NURSING PRACTICE V - CARE OF CLIENTS (PART C)

INSTRUCTION: Select the correct answer for each of the allowing questions, Mark only one answer for
each item by shading the how corresponding to the letter of your choice on the answer the provided
STRICTLY NO ERASURES ALLOWED.
SITUATIONAL

Situation - Eighteen year old Chimeya and her father came to clinic for possible depression. She has
a number of fears of getting sick and dying from COVID 19. She eats less and sleeps restlessly. She
has not taken a bath for a week, "always talks about her missing mother who died due to COVID 19
infection.

1. Working with a depressed Chimeya, the nurse should understand that depression is MOST
directly related to a person's _____.
A. remembering her childhood
B. stage in life
C. having experienced a sense of loss
D. experiencing poor interpersonal relationships with others

2. Early identification and treatment are essential to prevent long term depression. Preventive
measures do NOT include
A. medication as a treatment alone
B. providing astable home life
C. practicing open and honest communication.
D. facilitating a strong sense of self trust, resilience and self-esteem.

3. Chimeya was admitted in the hospital for treatment of her depression. Which antidepressant
drug is COMMONLY used ?
A. Norframin C. Prozac
B. Elavil D. Tofranil

4. To prevent the recurrence of depression, how long should the patient take the anti
depressant-drugs?
A. six months to two years C. one year to three years
B. two months to one year D. one to three months

5. Three days after the admission of Chimeya , the nurse observes she has taken a bath, worn a
clean dress, and combed her hair. What is the APPROPRIATE reaction of the nurse to the
behavioral change in Chimeya?
A. Something is different about you today. What is it?".
B: "oh, I'm so pleased that you finally put on a clean dress".
C. "I see that you have worn a clean dress and have combed your hair"
D."That's good. You have on a clean dress and have combed Your hair."

Situation - Mrs. Juan, a young female patient, believes that doorknobs are contaminated with Covid
19 and refuses to touch them except with the aid of tissue paper

6. Her diagnosis of obsessive-compulsive disorder constantly does repetitive cleaning. The nurse
knows that this behavior is probably MOST basically, an attempt to _______.
A. Decrease the anxiety to a tolerable level
B. Focus attention on non-threatening tasks
C. Control others
D. Decrease time available for interaction with people

7. What response should the nurse use in dealing with this behavior?
A. Encourage her to scrub the doorknobs with a strong antiseptic so she does not need to use
tissue papers.
B. Supply her with paper tissue to help her function until her anxiety is reduced.
C. Force her to touch doorknobs by removing all available paper tissue until she learns to
deal with the situation.
D. Explain to her that ideas about doorknobs with covid 19 are part of the i1lness and is not
necessary.

8. Signs such as using tissues to doorknobs develop because the patient is ________.

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 A. unconsciously controlling unacceptable impulses or feelings
B. Listening to voices that tell her that doorknobs are unclean
C. consciously using this method of punishing herself
D. fulfilling a need to punish others procedure by carrying out annoying

9. Therapeutic treatment for Mrs. Juan should be directed towards helping her to ______.
A. learn that her behavior is not serving a realistic purpose
B. forget her fears by administering antianxiety medications
C. redirect her energy into activities to help others
D. understand her behavior is caused by unconscious impulses that she fears

10. Thenurse plans to educate the entire family about obsessive compulsive disorder. Which of
thefollowing plans would be the MOST effective?
A. The nurse directs resources to help them 1earn about the illness medication to treat it.
B. The nurse teaches the family about Mrs. Juan’s illness and medication and suggests that
they educate her disease and the medications to treat it.
C. The nurse educates the entire famil1v at the same time about the disease and medications to
treat it.
D. The nurse teaches Mrs. Juan about her illness and her mediations and suggests that she
teaches her family what she has learned.

Situation - Glory, a 23 year old evening cashier of Seven Eleven 24 hour convenience store, was
sexually abused by a jeepney driver while on her way home from work one evening. She was brought to
the E R with bruises all over her body. She was crying uncontrollably Band appears to be anxious.

11. Which of the following therapeutic communication should Nurse Ann say for Glory?
A. You are upset calm yourself first Glory. I can't understand you.
B. "Can you identify your abuser?"
C. "I know something terrible and horrifying happened to you."
D. "Would you like to relate to me what happened?"

