FORMATIVE 2

1. The choice a nurse makes about how he or she defines his or her professional self affects not only his or her morale but also the nature of care
the patients receive. Bailey, a newly registered nurse, often wonders about what it takes to be called a professional. She is aware that nurses
should act “professionally.” This implies that nurses:
A. Are dedicated and committed in the practice of their professions
B. Consider health care cost and provide evidenced-based practice
C. Are knowledgeable, conscientious and are responsible to self and others
D. Use clinically documented evidenced-based practice in decision-making

Rationale:
Profession: a calling requiring specialized knowledge and often long and intensive academic preparation.
Characteristics of a Profession:
1. Specific body of knowledge
2. Specialized education
3. Autonomy
4. Service orientation
5. Code of Ethics
6. Accountability
7. Ongoing research

 Marie Jahoda’s definition implies that a profession is an organization of an occupational group based on application of special knowledge
which establishes its own rules and standards for the protection of the public and the professionals. A profession implies that the quality of
work done by its members is of greater importance in its own eyes and the society than the economic rewards they earn.
(Kozier, 8th ed, pg 16; ULG, pg 9)

2. The nurse is planning the budget to account for the months of June and July and has adjusted the budget because of operational costs and
purchase equipment. The activity of the nurse to oversee budgeting belongs under which management process?
A. Planning
B. Organizing
C. Directing
D. Controlling

Rationale:
The management process consists of planning, organizing, directing, and controlling.
Planning is thinking ahead, making future projections to achieve desired results. Activities under planning are the following:
 Establishing policies, procedures, definite course of action and methods.
 Prepare budget and allocate resources
 Develop and schedule programs, definite activities, methods, and set time frame
 Set objectives and determine results desired
 Forecast and estimate future
Organizing establishes formal authorities. Activities under organizing are:
 Set up organizational structure and identify groupings, roles and relationships
 Determine staff needed
 Develop and maintain staffing patterns
 Develop job descriptions, define qualifications and functions of personnel
Directing or leading actuates efforts to the accomplishment of goals. This includes:
 Utilization of various modalities of nursing care
 Updating policies and procedures
 Supervise, harmonize work through guidance
 Coordinating personnel and services
 Communicating via various routes
 Staff development programs
 Making sound decisions and judgment
Controlling leads to the assessment and regulation of performance of workers. This includes:
 Performance appraisal
 Apply discipline
 Monitor and evaluate nursing care and services
 Specify criteria standards and utilize performance standards
(Nursing Management by Venzon, 3rd ed, pg 6)

3. The hospital is planning to purchase new mechanical ventilators, cautery machines, and suction equipment. In preparing for the resources
needed to initiate such purchases, what kind of budget will be carried out by the hospital?
A. Hospital budget
B. Cash budget
C. Operating budget
D. Capital expenditure budget

Rationale:
Purchase of capital equipment is included in the capital budget. Capital budget outlines the programmed acquisitions, disposals, and improvements
in an institution’s physical capacity.
Operating budget deals primarily with salaries, supplies, contractual services, employee benefits, laundry service, drugs and pharmaceuticals, in-
service educations (such as the fire safety program), travels to professional meetings, books, repairs and maintenance. The operating budget is
composed of the revenue and expense budget.
The hospital budget is a financial plan to meet future service expectations.
The cash budget forecasts the amount of money received.
(Nursing Management by Venzon, 3rd ed, pg 26,30)

4. Staffing is the process of determining and providing the acceptable number and mix of nursing personnel to produce a desired level of care to
meet the patients’ demand. Nurse Felix was schedule to work at night shift but he called in sick at 2000h. The staffing ratio is now affected. As a
nurse manager what will be your action?
A. Look initially at your staffing complement for the night shift and adjust the staffing accordingly.
B. Look initially at your staffing complement for the night shift, determine the patient load for next shift and adjust the staffing as necessary.
C. Look initially at your staffing complement for the night shift and call the higher manager and ask for a staff nurse replacement.
D. Look initially at your staffing complement for the night shift and have an option prepared and present it to the incoming night charge nurse
during the endorsement.

Rationale:
In making a schedule, the nurse manager must be prepared for sudden changes that may occur. The scheduling system must function smoothly in
terms of:
 Ability to cover the needs of the unit (adequate nurse-patient ratio)
 Quality to enhance the nurse’s knowledge, training, and experience
 Fairness to the staff
 Stability
 Flexibility (ability to handle changes brought about by emergency leaves, scheduled or unscheduled leaves of absence)
Basically, the nurse manager can adjust the schedule when such things happen as long as it meets the criteria cited above so that nurses can
work in harmony.
Option A- you have to know the patient load first before adjusting an appropriate nurse-patient ratio.
Option C- no need to call for higher manager when the nurse manager can solve the problem herself. This is decentralization.
Option D- It is the nurse manager’s responsibility to have the schedule prepared and adjusted when changes brought about unscheduled leaves of
absence or emergency leaves occur. It is said that the scheduling system must be flexible.
(Nursing Management by Venzon, 3rd ed, pg 63)

5. The staffing and scheduling process incorporates professional nursing standards and accounts for the health-care setting, the care delivery
method, patient acuity, and the nursing staff. The Chief Nurse is preparing to make a 4-week schedule for the OR unit. He is thoroughly
reviewing the past schedule of the OR unit for flaws he should not repeat. Taking into consideration the many factors in making schedules, the
Chief Nurse will NOT incorporate which of the following to the new schedule, except:
A. Assigning a staff nurse to work 1 week straight on the PM shift.
B. Assigning a staff nurse with afternoon shifts after an ample of night shifts.
C. Assigning more staff in the afternoon shift than in morning and night shifts.
D. Assigning a staff nurse from the health education unit to relieve for an absent staff.

Rationale:
Nurses should be granted rotating work shifts. It is desirable that there be equal share of morning, afternoon, and night shifts as prolonged night
shifts may affect the health of the personnel. Although rotation from night to afternoon or morning shifts may be quite stressful, adequate rest is
provided before the rotation since it is inadvisable for nurses to stay in long periods of night shifts.
 Option A- Long stretches of consecutive working days should be avoided as much as possible because it might affect the health of the
nursing personnel. It is advisable that work days are not more than 4-5 consecutive days.
 Option C- Morning shifts needs most number of nursing personnel. Distribution of shifts in the Philippines is 45% for the morning shift, 37%
for the afternoon shift, and 18% for the night shifts.
 Option D- Unscheduled absences may require a staff to be pulled out from her regular area of assignment to cover for another unit.
However, this may cause disruption in the unity of work groups and job dissatisfaction the nurse does not have the necessary skill and
knowledge that the unit may require. Relievers are required to undergo cross-training and orientation to the special unit before being
assigned to one. In emergency cases, nurses with the experience on the area are usually assigned as relievers.
(Nursing Management by Venzon, 3rd ed, pg 62- 66)

6. The importance of traditional medicine in providing essential health care to the people should be recognized. The practice of traditional
medicine has gained a deep significance in our country's health care delivery, considering that western medical treatment is expensive and
most Filipinos could not afford it. Bruno, a resident of Barangay Patpatin, was invited to a government-funded seminar on the different
traditional and alternative modalities such as homeopathy, chiropractic, chelation therapy, macrobiotics and colonic detoxification. These
seminars and community-based trainings as well as the promotion of traditional and alternative health modalities are advocated by which law?
A. RA 9439
B. RA 9502
C. RA 8749
D. RA 8423

Rationale:
RA 8423 – “Traditional and Alternative Medicine Act (TAMA) of 1997” which aims to advocate the use, encourage scientific research and formulate
standards, guidelines and codes of ethical practice for traditional and alternative health care modalities.

A – RA 9439 is the Patient’s Illegal Detention Law which is the act prohibiting the detention of patients in hospitals and medical clinics on grounds of
nonpayment of hospital bills or medical expenses.
B – RA 9502 is the Universally Accessible Cheaper and Quality Medicines Act
C – RA 8749 is the Clean Air Act
7. Ethical codes are systematic guides for developing ethical behavior. They answer normative questions of what beliefs and values should be
morally accepted. Sam is a newly hired staff nurse. The training coordinator emphasized during the orientation that nurses must be guided by
ethico-moral principles during the execution of their functions. Who among the following nurses fails to practice this provision?
A. A nurse who regularly attends seminars on nursing
B. A nurse who delegates vital signs taking to the UAP
C. A nurse who refuses to go to clubs in her duty uniform
D. A nurse who acts as an advocate by insisting his beliefs to the client

Rationale:
Option D- According to Code of Ethics Art III (Nurses and Practice), Sec 8- nurses are the advocates of the patients. They uphold the client’s rights
when conflict arises regarding management of their care. The statement is wrong because the nurse insisted his beliefs to the client when the client
must have his own. The nurse merely supports the client’s decisions, and not imposes his own beliefs.
Option A- Article VI (Nurses and Profession) requires the nurse to commit to continual learning and active participation in the development and
growth of the profession
Option B- Article IV (Nurses and Co-Workers) encourages collegial and collaborative working relationship with colleagues
Option C- Article III (Nurses and Practice) says that the nurse’s actions have professional, ethical, moral, and legal dimensions. They strive to
perform their work in the best interest of all concerned.
(ULG, pg 479)

8. Nurse Angel admits a client with right upper quadrant pain and vomiting as chief complaints. The doctor ordered for an ultrasound and
laboratory work-up on amylase and lipase while Nurse Angel obtains informed consent. Which of the following principles correlates to the
nurse’s action?
A. Justice
B. Beneficence
C. Autonomy
D. Justice

Rationale:
Autonomy is the right to make one’s own decisions. This principle comes into play in the requirement that clients provide informed consent before
tests, procedures, or participating as a research subject.
Fidelity means to be faithful to agreements and promises. Justice is referred to as fairness wherein the nurse will need to weigh the facts carefully in
order to divide her time justly among her clients. Beneficence means doing good, that is, to implement actions that benefit clients and their support
persons. (Kozier, 8th ed, pg 85)

9. Statistical tests are procedures for testing research hypotheses and evaluating the believability of the findings. The types of mathematical
calculations that can be made with data depend on the level of measurement of the data. Gender, religious affiliation, and marital status are
considered to be in what level of measurement?
A. Nominal
B. Ordinal
C. Interval
D. Ratio

Rationale:
In the nominal level of measurement, objects or events are categorized. The categories must be distinct from each other and include all of the
possible ways of categorizing the data. The nominal level of measurement is considered the lowest level or least rigorous of the measurement levels.
 In ordinal measurement the attributes can be rank-ordered. Here, distances between attributes do not have any meaning. For example, on
a survey you might code Educational Attainment as 0=less than H.S.; 1=some H.S.; 2=H.S. degree; 3=some college; 4=college degree;
5=post college. In this measure, higher numbers mean more education. But is distance from 0 to 1 same as 3 to 4? Of course not. The
interval between values is not interpretable in an ordinal measure.
 In interval measurement the distance between attributes does have meaning. For example, when we measure temperature (in Fahrenheit),
the distance from 30-40 is same as distance from 70-80. The interval between values is interpretable. Because of this, it makes sense to
compute an average of an interval variable, where it doesn't make sense to do so for ordinal scales. But note that in interval measurement
ratios don't make any sense - 80 degrees is not twice as hot as 40 degrees
 In ratio measurement there is always an absolute zero that is meaningful. This means that you can construct a meaningful fraction (or
ratio) with a ratio variable. Weight is a ratio variable. In applied social research most "count" variables are ratio, for example, the number of
clients in past six months. Why? Because you can have zero clients and because it is meaningful to say that "...we had twice as many
clients in the past six months as we did in the previous six months."

10. Frequency distributions are a good way to organize data and clarify patterns. These impose an order on raw data, numeric values are ordered
from lowest to highest, accompanied by a count of the number (or percentage) of times each value was obtained. The following statements are
true about mean, except:
A. It is familiar to most people and intuitively clear.
B. It is not affected by extreme values in a set of data.
C. Data does not have to be arranged from highest to lowest.
D. It can be easily calculated and unique since every data set has one and only one mean.

Rationale:
 CHOICE B: It IS AFFECTED by extreme values in a set of data.
 The mean is equal to the sum of all scores divided by the total number of scores. The mean is the index usually referred to as an average.
 Unlike the median, the mean is affected by each and every score. If we were to exchange the 195- pound subject in this example for one
weighing 275 pounds, the mean would increase from 145 to 155. Such a substitution would leave the median unchanged. (Nursing
Research: Principles and Methods. 7th edition. Denise F. Polit and Cheryl Beck. [pp. 460])
STATISTICAL METHODS
MEASURES OF CENTRAL TENDENCY MEASURES OF DISPERSION
1. MODE: The number that occurs most frequently (simplest measure of 1. RANGE: simplest and easiest measure of variability distance between
central tendency). the highest and lowest scores in a distribution.
2. MEDIAN: Divides the distribution at the 50th percentile (the number 2. STANDARD DEVIATION: a measure of spread of scores. Number
above which and below which half the observations fall) indicating how closely the scores are clustered around the mean.
3. MEAN: The arithmetic average (summation of all scores divided by 3. VARIANCE: mathematical index of the average distance of the scores
number of cases) on an interval or ratio scale from the mean in squared units – square of
*Most reliable, stable and best measure and most useful summary the standard deviation (mean square)
statistics.

