. OPTION B- Claustrophobia is the fear of closed places. OPTION D- Xenophobia is the fear of foreign places or strangers. SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 311& 313 37. Cecilia's problem is that she always sees and thinks negative hence she is always fearful. Phobia is a symptom described as: a. organic b. psychosomatic c. psychotic d. neurotic CORRECT ANSWER: D RATIONALE: pertaining to neurosis, a category of mental disorder in which the symptoms are distressing to the person, reality testing is intact, behavior does not violate gross social norms and there is no apparent organic cause. The person who is neurotic is said to be emotionally unstable OPTION A- organic disease or condition is any disease associated with detectable or observable changes in one or more body organs OPTION B- expression of an emotional conflict through physical symptoms OPTION C- not in contact with reality SOURCE: Mosby, Mosbys Pocket Dictionary,4th ed, pp 856, 900, 1049, 1050 38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her: a. communication b. cognition c. observation d. perception CORRECT ANSWER: B RATIONALE: Irrational thoughts refer to the impaired cognition of the person. It is the inability to think properly and reasonably. Cognition is the mental process characterized by knowing, thinking, learning, understanding and judging. Cognitive Therapy is a treatment of mental and emotional disorders that help a person change attitudes, perceptions and patterns of thinking OPTION A- has nothing to do with irrational thoughts OPTION C- observation is an act of watching carefully and attentively, and its not related with treatments for irrational thoughts OPTION D- perception is the conscious recognition and interpretation of sensory stimuli that serve as a basis for understanding, learning and knowing SOURCE: Mosby, Mosbys Pocket Dictionary, 4th ed, pp 258, 880, 959 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 CORRECT ANSWER: A RATIONALE: Cognitive Behavior Therapy (CBT) helps improve a persons moods and behavior by examining confused or distorted patterns of thinking. During CBT the person learns that thoughts cause feelings and moods which can influence behavior. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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40. After discharge, which of these behaviors indicate a positive result of being able to overcome her phobia? a. she read 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 goes out with a friend CORRECT ANSWER: A RATIONALE: Reading a book in the public library indicates that the client has overcome her fear of being in an open or public place, knowing that agoraphobics avoids being alone outside OPTION B- driving alone doesnt involve too much people OPTION C- family is the comfort zone of the client 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 member's data bout patients because doing so is violation of patients' rights to: a. Informed consent b. Confidentiality c. Least restrictive environment d. Civil liberty CORRECT ANSWER: B RATIONALE: Confidentiality means respecting the clients right to keep private information about his or her mental and physical health and related care OPTION A- obtained when a client is subjected to surgery, electroconvulsive treatment or the use of experimental drugs or procedures OPTION C- means that a client does not have to be hospitalized if he or she can be treated in an outpatient setting or in a group home. It also means that the client must be free of restraint or seclusion unless it is necessary OPTION D- curtails the clients right to freedom-the ability to leave the hospital when he or she wishes. SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p170 and Videbeck, Psychiatric Mental health Nursing, 3rd ed, p 169, 170 & 171 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 CORRECT ANSWER: C RATIONALE: A mentally incompetent person cannot legally consent to medical or surgical treatment. The consent must be taken from the parents or legal guardian. SOURCE: Venzon, Professional Nursing in the Philippines, 10th ed. p175 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 CORRECT ANSWER: A For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Once the order is transcribed on the physicians order sheet, the order must be countersigned by the physician within a time period described by agency policy, but many acute care hospitals require that this be done within 24 hours. th SOURCE: Kozier, Fundamentals of Nursing, 7 ed, p 346 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 test. b. Has periods of crying, frequently verbalizes fear of what diagnostic tests will reveal c. Anxiety due to the unknown d. "I'm so worried about what else they'll find wrong with me" CORRECT ANSWER: B RATIONALE: Objective Data consist of information that is measured or observed by use of the senses OPTION A- it is more of planning the care for the client OPTION C- it is assessment or analysis drawn about the subjective and objective data OPTION D- subjective datainformation obtained from what the client says th SOURCE: Kozier, Fundamentals of Nursing, 7 ed, p 332 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 individuals health team members b. Identification of patient's responses to medical diagnosis and treatment c. Patient's responses to health and illness as a total person in interaction with the environment d. Step procedures for the management of common problems CORRECT ANSWER: C RATIONALE: Nursing Care Plan is a plan based on a nursing assessment and a nursing diagnosis carried out by a nurse. It has four essential components: a.) identification of the nursing care problems b.) statement of the expected benefit to the patient c.) statement of the specific actions by the nurse that reflect the nursing approach and achieve the goals specified d.) evaluation of the patients response to nursing care and readjustment of that care as required OPTION A- source-oriented recordeach person or department makes notations in a separate section or sections in he clients chart OPTION B- progress notesprovides information about the progress a client is making toward achieving the desired outcomes OPTION D- nursing interventionpart of the nursing care plan SOURCE: Kozier, Fundamentals of Nursing, 7th ed, 330, 339 and Mosbys Pocket Dictionary, 4th ed, p 874 Situation 10 - Marie is 5 years old and described by the mother as bedwetting at night. 46. Which of the following is NOT a common cause of night bedwetting? a. deep sleep factors b. abnormal bladder development or structure problems c. infections familial and genetic factors d. drinking plenty of water before sleep CORRECT ANSWER: D RATIONALE: Bedwetting or enuresis is the involuntary urination during the day or at night into clothing or bed by a child at least 5 years of age either chronologically or developmentally (Videbeck, 465). Bed-wetting isn't caused by drinking too much before bedtime. Causes of bedwetting are, genetic factors (it tends to run in families), difficulties waking up from sleep, slower than normal development of the central nervous system--this reduces the child's ability to For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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stop the bladder from emptying at night, hormonal factors (not enough antidiuretic hormone--this hormone reduces the amount of urine made by the kidneys), urinary tract infections and inability to hold urine for a long time because of small bladder (familydoctor.org). 