12. In providing nursing care for Glory during her acute stress reaction to rape trauma , Nurse
Ann may apply, which of the following?
A Physical assessment
B. Collaborate with community agencies
C. Crisis intervention techniques
D. Teaching and learning principles

13. Glory's physical assessment is complete and physical evidence has been collected. After three
days , Nurse Ann noted Glory to be withdrawn, confused and at times physically immobile. How
should Nurse Ann interpret these behaviors?
A. Evidence that the client is a high suicide risk
B. Signs of depression
C. Indicative of the need for longer hospital admission
D. Normal reactions to a devastating event

14. Emergency care to be given for rape victims are as follows:

I. If victim calls the hospital, tell her not to take a bath, wash or change clothes, just go
directly to the hospital
II. Provide privacy and be-judgmental
III. Stay' with the victim focus on physical safety and emotional security
IV. Assist on pelvic examination to collect evidences as semen stains
A. I, III, IV C. II, III, IV
B. I, II, III D. I, II, IV

15. Nurse Ann wanted to become a patient advocate to rape victims. Which of the following
RESPONSIBILITIES should she note?
A. Isolate the patient first to provide privacy while attending to other patients.
B. Call the press since this is a legal case.
C. Perform thorough physical assessment and document objectively all evidences of rape.
D. Postpone the physical examination until the patient is calm.

Situation - Nurses inform patients asking antipsychotic medication with the types of side effects
that may occur. She encourage patients to report instead of discontinuing the medications, Following
are related to patient teachings.

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 16. When taken antianxiety drugs like Benzodiazepines, which APPROPRIATE health teaching should
the nurse emphasize?
A. Antianxiety drugs can treat the underlying problem,
B. Patient should not drink alcohol because it potentiates its effect
C. Patient can discontinue the drug abruptly even without orders.
D. Patient can still drive his car cause of delayed response time.

17. When taking anticonvulsant drugs like Lithium, which APPROPRIATE HEALTH TEACHING should the
nurse emphasize?
A. Time of last dose must be accurate so that blood level monitoring be accurate
B. Patient can take drugs even without food intake.
C. Patient will not experience polyuria and polydipsia.
D. Patient will have constipation, thus 'he has to increase fluid intake.

18. Which of the following does NOT signify extrapyramidal symptoms (EPS) Haldol?
A. Acute dystonia C. Pseudo parkinsonism
B. Akathisia D. Increased libido

19. The patient often appears restless-anxious, agitated with rigid posture and lack of
spontaneous gestures. Which of the following describes this patient with intense need to move
about?
A. Withdrawal C. Dystonia
B. Dyskinesia D. Akathisia

20. When taking SSRI (Selective Serotonin Reuptake Inhibitors), which APPROPRIATE health teaching
should the nurse emphasize?
A. Aged cheese maybe allowed.
B. Patient should take the drug first thing in the morning
C. Peanuts are allowed.
D. Tyramine free diet can lower blood pressure.

Situation - Remedios, a 65-year-old housewife has been diagnosed with rheumatoid arthritis both
hands and knees

21. On a visit to the clinic, a patient reports the onset of early. symptoms of rheumatoid
arthritis. What will be the nurse focused assessment during patient interview?
A. Enlarged nodules
B. Early morning stiffness of the lower extremities
C. Limited motion of joints of upper extremities'
D. Deformed joints of the hands.

22. Patient Remedios complains she could not do household chores and her knees hurt whenever she
walks. Which nursing diagnosis would be MOST
A. Self-care deficit related to increasing joint pain.
B. Activity intolerance related to fatigue and joint pain
C. Disturbed body image related to fatigue and joint pain.
D. Ineffective coping related to increased joint pain.

23. For a patient in the acute phase of rheumatoid arthritis, which of following should the nurse
identify the LOWEST priority in the plan of care?
A. Preserving joint function C. Relieving pain
B. Preventing joint deformity D. Maintaining usual task

24. A patient with osteoarthritis develops 'coagulopathy. secondary to long-term nonsteroidal

anti-inflammatory drug (NSAID) use. The coagulopathy is most likely the result of _____.
A. decreased platelet adhesiveness C. impaired vitamin K synthesis
B. blocked prothrombin conversion D. factor VIII destruction

25. A nurse is teaching a patient with osteoarthritis about lifestyle changes. The nurse knows
the patient understands the teaching when she states that she will _____.
A. abstain from alcohol C. loss weight
B. avoid exercise D. restrict caffeine

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Situation- Korina, a 30-year old registered nurse with two children, legally separated from her
husband was admitted to the psychiatric unit three weeks ago.