11. Hygiene is a highly personal matter determined by individual values and practices. It involves care of the skin, feet, nails, oral and nasal
cavities, teeth, hair, eyes, ears, and perineal-genital areas. It is important for nurses to know exactly how much assistance a client needs for
hygienic care. The following questions apply to hygienic care. The nurse is providing morning care for her 52-year old female client. She is to
perform bed and bath hygiene care to her client. The nurse needs further instructions about the procedure if she performed which of the
following, except:
1. Checked the soiled bed linen for personal items such as eyeglasses
2. Finished care with back rub using rubbing alcohol
3. Put a clean gown on the strongest arm first, then the weak arm
4. Ensured that the temperature of the bath water is 110-115oF
5. Washed the feet by placing them in a basin with water
6. Observed standard precautions for exposed body fluids
7. Washed the client’s extremities from proximal to distal
8. Performed hand hygiene after disposing of client’s linen in the soiled hamper

A. 1, 2, 5, 6, 7
B. 1, 4, 5, 6, 8
C. 2, 3, 5, 6, 8
D. 2, 4, 6, 7, 8

Rationale:
Bathing removes accumulated oil, perspiration, dead skin cells, and some bacteria. Excessive bathing, however, can interfere with the intended
lubricating effect of the sebum, causing dryness of the skin. This is an important consideration, especially for older adults. who produce less sebum.
In addition to cleaning the skin, bathing also stimulates circulation. A warm or hot bath dilates superficial arterioles, bringing more blood and
nourishment to the skin. Vigorous rubbing has the same effect. Rubbing with long smooth strokes from the distal to proximal parts of extremities
(from the point farthest from the body to the point closest) is particularly effective in facilitating venous blood flow return unless there is some
underlying condition (e.g., thrombosis) that would preclude this. Bathing also produces a sense of well-being. It is refreshing and relaxing and
frequently improves morale, appearance, and self-respect.

Bed Bath Procedure:

1. Prior to performing the procedure, introduce self and verify the client's identity using agency protocol. Explain to the client what you are going to
do, why it is necessary, and how he or she can participate. Discuss with the client their preferences for bathing and explain any unfamiliar
procedures to the client.
2. Perform hand hygiene and observe other appropriate infection control procedures.
3. Provide for client privacy by drawing the curtains around the bed or closing the door to the room. Some agencies provide signs indicating the
need for privacy. Rationale: Hygiene is a personal matter.
4. Prepare the client and the environment.
 Invite a family member or significant other to participate if desired or requested by the client.
 Close windows and doors to ensure the room is a comfortable temperature. Rationale: Air currents increase loss of heat from the body
by convection.
 Offer the client a bedpan or urinal or ask whether the client wishes to use the toilet or commode. Rationale: Warm water and activity can
stimulate the need to void. The client will be more comfortable after voiding, and voiding before cleaning the perineum is advisable.
 Encourage the client to perform as much personal self-care as possible. Rationale: This promotes independence, exercise, and self-
esteem.
 During the bath, assess each area of the skin carefully.
5. Prepare the bed and position the client appropriately.
 Position the bed at a comfortable working height. Lower the side rail on the side close to you. Keep the other side rail up. Assist the
client to move nearyou. Rationale: This avoids undue reaching and straining and promotes good body mechanics. It also ensures client
safety.
 Place bath blanket over top sheet Remove the top sheet from under the bath blanket by starting at client's shoulders and moving linen
down toward client's feet. Ask the client to grasp and hold the top of the bath blanket while pulling linen to the foot of the bed. Rationale:
The bath blanket provides comfort, warmth, and privacy.
Note: If the bed linen is to be reused, place it over the bedside chair. If it is to be changed, place it in the linen hamper, not on the floor. Remove
client's gown while keeping the client covered with the bath blanket. Place gown in linen hamper.

6. Make a bath mitt with the washcloth. Rationale: A bath mitt retains water and heat better than a cloth loosely held and prevents ends of
washcloth from dragging across the skin.
7. Wash the face. Rationale: Begin the bath at the cleanest area and work downward toward the feet.
 Place towel under client's head.
 Wash the client’s eyes with water only and dry them well. Use a separate corner of the washcloth for each eye. Rationale: Using
separate corners prevent transmitting microorganisms from one eye to the other. Wipe from the inner to the outer canthus. Rationale:
This prevents secretions from entering the nasolacrimal ducts.
 Ask whether the client wants soap used on the face. Rationale: Soap has a drying effect, and the face, which is exposed to the air more
than other body parts, tends to be drier.
  Wash, rinse, and dry the client's face, ears, and neck.
 Remove the towel from under the client's head.
8. Wash the arms and hands. (Omit the arms for a partial bath.)
 Place a towel lengthwise under the arm away from you. Rationale: It protects the bed from becoming wet.
 Wash, rinse, and dry the arm by elevating the client's arm and supporting the client's wrist and elbow. Use long, firm strokes from wrist
to shoulder, including the axillary area. Rationale: Firm strokes from distal to proximal areas promote circulation by increasing venous
blood return.
 Apply deodorant or powder if desired. Special caution is needed for clients with respiratory alterations. Rationale: Powder is not
recommended due to the potential respiratory adverse effects.
 Optional: Place a towel on the bed and put a washbasin on it. Place the client's hands in the basin. Rationale: Many clients enjoy
immersing their hands in the basin and washing themselves. Soaking loosens dirt under the nails. Assist the client as needed to wash,
rinse, and dry the hands, paying particular attention to the spaces between the fingers.
 Repeat for hand and arm nearest you. Exercise caution if an IV infusion is present, and check its flow after moving the arm. Avoid
submersing the IV site if the dressing site is not a clear, transparent dressing. Rationale: A clear transparent dressing will keep water
from an IV site; however, a gauze dressing becomes contaminated when it becomes wet with the water.
9. Wash the chest and abdomen. (Omit the chest and abdomen for a partial bath. However, the areas under a woman's breasts may require
bathing if this area is irritated or if the client has significant perspiration under the breast.)
 Place bath towel lengthwise over chest. Fold bath blanket down to the client's pubic area. Rationale: Keeps the client warm while
preventing unnecessary exposure of the chest.
 Lift the bath towel off the chest, and bathe the chest and abdomen with your mitted hand using long, firm strokes. Give special attention
to the skin under the breasts and any other skin folds, particularly if the client is overweight. Rinse and dry well.
 Replace the bath blanket when the areas have been dried.
10. Wash the legs and feet. (Omit legs and feet for a partial bath.)
 Expose the leg farthest from you by folding the bath blanket toward the other leg, being careful to keep the perineum covered. Rationale:
Covering the perineum promotes privacy and maintains the client's dignity.
 Lift leg and place the bath towel lengthwise under the leg. Wash, rinse, and dry the leg using long, smooth, firm strokes from the ankle to
the knee to the thigh. Rationale: Washing from the distal to proximal areas promotes circulation by stimulating venous blood flow.
 Reverse the coverings and repeat for the other leg.
 Wash the feet by placing them in the basin of water.
 Dry each foot. Pay particular at tent ion to the spaces between the toes. If preferred, wash one foot after that leg before washing the
other leg.
 Obtain fresh, warm bathwater now or when necessary. Rationale: Water may become dirty or cold. Because surface skin cells are
removed with washing, the bathwater from dark-skinned clients may be dark, however, this does not mean the client is dirty. Lower the
bed and raise the side rails when refilling the basin. Rationale: This ensures the safety of the client.
11. Wash the back and then the perineum.
 Assist the client into a prone or side-lying position facing away from you. Place the bath towel lengthwise alongside the back and
buttocks while keeping the client covered with the bath blanket as much as possible. Rationale: This provides warmth and undue
exposure.
 Wash and dry the client's back, moving from the shoulders to the buttocks, and upper thighs, paying attention to the gluteal folds.
 Remove and discard gloves if used.
 Perform a back massage now or after completion of bath.
 Assist the client to the supine position and determine whether the client can wash the perineal area independently. If the client cannot do
so, drape the client as shown in Skill 33-2 and wash the area.
12. Assist the client with grooming aids such as powder, lotion, or deodorant.
 Use powder sparingly. Release as little as possible into the atmosphere. Rationale: This will avoid irritation of the respiratory tract by
powder inhalation. Excessive powder can cause caking, which leads to skin irritation.
 Help the client put on a clean gown or pajamas.
 Assist the client to care for hair, mouth, and nails. Some people prefer or need mouth care prior to their bath. (Kozier, 749)

12. Massage is a comfort measure that can aid relaxation, decrease muscle tension and ease anxiety because the physical contact between the
nurse and the client communicates care. The nurse plans to provide back massage to her client who always expresses anxiety towards her
incoming surgical procedure. The nurse decided to use Effleurage, she is aware that this massage technique involves:
A. The use of long, slow, gliding strokes
B. A firm, quick taps or strikes all over the body
C. Kneading the body by squeezing the soft tissues
D. The use of short, slow, circular strokes

Rationale:
Massage is a comfort measure that can aid relaxation, decrease muscle tension, and may ease anxiety because the physical contact communicates
caring. It can also decrease pain intensity by increasing superficial circulation to the area. Massage can involve the back and neck, hands and am is,
or feet. The use of ointments or liniments may provide localized pain relief with joint or muscle pain. Massage is contraindicated in areas of skin
breakdown, suspected clots, or infections
 EFFLEURAGE PETRISSAGE TAPOTEMENT
Effleurage means long, soothing, The movements which involve various ways of The fast and stimulating movements of
stroking movements which are performed using kneading, rolling and picking up the skin and massage are termed as Tapotement, or
the flat of the hand or fingers. One can apply oil muscles, is called Petrissage. These percussion movements. They include cupping,
evenly to the entire body using this method. movements help in strengthening the structures hacking, pounding (also called pummeling).
Relax the hands and mould them towards the by stimulating the deep layers of tissue, and Tapotement should not be used on a
contours of the body. Apply slightly more also help in increasing the supply of blood to particularly bony area or on broken or varicose
pressure when you take the stroke in the the area. At the same time, they also improve veins. The key to perfection is to keep the
direction of the heart to improve circulation and the flow of lymph. hands and wrists relaxed. These movements
lymph flow. If you are working away from the stimulate the blood circulation, tone and help
heart, keep the pressure firmer on the return It believes in working out a single group of strengthen sagging skin and muscles,
strokes. Following a fairly slow and continuous muscles, or an individual muscle, at a time. It is especially the soft tissue areas, such as thighs
movement is essential. performed by starting first with the fingers and buttocks, which are prone to cellulite.
pointing away from you, then pressing down
If Effleurage is used at the start of a massage, with the palm, grasping the flesh between While cupping, gently curve the hands to make
it helps in soothing and helping your fingers and thumb and pushing it towards the a loose-cupped shape, bending at the knuckles
partner get used to your touch. It also gives a other hand. A continuous action is followed while keeping the fingers straight and firm, do
relaxing finish, if used at the end of a which involves alternating the hands to not bend the fingers too far over. Using the
massage. In between, it helps in providing squeeze and release. Light kneading eases the cupped palm, make a cupping action against a
more stimulating strokes. top muscle layers, while firmer kneading works fleshy area, alternating the hands quickly,
on the deeper muscles. thereby creating suction against the skin.

While pounding (or pummeling), loosely clench

your fists, keeping the wrists relaxed. The
wrists can either stroke your partner with the
outer edges of the loose fist or with the front of
the knuckles. The speed and rhythm of the
movement will be brisk and firm, alternating the
hands, without too much thumping.

While hacking, the outer edge of the hand is

used to stimulate the area by striking it quickly
with alternate hands. The movement is brisk,
working rhythmically and rapidly over very
relaxed wrists and figures, and use the sides of
the palm rather than the fingers. Hacking also
helps in toning up the muscles and dispersing
the fluids.

13. Mr. Morrison is diagnosed of having Obstructive sleep apnea. His physician recommended multiple therapies and interventions to resolve the
problem. The nurse conducted health teaching about alcohol and smoking cessation but is aware that these actions are still not enough to
prevent apnea episodes. The treatment of choice for Mr. Morrison is:
A. Low flow oxygen therapy
B. CPAP device
C. Hypnosis
D. Cognitive therapy

Rationale:
Sleep apnea is characterized by frequent short breathing pauses during sleep. Although all individuals have occasional periods of apnea during
sleep, more than five apneic episodes or five breathing pauses longer than 10 seconds/hour is considered abnormal and should be evaluated by a
sleep medicine specialist.
 Symptoms suggestive of sleep apnea include loud snoring, frequent nocturnal awakenings, excessive daytime sleepiness, difficulties
falling asleep at night, morning headaches, memory and cognitive problems, and irritability. Although sleep apnea is most frequently
diagnosed in men and postmenopausal women, it may occur during childhood.
 The periods of apnea, which last from 10 seconds to 2 minutes, occur during REM or NREM sleep. Frequency of episodes ranges from 50
to 600 per night. Because these apneic pauses are usually associated with an arousal, clients frequently report that their sleep is
nonrestorative and that they regularly fall asleep when engaging in sedentary activities during the day.

Three common types of sleep apnea are obstructive apnea, central apnea, and mixed apnea.
 Obstructive apnea occurs when the structures of the pharynx or oral cavity block the flow of air. The person continues to try to breathe; that
is, the chest and abdominal muscles move. The movements of the diaphragm become stronger and stronger until the obstruction is
removed. Enlarged tonsils and adenoids, a deviated nasal septum, nasal polyps, and obesity predispose the client to obstructive apnea.
An episode of obstructive sleep apnea usually begins with snoring; thereafter, breathing ceases, followed by marked snorting as breathing
resumes. Toward the end of each apneic episode, increased carbon dioxide levels in the blood cause the client to wake.
 Central apnea is thought to involve a defect in the respiratory center of the brain. All actions involved in breathing, such as chest
movement and airflow, cease. Clients who have brainstem injuries and muscular dystrophy, for example, often have central sleep apnea.
At this time, there is no available treatment.
 Mixed apnea is a combination of central apnea and obstructive apnea.