47. All of the following, EXCEPT one comprise the concepts of behavior therapy program: a. reward and punishment b. extinction c. learning d. placebo as a form treatment CORRECT ANSWER: D RATIONALE: Behavior therapy is based on learning theory. It focuses on modifying observable and, at least in principle, quantifiable behavior by means of systematic manipulation of the environment and variables thought to be functionally related to behavior. Behaviorists believed that problem behaviors are learned, and therefore can be eliminated or replaced by desirable behaviors through new learning experiences. Behavior therapy techniques include behavior modification and systematic desensitization, aversion therapy, modeling, operant conditioning. th SOURCE: Shives, Psychiatric-Mental health Nursing, 5 ed, p 153 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 king attitude b. matter of fact in handling the behavior c. sympathize for the child d. be lowing yet firm CORRECT ANSWER: A RATIONALE: Bed wetting is modified and/or eliminated through behavior modification. Reinforcing positive behaviors. Rewarding the desired behavior and withholding rewards for undesirable behaviors. Disciplining the child in a king attitude will intimidate the child and make her feel that everything is her fault. The child might develop a low self-esteem. Situation must be handled in a matter of fact attitude, sympathizing the child, be lowing yet firm and not being too strict and demanding. SOURCE: Shives, Basic concepts of Psychiatric-Mental Health Nursing, 5 th ed, p153 49. Which of the following is used to treat enuresis? a. Imipramine (Tofranil) b. Methylphenidate (Ritalin) c. Olanzapine (Zyprexa) d. Resperidone (Risperdal) CORRECT ANSWER: A RATIONALE: Enuresis can be treated effectively with Imipramine (Tofranil), an antidepressant with a side effect of urinary retention. OPTION B- CNS stimulant use to treat patients with ADHD OPTION C- Antipsychotic use to treat Schizophrenia OPTION D- Antipsychotic, short-term treatment of schizophrenia th SOURCE: Lippincott Williams & Wilkins, Nursing Drug Handbook, 26 ed, pp 454, 495, 490, 509 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. CORRECT ANSWER: B
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RATIONALE: Behavior modification is based on the principle that behavior that is rewarded is more likely to be repeated. Developmentally appropriate behaviors are normally rewarded with validation by a significant adult in the childs life, so modifying behavior in this manner is a standard parenting technique. SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 875-876 Situation 11 - The nurse is often met with the following situations when clients become angry and hostile. 51. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual, the nurse should: a. keep an eye contact while staring at the client b. keep his/her hands behind his/her back or in one's pocket c. fold his/her arms across his/her chest d. keep an "open" posture, e.g. Hands by sides but palms turned outwards CORRECT ANSWER: D RATIONALE: The nurse should approach the client who is angry and hostile in a nonthreatening, calm manner and non aggressive posture while maintaining personal safety OPTION A- its like challenging the behavior of the client which is not therapeutic OPTION B- it may be misinterpreted by the client that you will try to harm him/her, especially if the client is paranoid OPTION C- shows a close, aggressive posture nd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 ed, p 197 52. During the pre-interaction phase of the N-P relationship the nurse recognizes this normal INITIAL reaction to an assaultive or potentially assaultive person. a. To remain and cope with the incident b. Display empathy towards the patient c. To call for help from the other members of the team d. To stay and fight or run away CORRECT ANSWER: B RATIONALE: Approach should be nonthreatening and in a calm manner. Conveying empathy for the clients anger or frustration is important. The nurse can encourage the client to express his/her angry feelings verbally, suggesting that the client is still in control and can maintain that control. OPTION A- Respond as early as possible OPTION C-Calling for help is not an initial reaction. It is necessary if the client becomes very physically aggressive OPTION D- Always maintain control of yourself and the situation; remain calm. Your behavior provides a role model for the client and communicates that you can and will provide control. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 nd ed, pp 197, 198, 203 53. Which of the following is an accurate way of reporting and recording an incident? a. "When asked about his relationship with his father, client became anxious." b. "When asked about his relationship with his father, client clenched his jaw/teeth made a fist and turned away from the nurse." c. "When asked about his relationship with his father, client was resistant to respond." d. "When asked about his relationship with his father, his anger was suppressed." CORRECT ANSWER: B RATIONALE: Recording and reporting should be documented descriptively or completely. It should describe every action and/or behavior undertaken by the client. OPTION A, C and Dvery vague descriptions. It doesnt show the manifestations of each behavior.
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54. To encourage thought. Which of the following approaches is NOT therapeutic? a. "Why do you feel angry?" b. "When do you usually feel angry?" c. "How do you usually express anger?" d. "What situations provoke you to be angry?" CORRECT ANSWER: A RATIONALE: It is non therapeutic because it requests an explanation from the client. There is a difference between asking the client to describe what is occurring or has taken place and asking him to explain why. Usually, a why question is intimidating. In addition, the client is unlikely to know why and may become defensive trying to explain himself or herself. OPTION B, C, D- Placing event in time or sequenceputting events in proper sequence helps both the nurse and client to see them in perspective. The client may gain insight into cause-andeffect behaviour and consequences. nd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 ed, pp 117, 120 55. A patient grabs a chair and about to throw it. The nurse best responds saying. a. "Stop. Put that chair down." b. "Don't be silly." c. "Stop, the security will be here in a minute." d. "Calm down." CORRECT ANSWER: A RATIONALE: The client is about to loss control of himself. The nurse must take control of the situation and should provide directions to the client in a calm, firm voice. The nurse should tell the client that aggressive behavior is not acceptable and that the nurse is there to help the client regain control. OPTION B- Ignoring the situation and belittling the clients capabilities. OPTION C- Threatening the client can lead to a more aggressive behavior OPTION D- It is true if the client is still in the triggering phase of aggressive behavior. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 rd ed, p 184 Situation 12 - Nursing care for the elderly. 56. In planning care for a patient with Parkinson's disease, which of these nursing diagnoses should have priority? a. potential for injury b. altered nutritional state c. ineffective coping d. altered mood state CORRECT ANSWER: A RATIONALE: The client has neuromuscular impairment, such as muscle weakness, tremors, bradykinesia and musculoskeletal impairment as manifested by joint rigidity; therefore the patient is potential for having an injury. OPTION B- Secondary nursing diagnosis OPTION C- not related to parkinsons disease OPTION D- not related to parkinsons disease SOURCE: Black et al, Medical-Surgical Nursing, 7th ed, vol. 2, p 2174 57. A healthy adaptation to aging is primarily related to an individual. a. Number of accomplishments b. Ability to avoid interpersonal conflict c. Physical health throughout life d. Personality development in his life span CORRECT ANSWER: C