26. You are the nurse attending to Korina. You have observed that she has a habit of washing her
hands repeatedly for long periods of time. This is a manifestation of what kind of behavior?
A. Negative C. Ritualistic
B. Hyperactive D. Nonconformist

27. Korina engages in this behavior to________.

A. Protect her self from undesirable people
B. Relieve her anxiety
C. Occupy herself with purposeful activity
D. Call the attention of others

28. A new nurse introduces herself to Korina and asks her name. Korina responds “I am an
obsessive-compulsive neurotic. I have had psychoanalysis for 10 years. What do you think can
you do for me”? Your best response would be ________.
A. “Can we talk about that Korina?” C. “You seem to feel hopeless”
B. “I need to know you Korina” D. “who was your psychoanalysis?

29. Korina tells you “ that new nurse makes me angry. Like you, she does not understand what my
real problem is “,Your BEST reply would be_______.
A. “ You seem to be upset. I will come back later”
B. “ You have the right to be upset when people don’t seem to understand”
C. “ That’s a common feeling. I understand. Let’s talk about it”
D. “ I know what your problem is. You are an obsessive-compulsive personality”

30. Diazepam (Valium) was prescribed for Korina. You gave her instructions effects of the drug.
What statement would indicate that Korina needs further health teaching about medication?
A. “I’m so glad I can still eat chocolate while I’m taking this”.
B. “I’m so glad no blood test are necessary while I’m taking this
C. “I’m so glad Valium won’t affect my driving skills ”
D. “I’m so glad I will only have to take this until I learn to be less anxious”

Situation - Mrs. Del, 70-year-old retired teacher is diagnosed of Dementia. She lives with her 24-
year-old granddaughter. Nurse Maxie attends to her when she goes for her OPD checkups.

31. Mrs. Del must be aware that the MOST common chronic incidence that brings about injury among
elderly persons is _____.
A. rheumatic fever C. gallbladder
B. hip fracture D. urinary tract infection

32. Nurse Maxie should recognize that the MOST common psychogenic disorder among elderly persons
is _____.
A. depression C. decreased appetite
B. sleep disturbances D. inability to concentrate.

33. Which of the following is the MOST common cause of dementia among elderly persons?
A. Parkinson's disease C. Amyotrophic lateral sclerosis
B. Alzheimer's disease D. Multiple sclerosis

34. Which of the following symptoms is COMMON to both the presenile and senile dementias-
associated with Alzheimer's disease?
A. Increased appetite C. Inappropriate behavior
B. Loss of short-term memory D. Inability to provide self-care

35. Patient with dementia suffers from "sundown syndrome". Which nursing action should be
included in this patient's care plan?
A. Maintain consistent schedule and sequence of daily activities.
B. Integrate patient's cultural preferences into the care provided.
C. Serve warm beverage and snack in the early evening.
D. Provide opportunities for patient to learn and practice new skills.

Situation - Mr. Rollan is diagnosed to have chronic schizophrenia.

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 36. To prevent relapses of schizophrenia with Mr. Rollan, which of the following Nurse Anna
should Not encouraged Mr. Rollan and his family ?
A. Keep any troubling side effects of medications with nurses.
B. Practice stress reduction techniques.
C. To follow the medication regimen accurately.
D. Participate regularly in any other forms of treatment.

37. Choose one nursing strategy Nurse Anna should NOT use.
A. Speak in a low calm tone of voice.
B. Let him interact with you while he is hallucinating.
C. Maintain a nonthreatening stance, keep a physical distance.
D. Maintaining safety for herself and Mr. Rollan.

38. Choose one LEAST Anna's nursing action while communicating with Mr. Rollan.
A. "Please let me know if I can be helpful."
B. Check his use of ordered PRN medication,
C. I'll let you sit here quietly and I will be at the nurse station."
D. "I'm just checking in with you to see if there is anything you need right now

39. Which of the following strategies would the nurse instruct the patient to do as a measure to
prevent relapse?
A. Report changes in sleeping, eating and mood.
B. Block hallucinations during daily activities.
C. Take additional medications on days when Mr. Rollan is "feeling bad".
D. Take stress management class.

40. Which of the following identified ability of Mr. Rollan that he can now effectively
participate in rehabilitation?
A. Ability to concentrate. C. Ability to talk.
B. Ability to think. D. Ability to do listen.