Treatment for sleep apnea is directed at the cause of the apnea. For example, enlarged tonsils may be removed. Other surgical procedures,
including laser removal of excess tissue in the pharynx, reduce or eliminate snoring and may be effective in relieving the apnea. In other cases, the
use of a nasal continuous positive airway pressure (CPAP) device at night is effective in maintaining an open airway. Weight loss may also help
decrease the severity of symptoms.
 Sleep apnea profoundly affects a person's work or school performance. In addition, prolonged sleep apnea can cause a sharp rise in blood pressure
and may lead to cardiac arrest. Over time, apneic episodes can cause cardiac arrhythmias, pulmonary hypertension, and subsequent left-sided heart
failure (Kozier, 1191).

14. An arterial blood gas test measures the acidity and the oxygen and carbon dioxide levels in the blood from an artery. When obtaining blood
samples, the nurse must select superficial arteries such as the brachial, radial and femoral arteries. Nurse Jacob is to collect blood sample for
ABG testing. He incorrectly performs the test if he does which of the following:
A. Perform Allen’s test before attempting to get an arterial sample.
B. Use a heparinised syringe and needle. Leave 0.5 mL of heparin inside the syringe before obtaining blood sample.
C. After blood collection, apply cotton ball and pressure for at least 5 minutes on the site.
D. Remove the air bubbles in the syringe after blood collection.
Rationale:
Test Procedure:
i. Have the client either sit or lie supine.
ii. Assess the collateral circulation to the wrist and hand prior to the radial puncture. If the ulnar circulation is inadequate, another site must be
chosen.
iii. Place the client’s wrist with the dorsal side up on a small pillow, and ask the client to extend the fingers downward. Brings the radial artery
closer to the skin surface.
iv. Cleanse the site with a local antiseptic. If the client is allergic to iodine, use only alcohol. Serious allergic reactions can result from injection of an
allergen into an allergy.
v. The health care provider may choose to anesthetize the site with a local anesthetic.
vi. The health care provider punctures the radial artery with a heparinized syringe. Clots will alter results.
vii. Withdraw 2-3 mL of blood from the artery and the needle is removed.
viii. Place direct pressure on the puncture site with a sterile dressing. Arterial punctures can cause serious bleeding.
ix. Maintain digital pressure for 5 min; then apply a sterile dressing.
x. Air bubbles in the syringe are expelled, and it is placed immediately into the ice. Waiting longer than 2 min to place the sample into ice will alter
the results.
xi. Label the tube with the time the sample was collected, the client’s temperature, whether the client was breathing room air, oxygen or was
ventilated. Fever and assisted oxygen or breathing alters test interpretation.

 0.2 ml of blood is required for arterial blood gas sampling. If the syringe is heparinized, the heparin should be removed as completely as
possible before drawing blood into the syringe; excess heparin left in the syringe decreases the pH value, dilutes the sample, and lowers
the PaCO2. Before drawing a sample from an indwelling arterial line, the line should be cleared by withdrawing 1 to 2 ml of blood which is
returned immediately thereafter.

Nursing Care
Before Test: Explain the test procedure and the purpose of the test. Assess the client’s knowledge of the test. Explain that the radial puncture will be
done after a local anesthetic or, if no anesthetic used, will cause a brief, sharp pain. Take the client’s temperature.
During Test: Adhere to standard precautions.
After Test: Monitor the puncture site every 5-10 min for at least 30 min following the test for bleeding. Check for signs of nerve impairment distal to
the puncture. Apply pressure for at least 5-10 min to the arterial puncture site. Explain that some bruising, discomfort, and swelling may appear at
the site and that warm, moist compresses can alleviate this (Note: only applied after bleeding is stopped). Monitor for signs of infection. (Delmar,
101)

15. The nurse reviews an ABG result of one of his patients hooked to a mechanical ventilator and notes the following: pH of 7.43, PCO2 of 30
mmHg, and HCO3 of 20mEq/L. The nurse analyzes these results as indicating:
A. Metabolic acidosis, compensated
B. Metabolic alkalosis, compensated
C. Respiratory alkalosis, compensated
D. Respiratory acidosis, uncompensated

Rationale:
16. A 24-year old female client was rushed to the Emergency Department because of intentional aspirin overdose. The patient appears confused,
pale with complaints of dizziness. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following to
patients suffering from ASA overdose?
A. A decreased pH and an increased CO2
B. An increased pH with an increased HCO3
C. An increased pH and a decreased CO2
D. A decreased pH and a decreased HCO3

Rationale:
Aspirin causes metabolic acidosis as acid is the end product of aspirin metabolism.
 Option A: respiratory acidosis
 Option B: metabolic alkalosis
 Option C: respiratory alkalosis

17. Anticoagulants are drugs used to prolong bleeding time and thereby preventing blood clot formation. They are widely used in the treatment of
thromboembolic disease. Madam Buenavista, a 42-year old patient with DVT, is on the out-patient unit for follow-up after a week’s therapy of
warfarin (Coumadin). Which of the following clotting parameters would indicate the need to increase Madam Buenavista’s current dose of
warfarin?
A. aPTT is two times the patient’s baseline level
B. INR is 2
C. PT remains at the patient’s baseline level
D. PT is two times the patient’s baseline level

Rationale:
Prothrombin time (PT) is the parameter for measuring the effectiveness of warfarin therapy while aPTT is used for heparin. If the patient’s PT
increases one to two times than that of the baseline level, then warfarin therapy is effective. If it does not increase, increasing the dose of the drug
may be necessary to achieve the therapeutic level. INR can also be used, and a value of 2-3.5 is considered therapeutic. (Adams, 2007)
 To achieve the therapeutic level of both hepa and warfa, formula is Controlled value (CV) multiplied by 1.5 to 2 seconds

18. The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and temporal artery. Rectal temperature
readings are considered to be very accurate. Chichay, 30 months old, is brought to the ER due to high fever and diarrhea. With her age, the
nurse is aware that the preferred route is tympanic. In taking the temperature via this route, the nurse needs further knowledge if she performs
which of the following actions?
A. The nurse pulls the pinna straight back and slightly upward
B. The nurse pulls the pinna straight back and slightly downward.
C. The nurse inserts the probe in a circular motion.
D. The nurse directs the probe tip anteriorly, toward the eardrum.

Rationale:
For children, the tympanic or temporal artery sites are preferred. The child is held in an adult’s lap with the child’s head held gently against the adult
for support. Tympanic route is avoided in a child with active ear infections or tympanic membrane drainage tubes.
 Option A- done for children over age 3.
 Option B- done in a child under 3 years old.
 Option C- the probe is inserted using a circular motion until snug, or enough to seal the ear canal.
 Option D- The tip is inserted toward the eardrum, but does not touch the eardrum/ tympanic membrane.
(Kozier, 8th ed, pg 536- 537)

19. A body temperature above the usual range is called pyrexia, hyperthermia, or fever. A very high fever, such as 41 C, is called hyperpyrexia.
The nurse is assigned to care for a 2-year-old child who is diagnosed with an upper respiratory tract infection. While doing initial assessment,
the nurse noted a 39C fever, cough, and colds. He noticed that the fever have a wide reading fluctuation over the shift but are all above
normal. The nurse is correct to document this as what type of fever?
A. Intermittent fever
B. Remittent fever
C. Relapsing fever
D. Constant fever

Rationale:
Four common types of fever:
 Intermittent fever- the body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal
temperatures
 Remittent fever- a wide range of temperature fluctuations (more than 2C) occurs over the 24-hour period, all of which are above normal.
 Relapsing fever- short febrile periods of a few days are interspersed with periods of 1- 2 days of normal temperature
 Constant fever- the body temperature fluctuates minimally but always remains above normal.
(Kozier, 8th ed, pg 530)

20. A single elevated blood pressure reading indicates the need for reassessment. Hypertension cannot be diagnosed unless an elevated blood
pressure is found when measured twice at different times. Nurse Arya is caring for post MI patients in the cardiac unit. She is to monitor their
Vital Signs every hour paying particular attention to their blood pressure. In assessing the blood pressure, Nurse Arya will NOT be reprimanded
if she performs which of the following, except?
A. She supports the patient’s forearm at heart level with palms facing up.
B. She places the bell side of the amplifier of the stethoscope over the brachial pulse site.
C. She releases the valve of the cuff, allowing pressure to decrease at the rate of 1- 2 mmHg per second.
D. She waits for at least 1- 2 minutes before repeating another measurement.
Rationale:
The valve of the cuff is carefully released so that the pressure decreases at the rate of 2- 3 mmHg per second. If the rate is faster or slower, an error
in measurement may occur. Deflating the cuff too quickly causes erroneously low systolic and high diastolic readings. Deflating cuff too slowly
causes erroneously high diastolic readings.
 Option A- The elbow should be slightly flexed with the palm of the hand facing up and the forearm supported at heart level since the blood
pressure increases when the arm is below heart level and decreases when the arm is above heart level.
 Option B- The bell side is used because the blood pressure is a low- frequency sound where it is best heard.
 Option D- 1- 2 minutes is enough to permit blood trapped in the veins to be released. Repeating assessment too quickly causes
erroneously high systolic or low diastolic readings.
(Kozier, 8th ed, pg 555- 557)

21. The blood pressure is usually assessed in the client’s upper arm using the brachial artery and a standard stethoscope. A 33-year-old male burn
victim is rushed to the ER. Assessment revealed 2 nd degree chemical burns all over the chest and both upper extremities. The nurse promptly
takes the BP to determine the client’s hemodynamic status and places the client in which of the following positions?
A. Upright position
B. Supine position with knee slightly flexed
C. Prone position with head at the side
D. Modified Trendelenburg position

Rationale:
In situations when the blood pressure cannot be measured on either arm because of burns or other trauma, assessing the blood pressure on the
thigh is indicated. Normally, if BP is to be taken on the thigh, the client is placed on a prone position. However, if the client cannot assume this
position (because of burns in the chest) BP can be measured while the client is in supine position with the knee slightly flexed. Slight flexing of the
knee will facilitate placing the stethoscope on the popliteal space.
(Kozier, 8th ed, pg 554, 557)

22. A stethoscope is used in assessing the apical pulse which is indicated for clients with cardiovascular, pulmonary, and renal diseases and those
receiving medications that affect heart action. Nurse Yna is caring for a client with CHF who is receiving Digoxin. Prior to giving the drug, she
remembers to assess the client’s apical pulse first. Nurse Yna incorrectly uses the stethoscope when she performs which of the following
actions, aside from?
A. Insert the ear piece of the stethoscope into the ears tilting them slightly forward.
B. Place the stethoscope against the chest after disinfecting it.
C. Place the stethoscope over the client’s clothing and listen for heart sounds.
D. Use the bell side of the stethoscope when listening to heart sounds.

Rationale:
The earpieces of the stethoscope are inserted into the ears in the direction of the ear canal, or slightly forward to facilitate hearing.
 Option B- After disinfecting, the diaphragm of the stethoscope is warmed by holding it in the palm of the hand for a moment before placing
it against the chest. The metal of the diaphragm is usually cold and can startle the client when placed immediately over the chest.
 Option C- Stethoscope is placed directly on the skin, not over the clothing in order to avoid noise made from rubbing the amplifier against
cloth.
 Option D- The diaphragm of the stethoscope is used in listening for heart sounds.
(Kozier, 8th ed, pg 544, 556)

23. The nurse is working on the Out-Patient Department of a Tertiary Hospital. A client approached the nurse with complaints of diminished hearing
on the right ear. He performed the Weber’s test and the client stated that he can hear the sound better on his right ear. Based on the client’s
response, the nurse evaluated that:
A. The client may be experiencing a bone conductive hearing loss
B. The client has sensorineural disturbance
C. Cranial nerve 8 damage may be suspected
D. It is a normal response to the test

Rationale:
WEBER TEST – lateralization test that compares right and left ear
 NEGATIVE – normal finding
 Sound is heard in both ears or is localized at the center of the head

 POSITIVE – abnormal finding

 Sound is heard better in impaired ear – Bone conductive hearing loss
 Sound is heard better in normal ear – sensorineural hearing loss
(ULG, 40)
24. The nurse is to perform the Rinne’s test to his client to assess for any hearing disturbances. He inaccurately performed the test if he did which
of the following, except:
A. Strike the tuning fork softly with the back of the hand and place it in the center of the client’s head or forehead then ask the client on what
ear is the sound heard better.
B. Strike a tuning fork and place the prongs in front of the external auditory ear canal. Ask the client when she can no longer hear the sound.
Move the base of the tuning fork on the mastoid process then ask when the client can no longer hear the sound.
C. Strike a tuning fork and place the base of the tuning fork on the mastoid process. Ask the client when she can no longer hear the sound.
Remove and strike again the tuning fork and place the prongs in front of the external auditory canal. Ask the client when she can no longer
hear the sound.
D. Strike a tuning fork and place the base on the mastoid process. Ask the client to tell you when the sound is no longer heard, then move the
tuning fork in front of the external auditory canal. Ask the client when she can no longer hear the sound.