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RATIONALE: Physical health also can influence how a person responds to psychosocial stress and illness. The healthier a person is, the better he or she can cope with stress and illness. OTHER OPTIONSsecondary reasons for healthy adaptation rd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 ed, p132 58. The frequent use of the older client's name by the nurse is MOST effective in alleviating which of the following responses to old age? a. Loneliness b. Suspicion c. Grief d. Confusion CORRECT ANSWER: D RATIONALE: Clients with delirium cannot focus, sustain or shift attention effectively, and there is impaired recent and immediate memory. To manage clients confusion, the nurse provides orienting cues when talking with clients, such as calling them by name and referring to the time of the day or expected activity. OPTION A- a lot of things causes loneliness to an elderly person, such as death of a spouse or relative, pain, certain times of the day or night. The role f the nurse is to let the client verbalize feelings and grow from the experience OPTION B- loss of sight or hearing, sensory deprivation and physical impairment often contribute to suspiciousness in elderly persons. Aging persons may feel that others are talking about them or conspiring against them. Nursing care focuses on establishing rapport; enhancing self-esteem; decreasing fears and suspicions; utilizing listening and acceptance OPTION C- loss of a spouse or loved one is the most stressful event across all ages. The role of the nurse as the facilitator in grief work is to help the client accept the loss, express feelings about the loss and learn and grow from the experience. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 nd ed, p517; Shives, Psychiatric Mental th Health Nursing, 5 ed, pp 288, 597, 598, 604 59. An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another bed when she returns. The MOST appropriate action the nurse would take is to: a. Assign client to a single room b. Leave a light on all night c. Remind client to call the nurse when she wants to get up d. put side rails on the bed CORRECT ANSWER: A RATIONALE: It may be difficult for client to be with other patients and engage them in a conversation because they are easily distracted and display marked attention deficits. Memory is often impaired. Assigning the client to a single room will help prevent the client from wandering; promote safety and decrease confusion. OPTION B- comes after assigning the client into a single room. It also promotes safety OPTION C- it fosters dependency to the nurse which is not therapeutic OPTION D- clients who are confused have errors in perception of sensory stimuli. They might mistake some objects into something dreadful and although putting the side rails up can promote safety, patients need to be oriented first about why there is a need for side rails because they might think that they are being held captive. It often becomes the object of the clients projected fear. SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 578, 579 60. An elderly who has lots of regrets, unhappy and miserable is experiencing: a. Crisis b. Despair c. Loss d. Ambivalence CORRECT ANSWER: B For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: If an individual does not develop as sense of satisfaction with life and its meaning and believe that life is not fulfilling and unsuccessful, that person is undergoing despair. They cant adapt to the changing environment and cant overcome what has been referred to as season of losses. OPTION A- Occurs when a person, family or group is inadequately prepared to handle the event or situation. Normal coping methods fail, tension rises and feelings of anxiety, fear, guilt, anger, shame and helplessness may occur. OPTION C- A person experiences a feeling of loss when a spouse or relative dies OPTION D- Presence of two opposing ideas, emotions, feelings at the same time. SOURCE: Shives, Basic concepts of Psychiatric Mental Health Nursing, 5 th ed, pp 161, 596 Situation 13 Graciela, 1 year old is admitted in the hospital from the emergency room with a fracture of the left femur due to a fall down a flight of stairs. Graciela is placed oh Bryant's traction. 61. While on Bryant's traction, which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction? a. Graciela's buttocks are resting on the bed b. The traction weights are hanging 10 inches above the floor c. Graciela's legs are suspended at a 90 degree angle to her trunk d. The traction ropes move freely through the pulley CORRECT ANSWER: A RATIONALE: Bryants traction is a type of running traction in which the pull is only in one direction. Skin traction is applied to the legs, which are flexed at a 90-degree angle at hips. The childs trunk provides counter traction. Buttocks are raised slightly off the bed. Traction weights are hanging 10 in above the floor and ropes move freely through the pulley. SOURCE: Hockenberry, Wongs Essential of Pediatric Nursing, 7th ed, p 1161 62. The nurse notes that the fall might also cause a possible head injury- She will be observed for signs of increased intracranial pressure which include: a. Narrowing of the pulse pressure b. Vomiting c. Periorbital edema d. A positive Kernig's sign CORRECT ANSWER: B RATIONALE: Manifestations of increased ICP are subtle and diligent observation for changes in the clients condition is necessary. Clinical manifestations include, any alteration in LOC, changes in speech, papillary reactivity headache, nausea, vomiting, diplopia (blurred or double vision), papilledema,increased systolic blood pressure with widened pulse pressure and bradycardia late response and indicates severe increased ICP OPTION A- Increased systolic blood pressure with widened pulse pressure not narrowed OPTION C- There is papilledema instead of periorbital edema, due to increased tension in the skull that is transmitted to the optic nerve OPTION D- Kernigs sign is a diagnostic sign for meningitis marked by loss of the ability of a supine patient to completely straighten the leg when it is full flexed at the knee and hip th SOURCE: Black et al, Medical- Surgical Nursing, 7 ed, pp 2191-2192 63. Graciela is assessed to have no head injury. The Bryant's traction is removed. A plaster of paris is applied to his spica. Which of these finding as a concern of immediate attention that must be reported to the physician immediately? a. Graciela is scratching the cast over her abdomen b. The toes of Graciela's left foot blanch when the nurse applies pressure on them c. Graciela's cast is still damp d. The nurse is unable to insert a finger under the edge of Graciela's cast on her left foot CORRECT ANSWER: D