Situation - Mrs. Labrador, 75 years old, is in the clinic for the treatment of acute closed-angle
glaucoma.

41. The physician would like to measure the intraocular pressure with non-contact (air puff)
tonometer. While preparing patient for her examination, the nurse informs the patient that
_____.
A. after the examination, a slight pain will be experienced
B. before the examination, a medication will be given
C. it is a painless procedure that has no side effects
D. during the ocular fundoscopy, atropine eye drop will be instilled

42. Which symptoms are ASSOCIATED With acute-closed angle glaucoma?

A. Diplopia and photophobia
B. Blurred vision and colored rings around lights
C. Episodic blindness and no pain
D. Sensation of curtain drawn across the visual field

43. The physician has prescribed Pilocarpine one percent eye drops every six -hours. The expected
OUTCOME for this medication is to
A. dilate the pupil by paralyzing the ciliary muscle
B. prevent dryness of the cornea and conjunctiva
C. promote drainage of aqueous humor from anterior chamber
D. reduce inflammation of the iris and choroid

44. The physician recommends peripheral iridectomy to relieve intraocular pressure. He prescribed
Meperidine Hydrochloride (Demerol) 50mg and Atropine Sulfate 0.3mg IM as the preoperative
medications. The nurse should _____.
A. recognize that atropine sulfate is given preoperatively to dilate the pupil
B. recognize this as a usual preoperative medication and administer it
C realize that the atropine sulfate is being given to dry up secretion
D. notify the physician and question the order

45. Which of these nursing diagnoses should the nurse give PRIORITY for an elderly patient who
has impaired vision due to glaucoma?

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 A. High risk for injury C. Grooming self-care deficit
B. Impaired physical mobility D. Feeding self-care deficit

Situation - Darwin, 35-year-old engineer met a vehicular accident while going to work. He suffered
head injury, responsive and admitted at the intensive care unit for close monitoring and management.

46. During nursing assessment, Darwin speaks a rambling manner and is unable to repeat words
spoken to him. Which are of the brain MOST likely is affected?
A. Wernicke's area C. Foramen magnum
B. Broca's area D. Brodmann's area

47. The physician orders a computerized transverse axial tomogram (CAT) scan Nursing preparation
of the patient for this procedure includes:
A. Explaining that the vital signs will be monitored for 2 hours after the examination.
B. Reassuring that CAT scanning is a noninvasive procedure.
C. Explaining that a spinal tap will be done so that a radioactive isotope can be injected.
D. Telling patient that a radiopaque dye is injected into an artery in the arm

48. The physician order to observe for EARLY signs of increased intracranial pressure which
includes _____.
A. restlessness and change in level of consciousness
B. elevated temperature and decerebrate posturing
C. rising blood pressure and bradycardia
D. widening pulse pressure and dilated pupils

49. All of the following signs indicate increased intracranial pressure EXCEPT?
A. Decreased level of consciousness C. Papilledema
B. Tachycardia D. Vomiting

50. The nurse noticed dressing is wet. Which action by the nurse can be safely used to determine
if the drainage contains cerebrospinal fluid (CSF)? What is the attending nurse should do?
A. Blot the drainage with sterile gauze pad and look for a clear wet ring around the spot of
blood.
B. Swab the orifice of the ear with a sterile applicator and send the specimen to the
laboratory.
C. Obtain a negative reading for sugar after testing the CSF with Test-Tape
D. Gently suction the ear and send the specimen to the laboratory

Situation - Annie is a 38-year-old-woman with three children history of otosclerosis. She is

admitted for ear surgery.

51. While taking nursing history on Annie, what will be the response of the patient that
indicates her present condition?
A. She frequently experiences vertigo nausea and nystagmus when sitting.
B. She has ear pain and discharge from the left ear when travelling.
C. She has had impaired hearing since birth.
D. Her hearing loss has become worse with each succeeding pregnancy

52. Annie states, “I 'm afraid to 1et my children out of my sight now that I can't hear them."
What is the nurse's BEST response?
A. Tell me about your fears of losing contact with your children now that you can't hear them."
B. Children need some freedom, and the mother has to learn trust them. "
C. Do the children usually misbehave when they cannot be seen or heard by you?"
D. "What can the children do to make you feel more comfortable?

53. What should be APPRORIATE the nursing care plan for Annie having otosclerosis?
A. A Substitute meaningful sensory input by the use of other senses.
B. Orient Annie to the staff, the unit, and all treatments
C. Give nursing care that will meet her psychological needs.
D. Make frequent calls to prevent isolation and loneliness.