Rationale:
RINNE TEST – compares air conduction with bone conduction
 POSITIVE – normal finding
 Air conduction is greater than bone conduction

 NEGATIVE – abnormal finding

 Bone conduction time is equal to or longer than air conduction (Conductive hearing loss)

Conducting the Rinne Test:

i. Hold the handle of the activated tuning fork on the mastoid process of one ear until the client states that the vibration can no longer be heard.
ii. Immediately hold the still vibrating fork prongs in front of the client’s ear canal.
iii. Push aside the client’s hair if necessary.
iv. Ask whether the client now hears the sound. Sound conducted by air is heard more readily than sound conducted bone. The tuning fork
vibrations conducted by air are normally heard longer. (Kozier, 607)

25. Gentamicin is an aminoglycoside antibiotic, used to treat many types of bacterial infections, caused by Gram-negative organisms. A 6 lb baby
boy with neonatal sepsis is ordered to receive gentamicin at 2.5 mg/kg/dose through IV every 12 hours. The stock of gentamicin in the 2 ml
ampule is 20 mg/ml. How many ml of the solution should the nurse administer each dose?
A. 0.31 ml
 B. 0.68 ml
C. 0.34 ml
D. 0.25 ml

Rationale:
Order: Gentamicin 2.5mg/kg/dose IV
Weight: 6lbs (convert  1kg= 2.2 lbs  6/ 2.2= 2.7 kg)
Desired: 2.5mg x 2.7 kg= 6.75mg/dose
Stock: 20mg/mL
D
Formula: x vol/tab
H
6.75 mg
Solution: x 1 ml=0.34 mL
20 mg
26. A nutritional program was initiated by nursing students in Brgy. Walang-bahid. Their program on nutrition, “Kumain ng Masustansiya, Para sa
Buhay na Masaya,” targets those members of the community who were identified to have faulty nutritional practices. In what level of prevention
does this intervention falls under?
A. Tertiary Prevention
B. Secondary Prevention
C. Specific Prevention
D. Primordial Prevention

Rationale:
A. Tertiary prevention is not the answer because activities under this level are for rehabilitation.
B. Secondary prevention is not the answer because it refers to early detection and treatment.
C. Specific prevention is the answer because the nurse is doing a health promotion class for those identified to have existing risk factors.
D. This is not the answer because interventions under this level are those aimed to prevent occurrence of risk factors. In the situation, there is
already an existing risk factor.

Levels of Prevention:
Primary Prevention – health promotion and disease prevention, e.g. immunization
 Primordial Prevention – prevention of the occurrence of risk factors, e.g. health education about smoking for preschoolers
 Specific Prevention – prevent the progression or eliminate risk factors, e.g. smoking cessation program for smokers
Secondary Prevention – early detection and treatment, e.g. OPLAN Timbang, DSSM
Tertiary Prevention – rehabilitation, e.g. health education on insulin therapy for chronically-ill diabetic patients

27. Before conducting a home visit, the nurse checks the clients’ records in the health center to have a background of their case and to formulate
objectives of the visit. This activity is included under which phase?
A. Professional
B. Closing
C. Planning
D. Socializing

Rationale:
Principles involved in preparing for a home visit:
 Have a purpose or objective
 Use available information (use of family records)
 Give priority to needs of individual and family
 Involve clients in the delivery of care
 Flexible plan
The home visit is a family-nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary
nursing care. In performing this activity, it is essential to prepare a plan of visit to meet the needs of the client and achieve best results or outcomes.
Planning for the care of the client includes a statement of objectives.

The nursing process is a systematic, scientific, dynamic, on-going interpersonal process in which the nurses and clients are viewed as a system with
each affecting the other. It is central to all nursing actions~ it is the very essence of nursing.
COMMUNITY HEALTH NURSING PROCESS
1. ASSESSMENT
a. Initiate contact- mutual trust and confidence
b. Demonstrate caring attitudes
c. Collect date from all possible sources
d. Identify health problems- categories of health problems (health deficit, health threat, forseeable crisis)
e. Assess coping ability
f. Analyze and interpret data
2. PLANNING NURSING ACTION
a. Prioritize needs
b. Establish goals based on needs
c. Construct a plan of action
d. Develop evaluation parameters
3. IMPLEMENTATION OF PLANNED CARE
a. Put NCP into action
b. Coordinate care/ services
c. Utilize community resources
 d. Delegate, supervise, monitor health services provided
e. Provide health education and training
f. Document responses to nursing action
4. EVALUATION
a. Nursing audit
b. Performance appraisal
c. Estimate cost benefit ratio
d. Revise plans as necessary
e. Identify needed alterations
(PHN by Reyala, pg 43)

28. During a home visit the nurse primarily focuses on the condition of the client. Aside from the client’s condition, which among the following
factors should the nurse prioritize:
A. Pay particular attention to the economic status of the family
B. Observe the family and the environment
C. Put emphasis on the children’s education
D. Observe the family’s spiritual practices

Rationale:
Purposes of Home Visit:
 Care is given to clients (to the sick, post partum mother and her newborn)
 Assess living conditions (to provide the appropriate health teaching)
 Relationship is established (between health agencies and public for the promotion of health)
 Educate regarding disease control & prevention
 Service utilization promotion (to promote the utilization of community services)

29. Nursing care in the home is giving to the individual patient the nursing care required by his specific illness to help him reach a level of
functioning at which he can maintain himself, or die peacefully in dignity. As a public health nurse, Leah must reach out to the families in far-
flung areas who cannot go to the health center. Leah is aware that all of the following are correct in giving nursing care in the home, aside from?
A. Nursing care is a meager opportunity in monitoring the progress of the patient.
B. Nursing care utilizes a medical plan of care and treatment.
C. Nursing care given at home is used as a teaching opportunity.
D. Nursing care given utilizes skill that would give maximum comfort.

Rationale:
Option A- It is not a meager, but a good opportunity to monitor patient’s progress

Principles in Nursing Care in the Home

1. Nursing care utilizes a medical plan of care and treatment.
2. The performance of nursing care utilizes skills that would give maximum comfort and security to the individual.
3. Nursing care given at home should be used as a teaching opportunity to the patient or to any responsible member of the family.
4. The performance of nursing care should recognize dangers in the patient’s over-prolonged acceptance of support and comfort.
5. Nursing care is a good opportunity for detecting abnormal signs and symptoms observing patient’s attitude towards care given and the
progress exhibited by the patient.
(Reyala, pg 54)

30. When planning to go on a home visit, it is necessary to assemble the records of the patients and list the names to be visited, study the case and
have a written nursing care plan. Among the patients the public health nurse has visited, who among them should be the LEAST priority in the
next visit?
A. Buboy, 7 years old, who is malnourished and has parasitism
B. A 3-day postpartum mother
C. Family planning program drop-outs
D. The Prima family who wants to learn about herbal medicines

Rationale:
The schedule of the visit may vary according to the need of the patient or family for nursing care.
Guidelines to consider regarding the Frequency of home visits:
 Needs of clients (physical, psychological, and educational needs)
 Acceptance of family and willingness to cooperate (least prioritize program drop-outs, uncooperative, and unwilling individuals)
 Policy
 Other health agencies & personnel involved
 Past services given
 Ability to recognize own needs

31. The bag technique is a tool by which the nurse will be able to perform a nursing procedure with ease and deftness. The nurse is performing the
bag technique. She is aware that among the following, which is considered an important principle of bag technique?
A. The bag should contain all necessary articles.
B. The bag technique can be performed in a variety of ways.
C. The arrangement of the bag’s contents should be what is convenient to the nurse.
D. The bag should be cleaned very often.

Rationale:
The bag technique is a tool by which the nurse, during her visit, will enable her to perform a nursing procedure with ease and deftness, to save time
and effort.
Principles of Bag Technique:
1. Minimize, if not prevent the spread of infection
2. Saves time and effort of the nurse
3. Should show effectiveness of total care given to an individual or family
4. Can be performed in a variety of ways

The Public Health Bag is an essential and indispensable equipment of a public health nurse which she has to carry along during her home visits.
Points to Consider in the use of the BAG:
1. The bag should contain all necessary articles, supplies, and equipments that will be used
2. The bag and its contents should be cleaned very often
3. The bag and its contents should be well-protected from contact with any articles in the patient’s homes
4. The arrangement of the contents of the bag should be the one most convenient to the user.
(ULG by Balita, pg 372)

32. The Bag Technique is a tool by which the nurse, during her visit will enable her to perform a nursing procedure with ease and deftness. Nurse
Paolo conducted a home visit to the Greyjoy Family. He is now to perform the bag technique, which of the following actions made by Paolo
shows that he has adequate knowledge regarding the proper use of the PHN Bag?
A. Nurse Paolo placed his PHN bag on top of a stable table.
B. The arrangement of the contents of the PHN Bag is based on Paolo’s own choice.
C. Nurse Paolo placed his BP cuff inside the PHN Bag.
D. After removing the apron, Nurse Paolo folded it towards him with the soiled side out and the clean side in, then placed it inside the PHN
Bag.

Rationale:
Important points to consider in the Use of the Bag:
1. The bag should contain all the necessary articles, supplies and equipments that will be used to answer emergency needs.
2. The bag and its contents should be cleaned very often, the supplies replaces, and ready for use anytime.
3. The bag and its contents should be well protected from contact with any article in the patient’s home. Consider the bag and its contents
clean and sterile, while articles that belong to the patients as dirty and contaminated.
4. The arrangement of the contents of the bag should be the one most convenient to the user, to facilitate efficiency and avoid confusion.
(Public Health Nursing in the Philippines: 2007. 10th edition. [pp. 53])
**Before putting the bag on top of the table, a paper lining should be placed first.

33. The public health bag contains basic medications and articles which are necessary for giving care. Only necessary articles and equipment
should be contained inside the PHN bag. Bearing this in mind, while Student Nurse Kylie is inspecting the contents of her PHN bag, she would
have to remove which of the following items, except:
A. Sulfuric acid
B. Baby’s scale
C. Hypodermic needle gauge 26
D. Masking tape

Rationale:
Sphygmomanometer (BP apparatus) and stethoscope are carried separately.

Contents of the PHN bag:

 Paper lining
 Extra paper for making waste bag
 Plastic/linen lining
 Apron
 Hand towel
 Soap in a soap dish
 Thermometers (oral and rectal)
 2 pairs of scissors (surgical and bandage)
 2 pairs of forceps (curved and straight)
 Disposable syringes with needles gauge 23 and 25
 Hypodermic needles gauge 19, 22,23, 25
 Sterile dressing
 Cotton balls (dry and with alcohol)
 Cord clamp
 Micropore plaster
 Tape measure
 1 pair of sterile gloves
 Baby’s scale
 Alcohol lamp
 2 test tubes
 Test tube holders
 Solutions of:
a. Betadine
b. Zephiran solution
c. Spirit of ammonia
d. Acetic acid
e. 70% alcohol
 f. Hydrogen peroxide
g. Ophthalmic ointment
h. Benedict’s solution
(Reyala, pg 52)

34. The Public Health Nurse uses various tools and procedures necessary for her to properly practice her profession and deliver basic health
service. Nurse Varys was observing Nurse Tyrion while the latter was performing bag technique during their home visit on one of their clients.
He will not have to correct him if he does the following actions, except:
A. Nurse Tyrion takes out the apron from the bag and put it on with the wrong side out.
B. He closes the bag and puts it in one corner of the living room.
C. Nurse Tyrion cleans all the articles that were used and performs handwashing.
D. He removes her apron, folding it away from him, the soiled side in and the clean side out.

Rationale:
Option B- Putting the bag in one corner of the living room would help prevent the bag from getting contaminated and from getting in the way of the
nurse.
Option C- Cleaning the articles used and performing hand hygiene is necessary to prevent the transfer of microorganisms from the patients to the
nurses and to the other patients that would be using the bag in the future.
Option D- Folding the apron away from the nurse would ensure that the soiled side would not touch the nurse.

Option A- Keeping the soiled side inside, and the clean side out, would minimize contamination of the apron with the other articles inside the bag.
The apron should be worn with the right side out, this would ensure that the care giver’s uniform is protected from being contaminated.
(Reyala, pg 53)

35. Effectivity, Efficiency, and Appropriateness are major criteria for selecting the type of family- nurse contact. The nurse is to conduct several
diagnostic procedures for a client who is suspected of having Tuberculosis. The most appropriate family – nurse contact to utilize in this
scenario is which of the following?
A. Job Site Visit
B. Telephone Conference
C. Clinic Conference
D. Written Communication

Rationale:
 CLINIC CONFERENCE – otherwise known as Office conference; less expensive for the nurse and provides the opportunity to use equipment
that cannot be taken to the home. In some cases, the other team members in the clinic may be consulted or called upon to provide additional
service. The clinic or office conference also emphasizes to the family the importance of empowerment and assuming responsibility for self-
help.
 TELEPHONE CONFERENCE – may be effective, efficient and appropriate if the objectives and outcomes of care require immediate access
to data, given problems on distance or travel time. Such data include monitoring of health status or progress during the acute phase of an
illness state, change in schedule of visit or family decision, and updates on outcomes or responses to care or treatment.
 WRTTEN COMMUNICATION – less time-consuming option for the nurse in instances when there are many priority families needing follow-
up on top of problems of distance and travel time. If the family is motivated and independent enough such that the nurse can use the
advantage of placing responsibility for action on the family, sending a letter, note (as reminder, follow-up on medication/ treatment or update
on progress or referral) and learning materials are appropriate, effective, and efficient options.
 SCHOOL VISIT OR CONFERENCE – provides a n opportunity to work with the family and school authorities on how to determine the degree
of vulnerability of and work out interventions to help children and adolescents on specific health risks, hazards, or adjustment problems.
 INDUSTRIAL PLANT OR JOB SITE VISIT – done when the nurse and the family need to make an accurate assessment of health risks or
hazards, and work with employer or supervisor on what can be done to improve on provisions for health and safety of workers. (Nursing
Practice in the Community; 2009. 5th edition. Araceli S. Maglaya. [pp. 91])

36. A mother brought her 3-year old child to the health complaining of stomachache and diarrhea. You are suspecting that the child has worm
infection. She said that she already gave her child 4 seeds of niyug-niyugan and she plans to give her child more since one of the nurses in
their barangay told her that it is a proven herbal medicine against parasitic infection. What is the best advice that you can give to the mother?
A. Ask the mother if there are any worms that has been expelled and instruct her to give another dose after 2 weeks if there is none
B. Ask the mother if there are any worms that has been expelled and instruct her to give another dose after one week if there is none
C. Advice the mother to give 5 seeds instead
D. Advice the mother to stop giving her child niyug-niyugan seeds

Rationale:
A - This is not part of the guidelines on the use of niyug-niyugan.
B - This is only applicable if the child’s age is 4 years old and above.
C - This is only applicable for child age 4 to 5 years old.
D - Niyug-niyugan seeds are contraindicated for children below 4 years old.