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RATIONALE: If the nurse is unable to insert a finger under the patients cast it means the client is suffering from compartment syndrome, brought about by excessive swelling that constricts the enclosed soft tissue OPTION AOPTION B- Normal capillary refill is about 2-3 seconds. Blanching of the foot when pressure is applied is normal. OPTION C- As the water from newly applied cast eventually evaporates, a mature cast of full strength develops. Plaster casts set quickly but take hours to days to dry completely SOURCE: Black et al, Medical- Surgical Nursing, 7th ed, pp 631, 633-634 64. Part of discharge plan is for the nurse to give instructions about the care of Graciela's cast to the mother. Which of statement by the mother indicates a need for further instructions? a. The cast may feel warm as the cast dries. b. If the cast becomes wet, a blow drier set on the cool setting may be used to dry cast. c. A small amount of white shoe polish can touch up a soiled white cast. d. I can use lotion or powder around the cast edges to relieve itching. CORRECT ANSWER: D RATIONALE: The mother must be instructed not to use lotion or powders on the skin around the cast edges or inside the cast, since lotions and powders can become sticky, caked and cause skin irritation. OPTION A- Feeling of warmth is normal when the cast is starting to dry up. OPTION B- If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. OPTION C- White shoe polish is used to touch up the soiled edges of a white cast. SOURCE: Silvestri, Saunders Comprehensive Review for the NCLEX-RN, 3rd ed, p 1004 65. The nurse counsels Graciela's mother ways to safeguard safety while providing opportunities of Graciela to develop a sense of: a. Trust b. Initiative c. Industry d. Autonomy CORRECT ANSWER: D RATIONALE: STAGE Infancy (0-1 yrs) >Trust vs. Mistrust
NEGATIVE EFECT General difficulties relating to people effectively; trust-fear conflict Toddlerhood (1 -3 yrs) Sense of self-control and Independence-fear >Autonomy vs. Shame & adequacy; free will conflict; sever feelings of selfDoubt doubt Preschool (3-6 yrs) Ability to initiate ones Aggression-fear conflict; >Initiative vs. Guilt own activities; sense of purpose sense of inadequacy or guilt School Age (6-12 yrs) Competence; ability to Sense of inferiority; >Industry v. Inferiority work difficulty learning and working SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 30
POSITIVE EFFECT Sound basis for relating to other people
Situation 14 - Jolina is an 18 year old beginning college student. Her mother observed that she is having problems relating with her friends. She is undecided about her future. She has lost insight, lost interest in anything and complained and complained of constant tiredness. 66. Jolina is out on antidepressant drugs. These drugs act on the brain chemistry, therefore they would be useful in which type of depression? a. exogenous depression b. neurotic depression For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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c. endogenous depression d. psychotic depression CORRECT ANSWER: B RATIONALE: Neurotic depression is any state of depression that is not psychotic. Neurotic disorders are mental disorders without any demonstrable organic basis in which the patient may have considerable insight and has unimpaired reality testing, in that he usually does not confuse his morbid subjective experiences and fantasies with external reality. OPTION A- Exogenous depression is an inappropriate state of depression that is precipitated by events in the person's life. OPTION C- Endogenous depression is a severe form of depression usually characterized by insomnia, weight loss, and inability to experience pleasure, thought to be of internal origin and not influenced by external events. Also called melancholia. OPTION D- Psychotic depression is a state of depression so severe that the person loses contact with reality and suffers a variety of functional impairments. 67. This is a tricyclic antidepressant drug: a. Venlafaxine (Effexor) c. Setraline (Zoloft) b. Flouxetine (Prozac) d. Imipramine (Tofranil) CORRECT ANSWER: D RATIONALE: TCAs are thought to act primarily by blocking the reuptake of norepinephrine and to a lesser degree, serotonin. OPTION A- it is a novel antidepressant. Venlafaxine blocks the reuptake of both norepinephrine and serotonin OPTION B- it is a SSRI that preferentially block the reuptake and thus the destruction of serotonin, with little or no effect on the other monoamine transmitters OPTION C- still a SSRI. SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 69, 72-73 68. After one week of antidepressant medication, Jolina still manifests depression. The nurse evaluates this as; a. Unusual because action of antidepressant drug is immediate b. Unexpected because therapeutic effectiveness takes within a few days c. Expected because therapeutic effectiveness takes 2-4 weeks d. Ineffective result because perhaps the drug's dosage is inadequate CORRECT ANSWER: C RATIONALE: One drawback to the use of antidepressant medication is that the client may have to take the antidepressant agents for 1-3 weeks before improvement is noticed. OPTION A- antidepressants doesnt take effect immediately OPTION B- it is expected because antidepressants take effect 2-3 weeks after ingestion OPTION D- it is not ineffective th SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4 ed, p 470 69. Jolina continues to verbalize feeling sad and hopeless. She is not mixing well with other clients. One of the nurse's important consideration for Jolina initially is to: a. Formulate a structured schedule so she is able to channel her energies externally b. Let her alone until she feels like mingling with others c. Encourage her to join socialization hour so she will start to relate with others d. Encourage her to join group therapy with other patients CORRECT ANSWER: C RATIONALE: Often clients decline to engage in activities because they are too fatigued or have no interest. The nurse can validate these feelings yet still promote participation. The nurse can let