54. The day after surgery, Annie expresses concern that hearing is not as good as it was before
admission. What is the BEST nurse action?
A. Encourage Annie to divert her attention by reading.

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 B. Encourage Annie to blow more her nose to Clear the Eustachian tubes.
C. Reassure Annie that it is temporary loss due to post-edema and ear packing.
D. Check the external ear for blood clots and remove them.

55. What post operative teaching will the patient strictly follow?
A. Reinforce that fact that airplane travel is no longer permitted.
B. Show patient how to gently 1rrigate the external auditory canal.
C. Inform physician any dizziness that develops after she is discharged.
D. Stress that hair washing should be avoided immediately after surgery

Situation - Mrs. Gomez, 63-year-old admitted for cataract extraction. Nurse Lucy is assigned to
prepare the patient for surgery.

56. Mrs. Gomez tells the nurse that she does not want to know about her surgery. What would be
the BEST response of the nurse?
A. "I must go over certain information with you."
B. "You are right; do not worry yourself tonight."
C. "You really sound quite concerned about your surgery."
D. "Well, I could talk to your son about this instead."

57. What should the nurse do before giving pre-operative teaching to the patient?
A. Determine Mrs. Gomez anxieties, level of understanding and expectations.
B. Research the surgical procedure so as to give step-to-step explanation.
C. Schedule teaching to begin 2-3 hours before surgery.
D. Give Mrs. Gomez general information because specifics might be threatening.

58. While doing health teaching to Mrs. Gomez, the attending nurse can BEST recognize that her
patient is learning by ______.
A demonstrating a positive change in her behavior
B. constant verbal reaffirmations that she understands
C. her ability to repeat what was discussed
D. nonverbal acknowledgement that she understands, such as nodding

59. The nurse prepares Mrs. Gomez for discharge. What would be the nurse MOST Important post
cataract surgery instruction to her patient?
A. Avoid the use of laxatives C. Avoid to touch the eye dressing
B. Use an eye shield at night D. Curtail most heavy activities

60. After discharge, Mrs. Gomez attends the eye clinic for follow-up visit. When she received her
cataract glasses, it is important that the nurse advise her that ______.
A. Magnification by the lens is only about 10 percent
B. Daily eye drops are required with eyeglasses
C. Her peripheral vision will be increased
D. Objects will appear closer than they really are

Situation - Head Nurse Alona ensures teamwork and collaboration in her unit to achieve efficient
shared decision-making and open communication' to provide safe patient care.

61. A nurse returns from vacation and finds a new model of I.V. pump attached to her patient's
I.V. How should the nurse proceed?
A. Read the I.V pump manual before caring for the patient.
B. Refuse to care for the patient.
C. Inform the charge nurse and ask her to provide an teaching session about how to use the pump.
D. Use the pump because it is somewhat like the old pumps on the unit.

62. A nurse is caring for a 72-year-old male patient who requires insertion of a central, venous
catheter. Who 15 responsible for obtaining informed consent?
A. Physician who will insert the catheter
B. Charge nurse
C. Attending physician
D. The nurse assisting with the procedure

63. A nurse reports that a patient coughs frequently after taking anything by mouth. The
dietitian recommends a swallow evaluation for the patient, in which the physician
participating in the team rounds writes the order. This is an example of collaboration-of-
client-care

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 A. with the ancillary care providers
B. between the physician and the dietary department
C. with the risk management team because of risk for aspiration
D. among members of the multidisciplinary group

64. Before delegating to a new nurse the task of giving a shower to a paraplegic elderly, the
charge nurse should FIRST ensure that the new nurse ______.
A. has demonstrated competency for the task
B. has received the assignment during endorsement time
C. is supervised at all times
D. provides companion to the patient

65. Which of the following tasks would be APPROPRIATE for the nurse to delegate to nursing aide?
A. Assist a new postoperative patient to the bathroom.
B. Teach a patient how to administer discharge medications.
C. Change a central line dressing.
D. Assist the patient during meal time.

Situation - Mr. Ferrer, 42 years old, is admitted to the hospital in a semi-conscious state
diagnosed with cerebrovascular accident.