Niyug-niyogan:
 Indication: Helminthiasis
 Contraindication: Not to be given to children below 4 years old; give anti-helminthic (mebendazole/albendazole) instead
 Preparation: Seeds are taken 2 hours after supper, may be repeated after one week if no worms are expelled
o Adult: 8-10 seeds
o 7-12 years old 6-7 seeds
o 6-8 years old 5-6 seeds
o 4-5 years old 4-5 seeds
37. You are assigned in a far-flung area as a community health nurse. One of your projects is the development of a herbal garden. One member of
the community asked you, “What are the herbal medicines that I can use for my toothache?” You answered it correctly if you said,
A. “Lagundi, Bawang and Guava can be used for your toothache.”
B. “Bawang, Yerba Buena and Guava can be used for your toothache.”
C. “Sambong, Bawang and Guava can be used for your toothache.”
D. “Bawang, Tsaang-Gubat and Guava can be used for your toothache.”

Rationale:
A. Lagundi is not recommended for toothache but rather for cough, colds, skin diseases, headache among others.
B. All of these herbal medicines are recommended for toothache.
C. Sambong is not a recommended herbal treatment for toothache. It is an anti-edema, diuretic and an anti-urolithiasis.
D. Tsaang Gubat is not a recommended herbal treatment for toothache. It is used for stomachache and diarrhea.

38. There has been a steady increase in the number of households having access to safe water supply sources; however, there is still insufficient
knowledge and inappropriate practices in the handling of water from the source up to the storage point in the house that could contaminate
drinking water. The nurse is conducting a health class regarding the different types of water supply facilities. Which among the following
statements by the nurse needs to be corrected?
A. “A level I facility normally serves around 15 to 25 households and its outreach must not be more than 250 meters from the farthest user.”
B. “Level II facilities are also known as point source facilities which are located not more than 25 meters from the farthest house.”
C. “A Level III facility is a system with a source, a reservoir, a piped distributor network and household taps.”
D. None of the above

Rationale:
Approved types of water supply facilities:
 Level I (Point Source)
o Outlet without a distribution system
o Serves 15-25 households
o Not more than 250 meters from farthest user
o Ex: protected well or a developed spring
 Level II (Communal Faucet System or Stand Posts)
o Source, reservoir, piped distribution network and communal faucets
o Located not more than 25 meters from farthest house
o Serves 100 households (with 1 faucet/4-6 houses)
 Level III (Waterworks System or Individual House Connections)
o Source, reservoir, piped distribution network and household taps
o Requires minimum treatment or disinfection
(PHN by Reyala, 2007, pg 313)

39. It is significant to note that there has been an increase in the proportion of households having sanitary toilet facilities both in the urban and rural
areas but there is also an increase in the absolute number of persons, which do not have an access to sanitary toilet facilities. Which among the
following statements made by a community folk would necessitate further teaching from the nurse?
A. “Our toilet facility requires pour flushing of small amounts of water to wash the waste into the receiving space; it is therefore considered as
Level I toilet facility.”
B. “As a Level II toilet facility, we use a water carriage type with water-sealed and flush type with septic tank disposal facilities.”
C. “Level III toilet facilities are connected to septic tanks and/or sewerage systems and are consequently connected to treatment plants.”
D. None of the above

Rationale:
Approved Types of Toilet Facilities:
 Level I
o Non-water carriage toilet facility (pit latrines)- no water is necessary to wash the waste
o Small amounts of water to wash waste into receiving space (pour flush, aqua privies)
 Level II
o Water sealed and flush type with septic vault/ tank disposal facilities
 Level III
o Water carriage connected to septic tanks and/or to sewerage system to treatment plant
(PHN by Reyala, 2007, pg 314)

40. Sanitation is very important in the community because most of the diseases there are can be acquired through improper wastes disposal,
pollution and poor food handling. There are four rights on food preparation safety which involve the process from obtaining raw products to
serving food. After conducting teachings to a group of housewives in Barangay Tsuwariwap, the nurse evaluated what the mothers have
learned before formally ending the session. Which statement made by the mothers will indicate that the goals were met?
A. “I should ensure that all parts of the food I’m cooking reach 60 degrees centigrade.”
B. “Whenever I doubt the source of the water, I should just boil the water up to 2 minutes.”
C. “I should not leave any cooked food outside the refrigerator for more than an hour.”
D. “Microorganisms easily multiply if food is kept at 10-70 degrees centigrade.”

Rationale:
When in doubt of the water source, boil water for 2 minutes. Letter A – ensure that the temperature of all parts of the food should reach 70 degrees.
Letter C – all cooked foods should be left at room temperature for not more than two hours to prevent multiplication of bacteria. Letter D –
Microorganisms easily multiply within the 10-60 degrees centigrade. (Reyala. 2007 ed. pp. 316)
41. A good clinical eye is needed in dengue to detect early signs of complications like bleeding and shock. There is no specific treatment for
dengue infection only symptomatic and supportive care is given. All of the following are true in Dengue Hemorrhagic Fever, except:
A. Characterized by thrombocytopenia
B. There is no specific treatment for DHF
C. Transmitted through the bite of a night biting Aedis Aegypti
D. Increased incidence is related to poor environmental sanitation

Rationale:
Dengue Hemorrhagic Fever:
 Etiologic Agent: Dengue virus 1, 2, 3, and 4 and Chikungungya virus
 Source of Infection: Bite of Aedes aegypti (day biting female mosquito that breeds in household or standing clean water)
 Incubation Period: 6 days- 1 week
 Occurrence: Cases peak in the months of June- November. Usually affects children 5-9 years old.
 Pathophysiology: increased vascular permeability and abnormal hemostasis (vasculopathy, thrombocytopenia, and coagulopathy)
 Diagnostic Test: Tourniquet Test (Rumpel Leads Test)
o (+) when 20 or more petechiae per 1 inch square are observed
 Symtomatic and supportive treatment!
 Control Measures: Eliminate vector by good environmental sanitation.
(ULG by Balita, pg 405)

42. The DOH, together with its partners, launched another campaign namely “Aksyon Barangay Kontra Dengue” or ABaKaDa that seeks to
reinforce the country’s drive against dengue by going back to the basics of comprehensive vector control supported by environmental
manipulation and modification. Which among the following activities is not supported by this campaign to control the increasing number of cases
of dengue in the Philippines?
A. Juan, who aims to search and destroy mosquito breeding places.
B. Pepe, who wears long-sleeved shirts to protect himself against mosquito bites.
C. Jose, who does not advocate fogging due to its impracticality.
D. Pedro, who seeks advice or consultation at the nearest health center.

Rationale:
ABaKaDa 4 S:
 Search & destroy mosquito breeding sites
 Self-protection by wearing long-sleeved shirts
 Seek early advise/consultation
 Say yes to fogging only when there is an impending outbreak (Option C)

43. Communicable diseases occur in every country, in every urban and rural area, and in every neighborhood, from the very rich to the very poor.
Physicians will usually diagnose the type of dengue virus and then begin to look for signs of dengue hemorrhagic fever. The tourniquet test is a
presumptive test which is positive in the presence of:
A. >20 petechiae in 1 square centimetre after 5 minutes
B. >20 petechiae in 1 square centimetre after 3 minutes
C. >20 petechiae in 1 square inch after 5 minutes
D. >20 petechiae in 1 square inch after 3 minutes

Rationale:
DENGUE DIAGNOSIS:
Tourniquet test (capillary fragility test or Rumpel Leads Test), a presumptive test which is positive in the presence of more than 20 petechiae within
an inch square, after 5 minutes of test

TOURNIQUET TEST PROCEDURE (BP Cuff):

1. Take the blood pressure. Take note of the Systolic and the diastolic pressure.
2. Take the average of the systolic and the diastolic pressure.
3. Inflate the BP cuff up to the average of the systolic and the diastolic and maintain inflated for 5 minutes.
4. After 5 minutes, deflate the cuff and draw an imaginary 1x1 inch box and count the petichiae within the imaginary box.
(Ultimate Learning Guide for Nursing Review by Dr. Carl E. Balita page 405)

44. Dengue is the most common mosquito-borne viral disease of humans that in recent years has become a major international public health
concern. Under what grade will you categorize a client whose temperature is 38.5 C, with a positive tourniquet test, abdominal pain, and
epistaxis?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4

Rationale:

Grade I Grade II Grade III Grade IV

Fever; (+) tourniquet test; (I); plus spontaneous bleeding (II); plus circulatory failure: weak, (III); plus profound shock with
abdominal pain thread pulse; narrow pulse undetectable pulse and blood
pressure; hypotension; pressure
restlessness
TREATMENT AND MANAGEMENT
DOH STRATEGIES  symptomatic and supportive relief
Case diagnosis, management, referral
Health education/ advocacy  fluids (most important treatment) like oresol and IV
Rapid response mosquito control  paracetamol (no aspirin)
Research and project development  fresh whole blood transfusion is ordered if thrombocytopenia and platelet declines
Integrated vector control  for nose bleeding, flex the neck to prevent aspiration
Surveillance  avoid unnecessary movement
Training  assist in the management of shock. Dorsal recumbent to trendelenburg position
 provide warmth
 monitor vital signs, especially temperature because the critical period for early
signs of shock is the transition from febrile to afebrile phase

(Ultimate Learning Guide for Nursing Review by Dr. Carl E. Balita page 405)
(http://www.unilab.com.ph/consumers/articles-and-advisories/physical/how-to-prevent-dengue/)

45. Thrombocytopenia, hemoconcentration and prolonged PT, PTT are seen in patients with dengue infections. A client with dengue suddenly had
an episode of epistaxis. All of the following are correct in the management of epistaxis, except:
A. Applying ice compress on the bridge of the nose
B. Applying a nasal pack moistened with epinephrine on the site
C. Tilting the head backward to control bleeding
D. All of the above are correct

Rationale:
Management of Epistaxis:
1. Apply direct pressure—pinch the soft outer portion of the nose 5-10 minutes continuously.
2. Allow patient to sit upright with head tilted forward (prevent swallowing and aspiration of blood).
3. Administration of cotton pledgets soaked in vasoconstricting solution (epinephrine, phenilephrine, cocaine) into the nose
(Brunner, 10th ed, pg 504)

46. Mr. and Mrs. Macaspac is a newlywed couple. 5 months after their wedding, Mrs. Macaspac found out that she is 4 weeks pregnant. She and
her husband wanted to make sure that everything is fine so they decided to go to the nearby clinic. Mrs. Macaspac complained to you that she
feels nauseated every morning and couldn’t find a way to stop it and feel well. You have made an incorrect response when you state:
A. “You should eat Sky Flakes in the morning before you get out of bed.”
B. “You shouldn’t eat fried, greasy, or spicy foods.”
C. “You should avoid foods with strong or bothersome odors.”
D. “You should remember to eat three large meals per day to ensure adequate nutrition.”

Rationale:
Eating three large meals per day causes the woman to have a full stomach which then contributes to vomiting. This is not advisable. On the other
hand small frequent meals are desirable because the stomach won’t be too full and will be easily digested. Advising her to eat dry foods like
crackers or oats in the morning before she gets out from bed would relieve her feeling of nausea. Avoiding foods with strong odor would help prevent
the stimulation of Gag reflex.

47. Nurses are responsible for providing pre-natal education in order to help address the possible discomforts which mothers may experience
during pregnancy. During a pre-natal visit of Mrs. Greta, 12 weeks pregnant, she confided that she has been experiencing muscle cramps. She
asked what she can do to deal with this discomfort. You will advise her to do which of the following:
A. Lie on her abdomen with knees extended and foot dorsiflexed until pain disappears
B. Lower milk intake every day as prescribed by the physician
C. Rest on her back with legs raised against the wall twice each day
D. Elevate affected leg and assume full leg extension several times each day

Rationale:
Lowering milk intake and supplementing with calcium lactate may help reduce phosphorous level. Decreased serum calcium, increased serum
phosphorous levels and interference with circulation commonly cause muscle cramps of the lower extremities during pregnancy. Letter A – Patient
must lie on her back, and not on her abdomen. Letter C – resting on her back with legs raised against the wall or elevated on a footstool twice each
day is a good precaution for varicosities. Letter D – Legs may be elevated frequently during the day to improve circulation, but full leg extension must
be avoided. (Pilliteri. 5th ed. pp. 280-282)

48. In Bartholomew’s rule of 4, when the level of the fundus is midway between the umbilicus and the xiphoid process, the estimated age of
gestation (AOG) is:
A. 5 months
B. 6 months
C. 7 months
D. 8 months

Rationale:
In Bartholomew’s rule of 4, the landmarks used are the symphysis pubis, umbilicus and xyphoid process. At the level of the umbilicus, the AOG is
approximately 5 months and at the level of the xyphoid process, 9 months. Thus, midway between these two landmarks would be considered as 7
months AOG.