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clients know they must become more active to feel better rather than waiting passively for improvement. OPTION A- Not applicable for depressed client OPTION B- The first priority is to determine whether a client is suicidal. Depressed client are more likely to be suicidal. Suicide precautions must be instituted. The client must not be left alone. OPTION D- Group therapy is indicated for schizophrenic clients and personality disorder rd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 ed, pp 319, 322 70. During the predischarge conference, the nurse suggests vocational guidance because it should help Jolina to: a. Find a good job b. Make some decision about her future c. Realistically assess her assets and limitations d. to solve her own problems CORRECT ANSWER: C RATIONALE: Vocational guidance aims to determine clients interests and abilities and matching them with vocational choices. OPTION A- comes after the client has assess her assets and limitations OPTION B- goal of psychotherapy OPTION D- still with psychotherapy rd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 ed, p 78 Situation 15 - Group Approach in Nursing. 71. Membership drop out generally occurs in group therapy after a member: a. Accomplishes his goal in joining the group b. Discovers that his feelings are shared by the group members c. Monopolizes the group d. Discusses personal concerns with group members CORRECT ANSWER: C RATIONALE: A person who monopolizes the group uses his compulsive speech as an attempt to deal with anxiety. As the client sees group tension grow, the clients level of anxiety rises and the clients tendency to speak increases even more. Therefore no one else gets the chance to be heard, and other group members eventually lose interest and begin to withdraw. Also clients who experiences feelings of frustration in the group drops out from it. OPTIONS A, B and D- shows that the client is interested in the group, happy to be in the group, fulfilled as a person and has overcome her undesirable behaviors. SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 943 72. Which of the following questions illustrates the group role of encourager? a. What were you saying? b. Who wants to respond next? c. Where do you go from here? d. Why haven't we heard from you? CORRECT ANSWER: B RATIONALE: Asking who wants to respond next is encouraging client to express self with out forcing the client to do it. OPTION A- Its like forcing the client to participate. Not therapeutic OPTION C- Testing the client forces the client to respond OPTION D- Why questions are intimidating and makes client defensive. rd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 ed, p 115 73. The goal of remotivation therapy is to facilitate: a. Insight For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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b. Productivity c. Socialization d. Intimacy CORRECT ANSWER: B RATIONALE: Remotivation therapy resocializes regressed and apathetic clients, reawakens interest in their environment, increases participants sense of reality and productivity and realizes more objective self image. OPTION C- is true in reminiscing therapy SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, p 906 74. The treatment of the family as a unit is based on the belief that the family: a. is a social system and all the members are interrelated components of that system b. as a unit of society needs the opportunity to change its own destiny c. who has therapy together will tend to remain together d. is "contaminated" by the presence of deviant member and all members need treatment CORRECT ANSWER: A RATIONALE: Family is a group related by heredity, such as parents, children and siblings. It is a social unit and all members are interrelated with each other. Although one family member usually is identified initially as the one who has problems and needs help, it often becomes evident through the therapeutic process that other family members also have emotional problems and difficulties. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 rd ed, p 63 75. The working phase in therapy group is usually characterized by which of the following? a. Caution b. Cohesiveness c. Confusion d. Competition CORRECT ANSWER: B RATIONALE: During the working phase, several group characteristics may be seen. Group cohesiveness is the degree to which members work together cooperatively to accomplish the purpose. Cohesiveness is a desirable group characteristic and is associated with positive group outcomes. Cohesiveness is evidenced when members value one anothers contributions to the group. OPTION D- Some groups exhibit competition, or rivalry, among members. This may positively affect the outcome of the group if the competition leads to compromise, improved group performance. Many times, however, competition can be destructive for the group. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 rd ed, p 62 Situation 16 It is the nurses primary responsibility to ensure a safe environment for the patients at the Psychiatry Ward. 76. All of the following concepts are true, EXCEPT: a. Hostility is destructive b. Frustration develops in response to unmeet needs, wants and desires c. Anger is incompatible with love d. Aggression can be expressed in a constructive as well as destructive manner CORRECT ANSWER: D RATIONALE: Aggression is a threatening behavior or action. It is a behavior in which a person attacks or injures another person or involves destruction of property. It is expressed in a destructive manner. OPTION A- Hostility is an emotion expressed through verbal abuse or threatening behavior. It intends to intimidate or cause emotional harm to another. It can lead to aggression. OPTION B- When goals are thwarted or desires are unsatisfied, frustration develops. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION C- Anger is the opposite of love. They cant go together due to basic differences. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 nd ed, p193 77. Carlo is acting out hostile and aggressive feelings such as yelling, agitated, threatening, clenched fist, threatening gestures, hostility. The MOST effective way to deal with Carlos behavior is initially to: a. set limits on the behavior by verbal command b. administer prn tranquilizer c. remove the harmful objects from the room d. restrain the patient and place him in the Isolation Room CORRECT ANSWER: A RATIONALE: Carlo is in the escalating phase of aggression. The nurse must take control of the situation. The nurse should provide directions to the client in a calm, firm voice and tell the client that aggressive behavior is not acceptable OPTION B- prn tranquilizers should be offered if ordered by the physician in the triggering phase OPTION C- removing of harmful objects is not necessary in the escalating phase OPTION D- Restraining the patient is required in the crisis phase, wherein client loses control emotionally and physically, throwing objects, kicking, hitting, screaming, etc. The staff must take charge of the situation for the safety of the client, staff and other clients SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 rd ed, p 196 78. Mrs. Dizon was visiting her son at the Psychiatry Ward. Which of the following items will the nurse not allow to be brought inside the ward? a. string rosary bracelet b. box of cake c. bottle of coke d. rubber shoes CORRECT ANSWER: C RATIONALE: When the patient becomes physically aggressive, he/she can broke the bottle of coke and injure him/her own self, the staff and even other patients. The environment must be free from potentially harmful objects. Promote safety of patients, other clients and the staff. OPTION A- A bracelet is too small to cause harm OPTION B- No harm at all OPTION D- Although it is painful being hit by a rubber shoes, but the damage is not fatal. 79. Which of the following will probably be most therapeutic for a patient on a behavioral modification ward? a. if the client is agitated, discuss the feelings especially anger b. insist to stop obscene language by verbal reprimand c. give client support and positive feedback for controlling use of obscene language d. provide a punching bag as an alternative to express upset emotions CORRECT ANSWER: C RATIONALE: Behavior Modification is a method of attempting to strengthen a desired behavior or response by reinforcement, either positive or negative. The group leader provides positive reinforcement by giving the client attention and positive feedback. Negative reinforcement involves removing a stimulus immediately after a behavior occurs. OPTION A- Although making the client verbalize his/her feelings is therapeutic, but the focus of behavior modification is reinforcing the desired behavior. OPTION B- Insisting the client to stop by verbal reprimand can stir up argument and promote more aggressive behavior OPTION D- Providing a punching bag can help to reduce upset emotions but you are not confronting the client directly. Nurses must be firm and direct in modifying the aggressive behavior SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3rd ed, p 58