66. The nurse obtains history of patient's present illness from his family. What significant
information can the nurse gather from the patient's family?
A. consistent hypertension and dizziness
B. palpitations and hypotension
C. family history about illness
D. emotional response to past illness

67. The PRIORITY nursing care for Mr. Ferrer during the acute phase is to
A. provide sensory stimulation
B. maintain respiratory and cardiac function
C. prevent contracture and deformities
D. maintain optimal nutrition

68. Part of nursing care plan is to observe Mr. Ferrer for signs of increased intracranial
pressure. Which of the following clinical manifestations would INDICATE this condition?
A Tachycardia and drop in blood pressure
B. Bradycardia and rising blood pressure
C. Bradycardia and drop in blood pressure
D. Tachycardia and rising blood pressure

69. Which of the following positions will be MOST APPROPRIATE to Mr. Ferrer's care?
A. Head of bed elevated in a lateral position
B. Head of bed elevated in a supine position
C. Right lateral position
D. Left lateral position

70. Mr. Ferrer's wife is very upset and asks if there is any hope to recover from his condition?
Which of the following is the MOST APPROPRIATE reply by the nurse?
A. "You must be patient, let's hope for the best outcome."
B. "You should never lose hope."
C. "It is too soon to tell what the outcome will be."
D. "Actually, manifestations may even get worse."

Situation - Liela, 5 years old, was diagnosed as autistic since she was 1 year old.

71. What behavior will Nurse Raffy observe as characterized by Liela?

A. Inappropriate behavior, poor attention span with impulsivity
B. Negativistic hostile and defiant behavior
C. Failure to develop interpersonal skills
D. Anxiety induced involuntary stereotype motor movements

72. At her age, Liela is in what stage of social development?

A. Initiative vs GuiltC. Industry vs Inferiority
B. Trust vs MistrustD. Autonomy vs Shame and Doubt

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 73. Nurse Raffy recognizes which of the following as COMMON Behavioral sign of autism?
A. Clinging behavior towards parent
B. Early language development
C. Indifference to being hugged or held
D. Creative imaginative play with peers

74. The BEST nursing intervention that Nurse Raffy can use to provide trusting relationship with
an autistic Liela is to
A. convey warmth through touch
B. reinforce positive behavior through praise and rewards
C. explain to the child activities and routines
D. provide a structured environment

75. Which pharmacologic treatment is APPROPRIATE for Liela's temper tantrum, aggressiveness, self
injury-and-stereotyped behavior?
A. Clonidine Catapres) C. Clomipramine (Anafranil)
B. Naltrexone (ReVia) D. Haloperidol( Haldol)

Situation- Patient safety remains a global health care challenge. There are basic principles of
infection control. These include standard precautions and transmission based precautions. The
following are transmission based precaution questions.

76. Which one of the following is considered the MOST important intervention in infection
control?
A. personal protective clothing
B. prevention of infection associated with catheter
C. safe use and disposal of sharps
D. hand hygiene of healthcare staff

77. Which mode of infection transmission is due to splashes of blood / body fluids into the
mucosa or contamination of non intact skin with infected blood and body fluids?
A. ingestion C. inoculation
B. airborne D. direct/ indirect contact

78. Which mode of infection transmission is due to microorganisms being transferred to other
patients from contaminated equipments and via the hands of nurses?
A. ingestions C. inoculation
B. airborne D. direct/ indirect contact

79. What mode of transmission is due to contaminated food and water being consumed?
A. Inoculation C. Ingestion
B. Direct/ indirect contact D. Airborne

80. Which of the following is NOT standard precautions?

A. respiratory hygiene C. personnel protective equipment
B. injection safety D. hand hygiene

Situation Charge Nurse Tessie works at the surgical ward. She ensures good record management
is implemented in her unit at a1 times.

81. A patient is having elective surgery under general anesthesia. Who is responsible for
obtaining the informed-consent?
A. Surgeon C. Nurse anesthetist
B. Nurse D. Anesthesiologist

82. Which statement by the patient indicates that the he understands the explanation of
the surgeon?
A. “I refuse to sign the consent form; another family member can sign for me-"
B. "Now I know what the alternative treatments and procedures are."
C. "If I refuse to sign the consent form, other treatment will be withdrawn. "
D. “I can't refuse the procedure after the consent, is signed."