49. A curious pregnant client asked her nurse about the different procedures and tests that would be done to determine fetal well-being. Because
the nurse is equipped with full knowledge, she explained each tests with their respective dates on when they will be performed. Which of the
following pairs are correctly matched?
 A. Fetal Electrocardiography: 8th week of pregnancy
B. Maternal serum Alpha fetoprotein: 15th week of pregnancy
C. Chorionic villi sampling: 16th-17th week of pregnancy
D. Amniocentesis: 11th week

Rationale:
There are number of actions or procedures which are helpful in detecting and documenting the fetal wellbeing. The following are the specific tests to
be done during pregnancy:
 Fetal ECG may be recorded as early as the 11th week of pregnancy. It is rarely used unless a specific heart anomaly is suspected.
 Alpha fetoprotein is a substance produced by the fetal liver that is present in the amniotic fluid and maternal serum. The level is abnormally
high if the fetus has an open spinal or abdominal defect. The level is abnormally low if the fetus has a chromosomal defect. It is traditionally
done during the 15th week of pregnancy.
 Chorionic Villi sampling is a biopsy and chromosomal analysis of chorionic villi that is done at 10 to 12th weeks of pregnancy.
 Amniocentesis is the aspiration of amniotic fluid from the pregnant uterus for examination which is typically scheduled between the 14 th and
16th weeks of pregnancy to allow for a generous amount of amniotic fluid to be present.
 Percutaneous umbilical blood sampling is the aspiration of blood from the umbilical vein for analysis.
 Fetoscopy is used in which the fetus is visualized by inspection through a fetoscope. Usually done at about the 16 th or 17th week of
pregnancy.

50. The passenger is the fetus. Whether a fetal skull can pass or not depends on both its structure and its alignment with the pelvis. A 22-year-old
primigravid woman came to the clinic to have her prenatal check-up. She told the nurse that she has read some pregnancy books and asked
him to describe the significance of fetal position. The nurse answers appropriately if he tells her which of the following:
A. “It is the relationship of your baby’s presenting part to your pelvis.”
B. “It simply shows the posture of your baby.”
C. “It can be your baby’s head or feet at your cervical os.”
D. “It shows the relationship of the fetal long axis to the mother’”

Rationale:
Fetal position is the relationship of the presenting part to a specific quadrant of a woman’s pelvis. Position is important because it influences the
process and efficiency of labor. Typically, a fetus is born fastest from an ROA (Right occipitoanterior) and LOA (left occipitoanterior) position.
Posterior positions may be painful for the mother because the rotation of the fetal head puts pressure on the sacral nerves, causing sharp back pain.
 Option B- Fetal attitude: Attitude describes the degree of flexion a fetus assumes during labor. The fetus may be in complete flexion (good
attitude), military position (moderate flexion), or partial extension.
 Option C- Fetal presentation: this denotes the body part that will first contact the cervix of be born first. It may be cephalic (vertex, brow,
face, or mentum), breech (complete, frank, or footling), and shoulder presentation.
 Option D- Fetal Lie: It is the relationship between the long axis of the fetal body and the long axis of the woman’s body. It determines
whether the fetus is lying in a horizontal (transverse) or vertical (longitudinal) position.
(Pillitteri, 5th ed, pg 493- 497)

51. The more a woman knows about true labor signs, the better, because then she will be able to recognize them. This is helpful to prevent preterm
birth and for the woman to feel secure during labor. The nurse is teaching a primigravid pregnant woman how to distinguish prelabor
contractions from true labor contractions. Which statements of the pregnant woman would indicate that she is experiencing prelabor
contractions?
1. “They’re regular.”
2. “I feel a pulling and tightening sensation over my pubic bone.”
3. “I feel them in my abdomen and groin.”
4. “They become more intense during walking.”
5. “They start in the back and radiate to the abdomen.”
6. “They disappear when I start to sleep.”

A. 1, 2, 4, and 5
B. 2, 3, 5, and 6
C. All except 1, 4, and 5
D. None except 2, 4, and 5

Rationale:
Signs of true labor involve uterine and cervical changes.

Difference Between True and False Labor Contractions

FALSE CONTRACTIONS TRUE CONTRACTIONS

Begin and remain irregular. Begin irregularly but become regular and
predictable.
Felt first abdominally and remain confined to Felt first in lower back and sweep around the
the abdomen and groin. abdomen in a wave.
Often disappear with ambulation and sleep. Continue no matter what the woman’s level of
activity.
Do not increase in duration, frequency, or Increase in duration, frequency, and intensity.
intensity.
Do not achieve cervical dilatation. Achieve cervical dilatation.

Braxton Hicks contractions cause pulling or tightening sensations, primarily over the pubic bone. Although these contractions may occur throughout
the pregnancy, they’re most noticeable during the last 6 weeks of gestation in primigravid clients and the last 3-4 months in multiparous clients.
(Pillitteri, 5th ed, pg 490)
52. To monitor the frequency of uterine contraction during labor, the right technique is to time the contraction:
A. From the beginning of one contraction to the end of the same contraction
B. From the beginning of one contraction to the beginning of the next contraction
C. From the end of one contraction to the beginning of the next contraction
D. From the deceleration of one contraction to the acme of the next contraction

Rationale:
Frequency of the uterine contraction is defined as from the beginning of one contraction to the beginning of another contraction. (OPTION B)
OPTION A: DURATION of contraction
OPTION C: INTERVAL
OPTION D: Acme is the technical term for the highest point of intensity of a uterine contraction.

53. Irelia, in her 9-month of pregnancy, was rushed to the emergency section of the OB-GYN Department because she felt contractions of
increasing intensity. The resident physician assessed the patient and said that the patient is in the latent phase of the 1 st stage of labor. Which
of the following is true of the latent phase?
A. The cervix is dilated 3-5 cm.
B. Contractions last 20-40 seconds.
C. Contractions are strong.
D. The interval between contractions is 3-5 minutes.

Rationale:
A. This is not the answer because cervical dilation in the latent phase is 0-3 cm.
B. This is true of the latent phase.
C. This is incorrect because contractions in the latent phase are mild to moderate.
D. This is incorrect because the interval between contractions in the latent phase is 5-30 minutes.

Phases Dilatation Duration/Interval Intensity

Latent 0-3 cm 20-40 secs; 5-30 mins Mild to moderate
Active 4-7 cm 40-60 secs; 3-5 mins Moderate to strong
Transition 8-10 cm 60-90 secs; 2-3 mins Strong

54. A client has been in labor for 6 hours and her contractions are occurring every 2 minutes and lasting 80 seconds, she is restless and is irritable
and tells the nurse “I can’t take it anymore.” Which stage or phase of labor is the client in?
A. Transitional phase
B. Second phase
C. Latent phase
D. Third phase

Rationale:
1st stage of labor consists of 3 phases: Latent, Active, and Transitional Phase. This stage begins with the first true contraction and ends with
complete effacement and dilation to 10 cm.

Differences between the 3 phases of 1st Stage of Labor:

LATENT PHASE: ACTIVE PHASE: TRANSITION PHASE:

Duration: 10-12 hours in primipara and Duration: 2-4 hours in primipara and 2-4 Duration: 2-4 hours in primipara and 1-2
8-10 hours in multipara in multipara in multipara
Cervical dilation is 1 to 4 cm Cervical dilation is 4-7 cm Cervical dilation is 8-10 cm
Uterine contractions occur every 15-30 Uterine contractions occur every 3-5 Uterine contractions occur every 2-3
minutes and are 15-30 seconds in minutes and are 30-60 seconds in minutes and are 45-90 seconds in
duration and mild intensity duration and of moderate intensity duration and strong intensity
Mother is talkative Mother becomes restless and anxious Mother may becomes tired, restless,
as contractions become stronger irritable, and feels out of control
Nursing Considerations: Mother may experience feeling of
Encourage mother and partner to helplessness Nursing Considerations:
participate in care Encourage rest between contractions
Change position and ambulation to Nursing Considerations: Inform the progress to mother and
comfort mother Encourage mother in maintenance of partner
Offer fluids an ice chips effective breathing. Provide privacy
Inform the progress to mother and Provide a quiet environment Offer fluids and ice chips
partner Inform the progress to mother and Encourage voiding every 1-2 hours
Encourage voiding every 1-2 hours partner
Backrubs, sacral pressure, pillow
support and position changes to promote
comfort
Offer fluids and ice chips
Instruct partner in effleurage
Encourage voiding every 1-2 hours

(Source: Pilliteri, Maternal & Child Health Nursing:Care of the Childbearing & Childrearing Family, 6 th Edition, p. 361)

55. Station refers to the relationship of the presenting part of a fetus to the level of ischial spines. You noted on the chart that the fetus is at station
1. Which of the following is true of the assessment finding?
 A. The fetal head is at the level of the ischial spine.
B. The fetal head is floating.
C. The fetal head is at the outlet.
D. The fetal head is below the ischial spine.

Rationale:

56. Cardinal Movements or Mechanisms of Labor are series of different position changes which happen to aid the passage of the fetus through the
birth canal. These changes in position allows for the smallest diameter of the fetal head to pass through the smallest diameter of the birth canal.
As a nurse in the delivery room, you must be well-versed with these cardinal movements which accompany labor and delivery. What is the
correct sequence of the mechanisms?
1. As abdominal muscles contract, fetal head bends forward onto chest
2. The fetal head extends and the foremost of the face, chin and neck are born
3. The rest of the body of the baby is born easily and smoothly.
4. The fetal head rotates bringing the shoulders in its best position for entering the pelvis.
5. Mother feels a pushing sensation as fetal head moves downward to the pelvic inlet
6. Mechanism gives way for the widest diameter of the fetal shoulders to be in line with the wide transverse diameter of the inlet.

A. 5, 6, 1, 4, 2, 3
B. 1, 5, 6, 4, 2, 3
C. 5, 1, 6, 2, 4, 3
D. 5, 4, 1, 2, 4, 3

Rationale:
Here is the sequence of the cardinal movements: Descent – is the downward movement of the biparietal diameter of the fetal to within the pelvic
inlet. The pressure of the fetal head on the sacral nerves causes the mother to feel a pushing sensation. Flexion - As abdominal muscles contract,
fetal head bends forward onto chest making the smallest anteroposterior diameter the one to be presented to the birth canal. Internal Rotation -
Mechanism gives way for the widest diameter of the fetal shoulders to be in line with the wide transverse diameter of the inlet. This movement brings
the shoulders into the optimal position to enter the inlet. Extension - The fetal head extends and the foremost of the face, chin and neck are born.
External Rotation - The fetal head rotates bringing the shoulders in its best for entering the pelvis. Expulsion - The rest of the body of the baby is
born easily and smoothly. (Pilliteri. 5th ed. pp. 497-499)

57. Wide variation exists among individuals in their patterns of labor contractions and in maternal responses to labor and birth. Certain signs,
however, indicate that the course of events is deviating from normal. Amor is on her second stage of her labor with a baseline blood pressure of
110/80. Which of the following signs should prompt you to alert the physician during the second stage of labor?
A. Blood pressure of 130/90 mmHg
B. Pulse rate of 94 bpm
C. Uterine contractions lasting for 60 seconds occurring every 90 seconds
D. A round bulge on the patient’s lower anterior abdomen

Rationale:
MATERNAL DANGER SIGNS OF LABOR

 High or low blood pressure

  Abnormal pulse

 Inadequate or prolonged contractions

 Pathologic retraction ring (Letter D)

 Abnormal lower abdominal contour

 Increasing apprehension

(Maternal and Child Health Nursing by Adele Pillitteri page 365-366)

58. The nurse needs to understand the physiologic, psychosocial, environmental and cultural situation of the current health condition and the
factors surrounding this condition. This acknowledgement ensures that the plan of care to be rendered will be acceptable not only to the nurse
but also the parents of the child (Manila, 2014). Elise was transferred to the delivery room because she is about to deliver her first child. Upon
delivery, her child was assessed using APGAR scoring. The child was observed to have cyanotic extremities, blue oral mucosa, heart rate of
80bpm, no response to stimuli and limp. These findings suggest a score of:
A. 1
B. 2
C. 3
D. 4
This scale is developed by Virginia Apgar.
Heart Rate: 80 bpm – 1
Skin color – blue oral mucosa (indicative of central cyanosis) – 0
Muscle tone – Limp – 0
Respiration – No response – 0
Reflex – No response – 0
(Williams, 2008)

Score Interpretation Management

0-3 Severely Depressed/Critical Resuscitation
4-7 Moderately Depressed/Guarded Clear airway, O2 by mask
8-10 Normal/Excellent Normal Care

59. APGAR Scoring is a tool used to assess newborn condition after birth. It was developed by Virginia Apgar. An APGAR score of 3 was obtained
for Baby Jinx after thorough assessment. Which of the following is the priority action?
A. Attach the infant to an O2 supply
B. Prepare for intubation
C. Initiate intravenous fluid therapy
D. Auscultate for lung sounds

Rationale:
A score of 0-3 indicates poor APGAR Score and warrants resuscitation. The priority action can be analyze using the principle of ABC (Airway,
breathing, circulation). Attaching the infant to an O2 supply is an intervention under breathing. An airway must be established first and thus the need
for immediate endotracheal intubation.

60. Nurse Lia is assigned in the Nursery. She knows that common assessment tools used in a normal NB are the following EXCEPT:
A. APGAR
B. Dubowitz
C. Ballards
D. Silverman Andersen tool

Rationale:
Silverman-Andersen score [sil´ver-man an´der-sen]
a system for evaluation of breathing performance of premature infants. It consists of five items: (1) chest retraction as compared with abdominal
retraction during inhalation; (2) retraction of the lower intercostal muscles; (3) xiphoid retraction; (4) flaring of the nares with inhalation; and (5)
grunting on exhalation. Each of the five factors is graded 0, 1, or 2. The sum of these factors yields the score. Adequate ventilation is indicated by a
0, severe respiratory distress is indicated by a score of 10.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders

61. Certain respiratory patterns are usual to normal term newborns. The nurse is taking care of Baby Daniel, 1 hour old. After respirations are
established, breaths are expected to be:
A. Deep, regular, no periods of apnea
B. Shallow, irregular, with short periods of apnea less than 20 seconds.
C. Deep, irregular, with short periods of apnea less than 15 seconds.
D. Shallow, irregular, with short periods of apnea less than 15 seconds.