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80. Which of the following must be considered while planning activities for the depressed patient? a. activities which require exertion of energy b. challenging activities to get him out of his depression c. reading materials to divert his thoughts d. variety of unstructured activities CORRECT ANSWER: A RATIONALE: In dealing with depressed clients, one must consider the clients energy level. Activities that require exertion of energy is best for depressed clients because the more energy the task requires, the less energy the client will have to engage in hostile, aggressive behavior and self inflicted harm OPTIONS B & CDepressed clients have impaired cognition and inability to concentrate. They will not be able to comprehend or think well if you will engage them in challenging activities and make them read. OPTION D- They should be involved in simple tasks to enhance their self-esteem and encourage concentration. Unstructured activities could bring about more impaired cognition and decrease concentration th SOURCE: Shives, Basic concepts of Psychiatric-Mental Health Nursing, 5 ed, pp 302, 304, 305 Situation 17 - Nurse's in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse. 81. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is: a. a common problem brought about by socioeconomic deprivation b. caused by multiplicity of factors c. predisposed by an inability to develop appropriate psychological resources to manage developmental stresses d. due to biochemical factors CORRECT ANSWER: B RATIONALE: The exact cause of drug use, dependence and addiction are not known, but various factors are thought to contribute to the development of substance-related disorders. OPTION A- People risk addiction when they lack other capacities, choices, interests or sources of attachment to something outside themselves. OPTION C- Some people use prohibited drugs and even alcohol as a coping mechanism or to relieve stress and tension, increase feelings of power and decrease psychological pain OPTION D- All drugs of abuse have one thing in commonthe stimulation of dopamine secretion. Dopamine is responsible for integration of emotions and thoughts and involved in decision making nd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 ed p411; Shives, Basic concepts of th Psychiatric-Mental Health Nursing, 5 ed, pp 427-428 82. Being in contact with reality and the environment is a function of the: a. conscience b. ego c. id d. super ego CORRECT ANSWER: B RATIONALE: In Freud's theory, the ego mediates among the id, the super-ego and the external world. Its task is to find a balance between primitive drives, morals, and reality while satisfying the id and superego. It is the part of the mind which contains the consciousness. OPTION A- Conscience is the awareness of a moral or ethical aspect of ones conduct together with the urge to prefer right over wrong. OPTION C-The id stands in direct opposition to the super-ego. It is dominated by the pleasure principle. It is responsible for our basic drives such as food, sex and aggressive impulses, and demands immediate satisfaction. It is amoral and egocentric, ruled by the pleasure-pain principle. It does not take social norms into account when 'thinking' or 'acting'. The id is the primal, or beastlike, part of the brain. For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION D- The super-ego acts as the conscience, maintaining our sense of morality and the prohibition of taboos. 83. Substance abuse is different from substance dependence in the sense that substance dependence: a. includes characteristics of adverse consequences and repeated use b. requires long term treatment in a hospital based program c. produces less severe symptoms than that of abuse d. includes characteristics of tolerance and withdrawal CORRECT ANSWER: D RATIONALE: Toleranceincreasing amount of the substance is required to achieve the desired effect or there is a markedly diminished effect with repeated use of the same dose. Withdrawalthe person following reduction or cessation of intake of the substance experiences a substance-specific syndrome. Such withdrawal signs could be physiologic or psychologic SOURCE: Sia, Psychiatric Nursing, p361 84. During the detoxification stage, it is a priority for the nurse to: a. teach skills to recognize and respond to health threatening situations b. increase the client's awareness of unsatisfactory protective behaviors c. implement behavior modification d. promote homeostasis and minimize the client's withdrawal symptoms CORRECT ANSWER: D RATIONALE: The first and most critical purpose of alcohol treatment or removal of the harmful physical and emotional effects of alcohol usage is to complete process of alcohol detoxification safely and with as few painful and dangerous withdrawal symptoms as possible. There is a very high element of danger that can occur during the process of detoxification when those alcohol dependents are made to stop using alcohol. It can result in dangerous side effects during the alcohol withdrawal process. These side effects can be serious enough to cause even death. For this reason, alcohol detoxification should never be attempted alone and be done by medical professionals. SOURCE: www.detox.org.il/alcohol-detoxification.asp 85. Commonly known as "shabu" is: a. Cannabis Sativa b. Lysergic add diethylamide c. Methylenedioxy methamphetamine d. Methamphetamine hydrochloride CORRECT ANSWER: D RATIONALE: Methamphetamine hydrochloride is the scientific name of shabu. OPTION A is commonly called marijuana. OPTION B is the most widely used hallucinogenic drug. Hallucinogenic drugs cause a person to see vivid images, hear sounds, and feel sensations that seem real but are not. LSD is also called acid, doses, hits, Microdot, sugar cubes, tabs, and trips. It is odorless and colorless and has a slightly bitter taste. It can be obtained as a colored tablet, clear liquid, or thin square of gelatin (window panes) or on blotter paper. Most often, LSD is licked off blotter paper or taken by mouth. However, the gelatin and liquid forms can be put in the eyes. OPTION C is most commonly known today by the street name ecstasy (often abbreviated to E, X, or XTC), is a semisynthetic member of the phenethylamine class of psychoactive drugs. The drug is well known for its ability to produce feelings of overwhelming euphoria, intimacy, and connectedness with others, and is commonly associated with the rave culture and its related genres of music. Situation 18 - It is common that client ask the nurse personal questions.