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 83. The unit secretary who transcribes the physicians' order asks the nurse to interpret an order
because she cannot read the writing. The nurse’s BEST action is to ______.
A. Clarify the order with the pharmacies
B. Clarify the order by calling the physician
C. Interpret the order according to the patient 's previous medication record
D. clarify the order with junior staff

84. The physician orders to transfuse 500ml packed RBC blood postoperatively. The nurse must
check the name on the label of the blood with the name on the patient's _______.
A. medication administration record
B. Wristband in the presence of another nurse
C. medical chart
D. wristband

85. The patient's wife is-so anxious about the condition of her husband. The MOST appropriate
INITIAL intervention for the nurse to make is to ________.
A. describe her husband 's medical treatment since admission
B. reassure her that the important fact is her presence
C. explain the nature of the injury and reassure her that husband's condition is stable
D. allow her to verbalize her feelings and concerns

Situation – you are a staff nurse in a psychiatric unit. Use of therapeutic communication is one of
your nursing responsibilities.

86. Verbal communication is the use of words when talking to your patient. The use of literal
words when you speak is the :
A. Understandable phrases C. The circumstances
B. Content D. Understandable sentences

87. Context of a verbal communication is the:

A. Use of understandable C. Use of clear sentences
B. Use of literal words D. Environment where communication occurs

88. Non verbal communication is the behavior that accompanies verbal communication, which of the
following is NOT an indicator of this
A. Eye contact C. Grunts and groans
B. Words representing an object D. Body language

89. Which of the following give meaning and context to the message?
A. Process C. Context
B. Phrases and sentences D. Thoughts and feelings

90. Which of the following situation is an example of incongruent message?

A. When the nurse means what she says
B. When the words and behavior of the nurse agree
C. When what the nurse says and does do not agree
D. When content and process agree

Situation -Sandro 8 years old,1st grader child has always been the subject of her mother's
prompting and care. He always tests his mom’s rule in preparing for school. Although this has been
five months now, Sandro still has to be reminded in getting dress completely and dilly dally eating
his breakfast. He still plays. With his toys and interferes with her sister in playing blocks. The
mother is so anxious in reminding Sandro that his school bus will be arriving in 10 minutes every
day.

91. Attention deficit, Hyperactivity, disorder (ADHD) is characterized by NOT one of the
following?
A. Mental retardation C. Inattentiveness
B. Over activity D. Impulsiveness

92. Which of the following would the nurse expect to see as symptoms in a child with ADHD,
EXCEPT?
A. Moody, sullen and pouting behavior

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 B. Interrupts others and can't take turns
C. Excessive running, climbing and fidgeting
D. Easily distracted and forgetful

93. Sandro is taking pemoline (Cylert) for ADHD. The nurse must be aware of which of the
following side effects?
A. Decreased red blood cell count
B. Decreased thyroid stimulating hormones
C. Elevated white blood cell count
D. elevated liver function test results

94. An effective nursing intervention for the impulsive and aggressive behaviors that accompany
conduct disorder is ______.
A. open expression of feelings C. negotiation of rules
B. assertiveness training D. consistent limit setting

95. Nursing diagnosis commonly used when working with Sandro is

A. ineffective role performance C. Compromised family coping
B. impaired social interaction D. risk for injury

Situation- You are the staff nurse in the psychiatric unit of a private hospital. Teresa a 20- year
old stage actress was admitted with the chief complaints of getting angry easily and inability to
tolerate being alone . She claim that she has also the tendency to manipulate people and feels
unhappy most of the time. She was diagnosed to be suffering from borderline personality disorder
(BPD).

96. You have observed that Teresa is manifesting “spitting”. This characteristics of BPD is BEST
defined as_____.
A. Viewing people and objects as parts, either good or bad
B. Having two personalities
C. Talking about other people behind their back
D. Literally spitting in other people’s face

97. When assessing a patient with BPD which of the following information would you focus on?
A. Ability to get people on his/her side
B. Disruption in some aspects of his/her life
C. Desire for intimate relationship
D. increased acceptance from other people

98. Teresa revealed she has a tendency to manipulate others. What would be the MOST APPROPRIATE
short-term goal for her? For Teresa to_____.
A. Have an intimate relationship C. Stop arguing with other people
B. Acknowledge her own behavior D. Express her feeling verbally

99. Patients with BDP manifest transient psychotic symptoms. What is the drug of choice to treat
these symptoms?
A. Mood stabilizer C. Lithium
B. Benzodiazepines D. Antipsychotics

100. Lorenz has a history of alcohol abuse so she was started on Antabuse. Which of the
following is a COMMON side effect of this drug?
A. Hypertension C. Depression
B. Bradycardia D. Elation

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