Rationale:
The respiratory rate of a newborn in the first few minutes of life may be as high as 80 breaths per minute. As respiratory activity is established and
maintained, this rate settles to an average of 30 to 60 breaths per minute when the newborn is at rest. Respiratory depth, rate, and rhythm are likely
to be irregular, and short periods of apnea (without cyanosis) which last less than 15 seconds, sometimes called periodic respirations, are normal. .
(pp. 451, Maternal and Child Health Nursing by Pillitteri, 6th edition, 2010)

62. A newborn should have a thorough evaluation performed within 24 hours of birth to identify any abnormality that would alter the normal newborn
course or identify a medical condition that should be addressed. The nurse is doing a thorough physical examination on a neonate. The
circumference of the neonate’s head and chest when compared at birth is normally:
A. Head equals chest circumference.
B. Head circumference is 2 cm larger than the chest.
C. Head circumference is 2 cm smaller than the chest.
 D. None of the above.

Rationale:
At birth, the neonates head circumference is approximately 2 cm larger than the chest circumference. Head circumference 33-35 cm (13-14 inches),
Chest circumference 30-33 cm (12-13 inches) body length 44-55 cm (18-22 inches).
(Pillitteri, 5th ed; ULG)

63. A complete physical examination is an important part of newborn care. Each body system is carefully examined for signs of health and normal
function. The physician also looks for any signs of illness or birth defects. An assessment of a newborn includes the differentiation between
cephalhematoma and caput succedaneum. When making this assessment, the nurse understands that caput succedaneum is characterized by
which of the following?
A. Edema crosses the suture line
B. Swelling increases within 24 hours
C. Area surrounding the swelling will be tender
D. Scalp over the swelling becomes ecchymotic

Rationale:
This is the sign that differentiates between these two conditions; with caput succedaneum, the swelling crosses the suture line and it does not with
cephalhematoma.
Option B- the swelling decreases in size; if the swelling increases, the newborn would have for signs of increased intracranial pressure
Option C- pain is not associated with either condition
Option D- bruising can occur with either condition
(Mosby, 5th ed)

64. As important as the physical care is, so too is the education that nurses must impart to the parents of new babies. A mother calls the nurse to
her room because “My baby’s eyes are bleeding.” The nurse notes bright red hemorrhages in the sclerae of both of the baby’s eyes. Which of
the following actions by the nurse is appropriate at this time?
A. Notify the pediatrician immediately and report the finding.
B. Notify the social worker about the probable maternal abuse.
C. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.
D. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.

Rationale:
OPTION C- Subconjunctival hemorrhages are a normal finding and are not pathological. They will disappear over time. Explaining this to the mother
is the appropriate action. Hemorrhages in the sclerae are considered normal, resulting from pressure changes at birth. Although the mother is frantic,
the nurse’s assessment shows that this is a normal finding. The nurse, therefore, provides the mother with the accurate information.
OPTION A- This is not an emergent problem needing physician intervention.
OPTION B- There is nothing in the stem that implies that the child has been abused.
OPTION D- There is nothing in the stem that implies that there has been any intraocular damage.

To inspect the eyes, lay the newborn in a supine position and lift the head. This maneuver causes the baby to open the eyes. A newborn’s
eyes should appear clear, without redness or purulent discharge. Occasionally, the administration of an antibiotic ointment such as erythromycin
given at birth, to protect against Chlamydia infection and ophthalmia neonatorum (gonorrheal conjunctivitis), has caused a purulent discharge
that lasts for the first 24 hours of life.
Pressure during birth sometimes ruptures a conjunctival capillary of the eye, resulting in a small subconjunctival hemorrhage. This appears
as a red spot on the sclera, usually on the inner aspect of the eye, or as a red ring around the cornea. The bleeding is slight, requires no treatment,
and is completely absorbed within 2 or 3 weeks. You can assure parents that these hemorrhages are normal variations. Otherwise, they may
assume that their baby is bleeding from within the eye and that vision will be impaired.

65. Thermoregulation is critical for newborn because of the inability of the newborn to shiver. Prompt action should be given by the nurse to prevent
heat loss. Which of the following nursing interventions would protect the newborn from heat loss via convection?
A. Drying the newborn thoroughly
B. Removing wet linens from the baby
C. Placing the newborn away from open windows
D. Pre-warming the examination table

Rationale:
Convection is the flow of heat from the newborn’s body surface to cooler surrounding air. The effectiveness of convection depends on the velocity of
the flow (a current of air cools faster than nonmoving air). Eliminating drafts from windows or air conditioners reduces convection heat loss. (pp. 450,
Maternal and Child Health Nursing by Pillitteri, 6th edition, 2010)

66. The function of the immune system is to protect the body from harmful substances, such as pathogens and environmental pollutants. The
immune system provides three lines of defense. The immune response belongs under which line of Defense?
A. First line of defense
B. Second line of defense
C. Third line of defense
D. Fourth line of defense
The first line of defense is the barrier, the second line of defense is the inflammatory process, the third line of defense is the immune response.
There is no fourth line of defense.
(Ultimate Learning Guide for Nursing Review by Dr. Carl E. Balita page 399)

67. Mr. Lannister, a 65 year old client, is known to have eaten contaminated food, but has not become ill. The gerontology nurse practitioner
explains to the healthcare team on the unit that gastric acidity will kill some microorganisms. This type of response is known as:
A. Adaptation
B. Innate immunity
C. Passive immunity
D. Acquired immunity

Rationale:
The defense of natural immunity, or innate immunity, is not produced by the immune response that is present at birth. Defenses of the innate
immune system consist of a variety of physical barriers and biochemical and cellular defense mechanisms to prevent the establishment of potential
pathogens within the body.

IMMUNITY
A. Innate immunity
 Innate immunity is also called native or natural immunity. It is present at birth and includes biochemical, physical, and mechanical barriers
of defense, as well as the inflammatory response.
B. Acquired immunity
 Acquired or adaptive immunity is received passively from the mother’s antibodies, animal serum, or antibodies produced in response to a
disease. Immunization produces active acquired immunity.

68. Which among the following conditions can be classified under Type IV hypersensitivity reaction?
1. Systemic anaphylaxis
2. ABO incompatibility
3. Asthma
4. Contact dermatitis
5. Tuberculosis
6. Transplant rejection
7. Systemic Lupus Eryhematosus
8. AGN
9. Rheumatoid arthritis

A. 1 and 3 only
B. 2 only
C. 4, 5, 6
D. 7, 8, 9

Rationale:
There are 5 classifications of hypersensitivity reactions: Type I (Anaphylactic), Type II (Cytotoxic), Type III (Immune complex), and Type IV
(Hypersensitivity reaction) is also called delayed hypersensitivity. Tissue is damaged as a result of a delayed T cell reaction to an antigen. Examples
of Type IV hypersensitivity include Contact dermatitis, transplant rejection, and TB are examples of Type IV hypersensitivy reaction, tuberculin
reactions, and transplant rejections.

Option A: are examples of type I; type 1 hypersensitivity is now synonymous with allergy; this is due to activation, by a specific antigen, of sensitized
mast cell coated with IgE.
Option B: example of Type II; type II occurs when the system mistakenly identifies a normal constituent of the body as foreign.
Option D: examples of Type III which is caused by auto-antibody production; in involves immune complexes that are formed when antigens bind to
antibodies. The joints and kidneys are particularly susceptible to this type of injury.
69. Systemic Lupus Erythematosus (SLE), a Type III hypersensitivity reaction, is a result of disturbed immune regulation that causes an
exaggerated production of autoantibodies. This disease can affect any body system. Mrs. Stark has been admitted to the medical ward because
of suspected SLE. You are the nurse facilitating his admission to the hospital. Which of the following assessment data from Mrs. Stark would
least likely indicate she has SLE?
A. Morning stiffness, joint swelling, tenderness and pain of joints upon movement
B. Butterfly-shaped rash across the bridge of the nose and cheeks
C. Pericardial friction rub noted
D. Urine output and creatinine excretion within normal range

Rationale:
Involvement of the musculoskeletal system, with arthralgias and arthritis (synovitis), is a common manifestation of SLE. Frequently, these are
accompanied by morning stiffness. The most familiar skin manifestation (occurring in more than 50% of patients with SLE) is an acute cutaneous
lesion consisting of a butterfly-shaped rash across the bridge of the nose and cheeks. The lesions often worsen during exacerbations (flares) of the
systemic disease and possibly are provoked by sunlight or artificial ultraviolet light. Pericardial friction rub is a diagnostic indication of pericarditis.
Pericarditis is the most common cardiac manifestation. Renal involvement may also present with either chronic renal failure or nephritis.

70. Immune function is affected by age and by a variety of other factors, such as central nervous system function, emotional status, medications,
and the stress of illness, trauma, and surgery. Dysfunctions involving the immune system occur across the life span. Many are genetically
based; others are acquired. The nurse knows that laboratory results support the diagnosis of systemic lupus erythematosus (SLE) are:
A. Elevated serum complement level
B. Thrombocytosis, elevated sedimentation rate
C. Pancytopenia; elevated antinuclear antibody (ANA) titer
D. Leukocytosis; elevated blood urea nitrogen (BUN) and creatinine levels

Rationale:
Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have
elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE.

Anti-nuclear antibody (ana) titer determination

 The ANA titer determination is a blood test used for the differential diagnosis of rheumatic diseases and for the detection of anti-nucleoprotein
factors and patterns associated with certain autoimmune diseases.
 The test is positive at a titer of 1:20 or 1:40, depending on the laboratory.
 A positive result does not necessarily confirm a disease.
 The ANA titer is positive in most individuals diagnosed with systemic lupus erythematosus (SLE); it may also be positive in individuals with
systemic sclerosis (scleroderma) or rheumatoid arthritis.
 An ANA titer result can be false positive in some individuals.

71. Stages of HIV disease is based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and
infections and malignancies. Mr. Calibugar, has long been your institution’s patient due to his HIV infected status for a year and a half now. His
current CD4 level count is 350 cells/mm3. He has been experiencing bouts of diarrhea for over a week now. You recognize that Mr. Calibugar is
in what stage of his HIV disease?
A. Primary Infection
B. HIV Asymptomatic (CDC Category A)
C. HIV Symptomatic (CDC Category B)
D. AIDS (CDC Category C)
Rationale:
OPTION C. HIV Symptomatic (CDC Category B). CD4 count falls between 200-499 cells). The patient had a disease condition due to his infection.

Primary Infection
 Period of intense viral replication
 Symptoms none to intense flu-like symptoms
 Fever
 Rash
 Head aches
  Muscle aches
HIV Asymptomatic (CDC Category A)
 Apparent good health continues because CD4 remains high enough to preserve body’s immunity
 More than 500 CD4 cells

AIDS (CDC Category C)

 CD4 cells below 200
 Immune system significantly impaired
 Anemia
 Any opportunistic infections

72. Nurses in all settings encounter people with HIV infection and AIDS; thus, nurses need an understanding of the disorder, knowledge of the
physical and psychological consequences associated with the diagnosis, and expert assessment and clinical management skills to provide
optimal care for people with HIV infection and AIDS. The nurse is assisting the patient to interpret a negative HIV test result; she should inform
the patient that the result means which of the following?
A. Antibodies to the AIDS virus are not present in his blood
B. He has not been infected with HIV.
C. He is immune to the AIDS virus.
D. Antibodies to the AIDS virus are present in his blood.

Rationale:
Option A: A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is
drawn.
Option B: A negative test result should be interpreted as demonstrating that if infected, the body has not produced antibodies (which take from 3
weeks to 6 months or longer). Therefore, subsequent testing of an at-risk patient must be encouraged.
Option C: The test result does not mean that the patient is immune to the virus, nor does it mean that the patient is not infected. It just means that the
body may not have produced antibodies yet.
Option D: When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

73. Human immunodeficiency virus (HIV) is a retrovirus that gradually destroys the immune system’s function. When the retrovirus becomes active,
the patient develops acquired immunodeficiency syndrome (AIDS), which is characterized by profound immunological deficits, opportunistic
infection, secondary infections, and malignant neoplasms. A 33-year-old client is diagnosed with human immunodeficiency virus (HIV) and was
prescribed to take Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
A. Limit the client's activity
B. Encourage a high-carbohydrate diet
C. Utilize an incentive spirometer to improve respiratory function
D. Encourage fluids

Rationale:
OPTION D-. Clients taking Acyclovir should be encouraged to drink plenty of fluids because renal impairment can occur. Acyclovir (Zovirax), an
antiviral agent, is the medication of choice in HSV treatment .The mode of action is the inhibition of viral DNA replication. It is usually well tolerated
by the patient. To prevent relapse, treatment should continue for up to 3 weeks. Slow administration over 1 hour will prevent crystallization of the
medication in the urine. The usual dose of acyclovir is decreased if the patient has a history of renal insufficiency . Limiting activity is not necessary,
nor is eating a high-carbohydrate diet. Use of an incentive spirometer is not specific to clients taking Acyclovir; therefore, answers A, B, and C are
incorrect.

74. Several features of breast tumors contribute to the prognosis. Generally, the smaller the tumor, the better the prognosis. The following are
complementary screening modalities for breast cancer that are to be used in combination rather than singly, except:
A. Mammography
B. Biopsy
C. Clinical breast examination
D. Breast self examination

Rationale:
Even though imaging tests like the mammogram and ultrasound can find a suspicious area, they cannot tell whether it’s cancer. A biopsy is the only
sure way to diagnose breast cancer.