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86. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship? a. Orientation phase b. Working phase c. Pre-interaction phase d. Termination phase CORRECT ANSWER: B RATIONALE: Describing, and often re-experiencing in the working phase, old conflicts generally awakens high levels of anxiety in the client. Clients may use various defenses against anxiety and displace their feelings onto the nurse. Therefore during the working phase, intense emotions such as anxiety, anger, self-hate, and hopelessness may surface. Behaviors such as acting out anger inappropriately withdrawing, intellectualizing, manipulating and denying are to be expected. Nurses are often manipulated by client to change roles. This keeps the focus off the client and prevents the building of a relationship. Testing and manipulating behaviors of clients during working phase, challenges the nurse to stay focused and not to react or be distracted. OPTION A- During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies clients problems; and clarifies expectations OPTION C- Pre interaction is where the nurse or nursing students together with their instructors, discusses the common concerns regarding the exposure to a psychiatric unit. It usually revolves around planning the first interaction with the client. OPTION D- Final step of the therapeutic relationship. The nurse terminates the relationship when the mutually agreed-on goals are reached, the client is transferred or discharged, or the nurse has finished the clinical rotation. As separation occurs, it is common for the client to exhibit regressive behavior, demonstrate hostility or experience sadness. SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed, pp 232, 235, 247 and Shives, Psychiatric-Mental Health Nursing, 5th ed, p 139 87. The client asks for the nurse's telephone number, which of these responses is NOT appropriate? a. "it is confidential I just don't give it to anyone." b. "What would you do with my number if I give it to you?" c. "If I say no to your request, what are your thoughts about it?" d. "Are you asking for an official number of the hospital/clinic for your reference?" CORRECT ANSWER: A RATIONALE: Rejectingthis technique closes the possibility of exploration of the clients feelings. In turn, the client may feel personally rejected along with his/her ideas OPTION B- Exploringhelps examine the issue more fully. Promotes further discussion OPTION C- Encouraging expressionencourages the client to make his/her own appraisal rather than accepting the opinion of others OPTION D-Seeking Clarificationhelps the nurse to avoid making assumptions. It helps client to express thoughts, feelings and ideas more clearly nd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 ed, pp 116, 117, 120 88. When the client asks about the family of the nurse the MOST appropriate response is: a. Avoid the situation and redirect the client's attention b. Give a brief and simple response and focus on the client c. "Why don't we talk about your family instead?" d. Introduce another topic like the client's interests CORRECT ANSWER: B RATIONALE: Answer directly and briefly and then go back to the topic you were discussing. Nurses should show understanding and acceptance to the client and at the same time setting limits to the behavior. Therapeutic relationship should be client-centered. OPTION A- Rejectingthis technique closes the possibility of exploration of the clients feelings. In turn, the client may feel personally rejected along with his/her ideas
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OPTION C- Requesting an explanationthis question is intimidating and client may become defensive OPTION D- Introduction of unrelated topicthe nurse takes the initiative for the interaction away from the client SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 nd ed, p 120 89. When the nurse is asked a personal question, which of these reactions indicates a need for her to introspect? a. The client is simply curious b. His/her right to privacy is being intruded c. The client knows no other way to begin a conversation d. Some patients are like children in seeking recognition from the nurse CORRECT ANSWER: D RATIONALE: The nurse must understand that some clients who are mentally ill feel rejected, seeks attention and need to be loved and cared for. Sometimes they are like children who constantly seek attention and be recognized. What they havent experienced from their own family, they try to get it from the nurse and other people. They need to feel that somebody cares for them. OPTION A- Mentally ill clients are not curious OPTION B- The nurse has the option whether to answer or not answer the clients question. If she chooses to answer then it cant be said that her right to privacy has been intruded. OPTION C- It could be that clients know no other way to start a conversation with the nurse 90. It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate response is: a. "Are you bored?" b. "It is 10 o'clock." c. "Why do you ask?" d. "Guess, what time is it?" CORRECT ANSWER: B RATIONALE: Giving Informationinforming the client of facts increases his or her knowledge about a topic. The nurse is functioning as a resource person. Giving information also builds trust with the client. OPTION A- Interpreting--the clients thoughts and feelings are his or her own, not to be interpreted by the nurse or for hidden meaning. Only the client can identify or confirm the presence of feelings OPTION C- Requesting an explanationwhy question is intimidating OPTION D- Indicating the existence of an external sourceimplies that the client was made or compelled to think in a certain way SOURCE: Videbeck, Psychiatric Mental Health Nursing, 3 rd ed, pp 112-115 Situation 19 Jim, age 25, recalled that his problem began around age 15 or 16. He would count pencils in a mug over and over with the thought that stopping could result in something bad happening. 91. There are many things Jim seems he has to do to keep him from getting: a. confused b. suspicious c. excited d. anxious CORRECT ANSWER: D RATIONALE: Jim has an obsessive-compulsive disorder. OCD can be manifested through many behaviors that are repetitive, meaningless and difficult to conquer. The person understands that these rituals are unusual and unreasonable but feels forced to perform them to alleviate anxiety or to prevent terrible thoughts.
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OPTION A- defined as having impaired psychological capacity to the extent of being forgetful and no longer able to carry out simple everyday task OPTION B- believing that something is wrong. A characteristic of paranoid PD. OPTION C- feeling or condition of lively enjoyment or pleasant anticipation SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 nd ed, p 285 92. He has to change clothes 20 times before work, chew each bite he eats 24 times and go up and down the stairs four to five times before it feels right. He is demonstrating: a. ideas of reference b. denial and projection c. obsession and compulsion d. rationalization and over reaction CORRECT ANSWER: C RATIONALE: Obsession is a recurrent, persistent, unpleasant and unwanted thoughts, images or impulses that cause marked anxiety and interfere with interpersonal, social or occupational functions. Compulsion on the other hand is a ritualistic or repetitive behavior or mental acts that a person carries out continuously in an attempt to neutralize anxiety. 285 OPTION A- Ideas if reference is the clients in accurate interpretation that general events are personally directed to him/her 162 OPTION B- Denial is a defense mechanism that shows failure to admit reality of a situation; Projection is the unconscious blaming of unacceptable thoughts or inclinations on an external object. OPTION D- Rationalization is the act of excusing own behavior to avoid guilt, responsibility, conflict, anxiety or loss of self-respect; Over reaction nd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 ed, pp 51, 162, 285 93. The objective of nursing care for Jim is to develop or increase feelings of: a. self-mastery b. self actualization c. self worth d. self-determination CORRECT ANSWER: C RATIONALE: People with OCD have low self-esteem due to feelings of powerlessness to control the obsessions and compulsions. It is important for the nurse to offer support and encouragement to the client by validating the overwhelming feelings the client experiences while indicating the belief that the client can make needed changes and regain a sense of self control. OPTION A- More like self-actualization OPTION B- Self-actualized are those persons who have achieved all the needs of the hierarchy and have developed his/her fullest potential in life. OPTION D- Self-determination is having a firm purpose, will or intention. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 nd ed, p 56, 267 94. All of these are therapeutic interventions, EXCEPT: a. impose limits every time the behaviour becomes repetitive b. establish a routine for him c. assign task that can be done repetitively d. facilitate self-expression CORRECT ANSWER: C RATIONALE: The goal of treatment for people with OCD is response prevention, which focuses on delaying or avoiding performance of rituals. The person learns to tolerate the anxiety and to recognize that it will recede without the disastrous imagined consequences. The client will spend less time performing rituals. OPTION A- Imposing limits can help the client gain self-control and avoid spending time doing the rituals. Clients are engage in a behavior therapy that targets response prevention, delaying or avoiding performance of rituals For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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OPTION B- To complete tasks efficiently, the client initially may need additional time to allow for rituals. It is important for the nurse not to interrupt or attempt to stop the ritual because doing so will escalate the clients anxiety. The nurse and client can agree on a plan to limit the time spent performing rituals. When the client has completed the ritual or the time allotted has passed, the client then must engage in the expected activity. At home, the client can continue to follow a daily routine that helps him/her to stay on tasks and accomplish activities and responsibilities. OPTION D- The nurse encourages the client to talk about the feelings and to describe them in as much detail as the client tolerate. Because many clients try to hide their rituals and to keep obsessions secret. Doing so can begin to relieve some of the burden the client has been keeping to himself/herself. nd SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 ed, p 265, 268 95. Jim is aware of his behavior, yet realizes that it is very disturbing to him. This is a pattern of: a. personality disorder b. psychosis c. neurosis d. habitual disorder CORRECT ANSWER: A RATIONALE: Personality disorder is described as a non psychotic illness characterized by maladaptive behavior, which the person uses to fulfill his/her needs and brings satisfaction to self. The person with personality disorder is in contact with reality but has difficulty dealing with it. OPTION B- Psychosis displays symptoms of delusions, hallucinations and disordered thinking. OPTION C- Neurosis is a mental disorder in which the symptoms are distressing to the person, reality testing is intact. OPTION D- No such thing as habitual disorder. SOURCE: Shives, Basic concepts of Psychiatric Mental Health Disorder, 5th ed, p 362; Videbeck, Psychiatric Mental Health Nursing, 2nd ed, p 298 Situation 20 - The abuse of dangerous drug is a serious public health concern that nurses need to address 96. The nurse should recognize that the unit primarily responsible for education and awareness of the members of the family on the ill effects of dangerous drugs is the: a. law enforcement agencies b. school c. church d. family CORRECT ANSWER: D RATIONALE: A family is the primary unit of our society and health education takes place in the home. Learning about health results from a wide variety of contacts between members of the family. Nurses educate the family, and the family educates its own family members after learning some information from the health teaching of the nurse. OPTION A- they are more concerned about the rules and regulations of our country. They are secondary unit responsible for education OPTION B- secondary OPTION C- secondary SOURCE: Reyala et al, Community Health Nursing Services in the Philippines, 9th ed, p 308 97. A drug dependent utilizes these defense mechanisms, EXCEPT: a. sublimation b. rationalization c. projection d. denial CORRECT ANSWER: A For more nursing reviewers, contact ebookwholeseller@yahoo.com 09394837323
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RATIONALE: Sublimation is the unconscious process of substituting constructive and socially acceptable activities for strong impulses that are not acceptable in their original form. OPTION B- Used to falsify an experience by giving a contrived socially acceptable and logical explanation to justify an unpleasant experience or questionable behavior OPTION C- Attributing an unconscious impulse, attitude or behavior to someone else OPTION D- Escaping unpleasant realities by ignoring their existence SOURCE: Varcarolis, Foundations of Psychiatric Mental Health Nursing, 4th ed p 755 98. This drug produces mirthfulness, fantasies, flight of ideas, loss of train of thought, distortion of size, distance and time, and "bloodshot eyes", due to dilated pupils. a. Opiates b. LSD c. Marijuana d. Heroin CORRECT ANSWER: B RATIONALE: LSD or lysergic acid diethylamide is a hallucinogen. It is quite unpredictable. One experience with them may be good but the next may be disastrous. They are dangerous because they can lead to panic, paranoia, flashbacks or death. Physiologic symptoms include increased pulse rate, blood pressure and temperature, dilated pupils, tremors of hands and feet. Effects on the central nervous system include an increased distortion of senses, loss of the ability to separate fact from fantasy, ambivalence and the inability to reason logically. OPTION A- Opiates are narcotic drugs that induce sleep, suppress coughing and alleviate pain. User becomes passive and listless as the opiates depress the respiratory center of the brain, causing shallow respirations. The person also experiences reduced feelings of hunger, thirst, pain and sexual desire. OPTION C- Known as Cannabis Sativa. It can act as a stimulant or depressant and is often considered to be a mild hallucinogen with some sedative properties. General physiologic symptoms include increased appetite, lowered body temperature, depression, drowsiness, unsteady gait, inability to think clearly, excitement, reduced coordination and reflexes, and impaired judgment. OPTION D- Heroin is an opiate. Physical symptoms include decreased respiration. It causes respiratory depression-arrest SOURCE: Shives, Psychiatric-Mental Health Nursing, 5th ed, pp 434-436 and Varcarolis, Foundations of Mental Health Nursing, 4th ed, p 760 99. The nurse evaluates that-.her health teaching to a group of high school boys is effective if these students recognize which of the following dangers of inhalant abuse. a. Sudden death from cardiac or respiratory depression b. Danger of acquiring hepatitis or AIDS c. Experience of "blackout" d. Psychological dependence after prolonged use CORRECT ANSWER: A RATIONALE: Inhalants are diverse group of drugs. Inhalant intoxication involves dizziness, nystagmus, lack of coordination, slurred speech, unsteady gait, tremor, muscle weakness, and blurred vision. Acute toxicity causes anoxia, respiratory depression, vagal stimulation and dysrythmias. Death may occur from bronchospasm, cardiac arrest, suffocation or aspiration of the compound or vomitus. OPTION B- Danger of acquiring hepatitis or AIDS is often associated with injectables OPTION C- Alcohol is a central nervous system depressant. Initially the effects are relaxation and loss of inhibitions. With intoxication, there is slurred speech, unsteady gait, impaired concentration, memory and judgment. The person who is intoxicated may experience a blackout, which is an episode during which the person continues to function but has no conscious awareness of his /her behavior at the time or any later memory of the behavior. SOURCE: Videbeck, Psychiatric Mental Health Nursing, 2 nd ed, pp 412, 417
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100. The mother of a drug dependent would never consider referring her son to a drug rehabilitation agency because she fears her son might just becomes worse while relating with other drugs users. The mother's behavior can be described as: a. Unhelpful b. Codependent c. Caretaking d. Supportive CORRECT ANSWER: A RATIONALE: Mother displays unwillingness in providing assistance and support to her son in getting well OPTION B- a situation in which a person such as the partner of an alcoholic or parent of a drugaddicted child needs to feel needed by the other person OPTION C- giving care or emotional support to another OPTION D- being understanding, giving moral or emotional support SOURCE: Encarta Dictionaries
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For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com

For more nursing reviewers, contact ebookwholeseller@yahoo.com