Option A: There are two types of mammography – screening and diagnostic mammogram. During a diagnostic mammogram, more x-rays are taken
of the breast than during a screening mammogram. Extra pictures are focused on the area of concern. However, mammograms alone cannot prove
that an abnormal area is cancer. Tissue from the area must be taken out and looked at under a microscope. This is called a biopsy. Breast cancer
cannot be diagnosed without a biopsy.

Option C and D: CBE and BSE are all screening tests that are performed/given routinely to people who appear to be healthy and are not suspected
of having breast cancer. Their purpose is to find breast cancer early, before any symptoms can develop and the cancer usually is easier to treat.

Biopsy: to obtain a tissue sample for analysis of cells suspected to be malignant. In most instances, the biopsy is taken from the acutal tumor. The 3
most common are excisional, incisional, and needle methods.
1. Excisional biopsy – frequently used for easily accessible tumor of the breast; palpable breast mass. The entire lesion, plus a margin of
surrounding tissue, is removed; aka lumpectomy. This removal of normal tissue beyond the tumor area decreases the possiblity that residual
microscopic disease cells may lead to a recurrence of the tumor.
2. Incisional biopsy – performed is the tumor is too large to be removed; tissue sampling alone is required; both to confirm a diagnosis and to
determine the hormonal receptor status.
3. Needle Biopsy – are performed to sample suspicious masses that are easily accessible, such as some growths in the breast, thyroid, lung, etc.
Needle biopsies are fast, relatively inexpensive, and easy to perform and usually require only local anesthesia. Needle aspiration biopsiy
involves aspirating tissue fragmnts through a needle guided into an area suspected of bearing disease. In some instances, the aspiration biopsy
 does not yield enough tissue to permit accurate diagnosis. A needle core biopsy uses a specially designed needl to obtain a small core of
tissue. Most often, this specimen is sufficient to permit accurate diagnosis.

Management:
1. avoid use of agents that can interfere with blood clotting and increase the risk for bleeding - nonsteroidal anti-inflammatory drugs, vitamin E
supplements, herbal substances (such as gingko biloba and garlic supplements), warfarin, and products containing aspirin
2. dressing covering the incision is usually removed on the second day
3. supportive bra is encouraged immediately after the procedure for 3 to 7 days to limit movement of the breast and reduce discomfort.

75. A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS,
N0, M0. What does this classification mean?
A. No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis
B. Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
C. Can't assess tumor or regional lymph nodes and no evidence of metastasis
D. Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis

Rationale:
A complete diagnostic evaluation includes identifying the stage and grade of the tumor. This is accomplished before treatment begins to
provide baseline data for evaluating outcomes of therapy and to maintain a systemic and consistent approach to ongoing diagnosis and treatment.
Treatment options and prognosis are determined on the basis of staging and grading

Option A: No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis is classified as T0, N0, M0.
Option C: If the tumor and regional lymph nodes can't be assessed and no evidence of metastasis exists, the lesion is classified as TX, NX, M0.
Option D: A progressive increase in tumor size, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant
metastasis is classified as T1, T2, T3, or T4; N0; and M1, M2, or M3.

GRADING– classification of tumor cells; cellular aspects of cancer

Grade I: Cells differ slightly from normal cells and are well differentiated (mild dysplasia).
Grade II: Cells are more abnormal and are moderately differentiated (moderate dysplasia).
Grade III: Cells are very abnormal and are poorly differentiated (severe dysplasia).
Grade IV: Cells are immature (anaplasia) and undifferentiated; cell of origin is difficult to determine.

STAGING– determining the size of the tumor and existence of metastases, for purposes of determining extent of disease, prognosis, and guide to
proper management.
 Staging classifies the clinical aspects of the cancer and degree of metastasis at diagnosis.
Stage 0: Carcinoma in situ
Stage I: Tumor limited to the tissue of origin; localized tumor growth
Stage II: Limited local spread
Stage III: Extensive local and regional spread
Stage IV: Distant metastasis

76. In most cases, laryngeal and hypopharyngeal cancers are found because of the symptoms they cause. Which of the following signs and
symptoms would the nurse include in teaching plan as an early manifestation of laryngeal cancer?
A. Stomatitis
 B. Airway obstruction
C. Hoarseness
D. Dysphagia

Rationale:
Early warning signs of laryngeal cancer can vary depending on tumor location. Hoarseness lasting 2 weeks should be evaluated because it is one of
the most common warning signs. Laryngeal cancers that form on the vocal cords (glottis) often cause hoarseness or a change in the voice. This can
lead to them being found at a very early stage. For cancers that don’t start on the vocal cords, hoarseness occurs only after these cancers reach a
later stage or have spread to the vocal cords. These cancers are sometimes not found until they have spread to the lymph nodes and the person
notices a growing mass in the neck.

LARYNGEAL CANCER
 Laryngeal cancer presents as malignant ulcerations with underlying infiltration and is spread by local extension to adjacent structures in the
throat and neck, and by the lymphatic system.
 Diagnosis: laryngoscopy and biopsy showing a positive cytological study for cancer cells. Laryngoscopy allows for evaluation of the throat and
biopsy of tissues; chest radiography, CT, and MRI are used for staging.
 Risk factors: Cigarette smoking, heavy alcohol use and the combined use of tobacco and alcohol, exposure to environmental pollutants (e.g.,
asbestos, wood dust), chewing tobacco, exposure to radiation.
 Assessment: Persistent hoarseness or sore throat, painless neck mass, feeling of a lump in the throat, burning sensation in the throat,
dysphagia, change in voice quality/dysphonia/aphonia, dyspnea, weakness and weight loss, hemoptysis, foul breath odor/halitosis/fetor
 Interventions:
 POSITION: Place in Fowler’s position to promote optimal air exchange.
 Monitor respiratory status. Monitor for signs of aspiration of food and fluid.
 Administer oxygen as prescribed. Provide respiratory treatments as prescribed.
 Provide activity as tolerated.
 DIET: Provide a high-calorie and high-protein diet. Provide nutritional support via parenteral nutrition, nasogastric tube feedings, or
gastrostomy or jejunostomy tube, as prescribed.
 Administer analgesics as prescribed for pain.

77. Breast cancer is the most common invasive cancer in females worldwide. It accounts for 16% of all female cancers and 22.9% of invasive
cancers in women. 18.2% of all cancer deaths worldwide, including both males and females, are from breast cancer. Ms. Belen was diagnosed
with stage 4 breast cancer. She asked you about the different risk factors associated with the condition. You would include which of the
following? Select all that apply:
1. Increasing age (>50 years old)
2. Late menarche
3. Nulliparity
4. Early menopause
5. Obesity
6. Exposure to ionizing radiation

A. 1, 2, 4, 6
B. 1, 3, 5. 6
C. 1, 2, 5, 6
D. 1, 4, 5, 6

Rationale:
78. Ms. Belen underwent modified radical mastectomy. On the first postoperative day, the nurse provides instruction regarding post-mastectomy
exercises that should be initiated on the second post-operative day. She further instructs the patient that post-mastectomy exercises are usually
performed three times daily for 20 minutes at a time until full range of motion is restored. Which of the following exercises is MOST
APPROPRIATE for Ms. Belen to do? Select all the apply:
1. Wall hand climbing
2. Pulley lifting
3. Rod lifting
4. Broomstick lifting
5. Pulley tugging
6. Rope turning

A. 2, 3, 4, 5, 6
B. 1, 3, 4, 5, 6
C. 1, 2, 4, 5, 6
D. 3, 4, 5, 6

Rationale:

79. Brachytherapy means short or close therapy. The radiation source comes into direct, continuous contact with the tumor tissues for a specific
period of time. There are two types, namely unsealed and sealed or solid radiation source. Mrs. Powers, a patient diagnosed with uterine
cancer, is currently receiving intracavitary radiation therapy. The radiologist prescribes that the device stays for 4 days until it is removed from
her uterus. Knowing that exposure to radiation is harmful to the health, the nurse should employ safety measures in handling patients receiving
brachytehrapy, except for:
A. Warn visitors to maintain a 6-feet distance from the patient and limit each visit to half an hour each day.
B. The client is considered as a source of radiation as long as the device is present in her body, so the nurse must wear a lead shielding
apron and face the patient at all times.
C. Wear a dosimeter film badge at all times while caring for the patient.
D. The excreta and urine of the patient is considered as radioactive, so the nurse must be careful in disposing these waste products.
Rationale:
OPTION D: In sealed or solid radiation implants (like the one the patient has), the client emits hazardous radiation but excreta are not radioactive,
while in unsealed radiation sources (given via oral or IV), excreta is considered as radioactive. With all types of brachytherapy, the radiation source is
within the patient, and therefore emits hazardous radiation to others. A dosimeter film badge does not offer any protection against radiation but
measures an individual’s exposure to radiation. Each badge should be used only by one individual. Exposure to the patient should be limited to only
30 minutes per day, and should be distributed throughout the day if possible. A distance of at least 6 feet should also be maintained. Pregnant or
people aged 16 or younger should not be allowed near the patient. (pp. 489-490 and 1844, Medical-Surgical Nursing by Ignatavicius and Workman
5th edition, 2006)
 Brachytherapy is used for small localized tumours that are accessible for the application of sources, which are then removed after the
required dose has been delivered. There are three types of brachytherapy: interstitial, intracavitary and surface applicator (or mould)
treatments.
 Interstitial treatments involve the implantation of radioactive sources, in the form of needles, pins, hairpins or seeds, directly into the
tumour. Rigid guide tubes may be first inserted into the tissue and after verifying their position is correct, the radioactive source is
introduced, such as flexible iridium-192 wire. This approach is termed ‘afterloading’ and reduces the radiation exposure to staff as well as
increasing the accuracy of source placement. Caesium-137 needles may be used as an alternative to iridium wire. Sites most commonly
treated by interstitial brachytherapy are the tongue, breast, vulva and anus. From the time of insertion of the radioactive sources to their
removal, which could be several days, the patient is effectively a source of radiation. Patients must therefore remain in their own private
rooms with appropriate radiation shielding. There are limits to visiting times and the time that staff can spend caring for the patient. Once
the sources have been removed, the patient is no longer a source of radiation.
 Intracavitary brachytherapy involves placing sealed radioactive sources (usually caesium-137), within natural body cavities. The most
common application of the technique is for gynaecological tumours of the cervix, uterus and vagina.
 Surface applicators or moulds are used to treat superficial tumours. The plastic moulds are designed individually for each patient and
contain a distribution of sealed radioactive sources. They are worn externally continuously or intermittently for an accurately prescribed
time while the patient is isolated in hospital. Sites suitable for treatment with moulds include the hand, the pinna and the lip. Surface
applicators are also used for ocular tumours. With the increasing availability of electron treatment units the usefulness of this form of
brachytherapy is diminishing.

80. At the beginning of her shift, the nurse plans her visit to a uterine cancer patient undergoing sealed internal radiation. She thinks that her rounds
will take 3 minutes, vital signs taking and general assessment for the whole shift will take 20 minutes, giving medications will take 5 minutes.
The head nurse sees this plan schedule. Her most appropriate action is to:
A. Divide the schedule with another nurse.
B. Advise the nurse to delegate rounds to another nurse.
C. Do nothing and let the nurse follow the schedule.
D. Advise the nurse to revise the schedule and limit exposure to the patient to 20 minutes.

Rationale:
OPTION C- The nurse’s schedule of activities is within the limit recommended time limit of exposure in internal radiation principles which is not more
than 30 minutes per shift. (ULG, p.356)

Because patients receiving internal radiation emit radiation while the implant is in place, contacts with the health care team are guided by
principles of time, distance, and shielding to minimize exposure of personnel to radiation. Safety precautions used in caring for the patient receiving
brachytherapy include assigning the person to a private room, posting appropriate notices about radiation safety precautions, having staff members
wear dosimeter badges, making sure that pregnant staff members are not assigned to this patient’s care, prohibiting visits by children or pregnant
visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance from the radiation source.

81. Mrs. Cersei, a patient diagnosed with uterine cancer, is currently receiving intracavitary low dose radiation therapy. The radiologist prescribes
that the device stays for 3 days until it is removed from her uterus. In caring for Mrs. Cersei, the nurse should observe which of the following
principles? Select all that apply:
1. Limit the time with the client to 1 hour per shift.
2. Do not allow pregnant women into the client's room.
3. Remove the dosimeter badge when entering the client's room.
4. Individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client.
5. The patient should be maintained in bed rest in a specially prepared private room
6. Encourage the patient to increase fiber and fluid intake
7. Insert an indwelling urinary catheter
8. Administer antidiarrheal agents as ordered.

A. 1, 2, 5, 7, 8
B. 2, 5, 7, 8
C. 2, 3, 5, 6, 7, 8
D. 2, 4, 5, 7, 8

Rationale:
The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be
worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room. The patient is
maintained on bed rest in a specially prepared private room typically for 72 hour and log-rolled to prevent displacement of the intracavitary delivery
device. An indwelling urinary catheter is inserted to ensure that the bladder remains empty. Low-residue diets and antidiarrheal agents are provided
to prevent bowel movements during therapy, which would displace the radioisotopes. Visitors and personnel must limit their time and proximity to the
patient due to the risk of radiation exposure.

82. The nurse is caring for Ms. Amor, a 35-year-old client diagnosed with cervical cancer. During the endorsement, she was informed that Ms. Amor
is to receive a radioactive implant in her shift. In preparation for her care for Ms. Amor, the nurse should bear in mind that:
A. Special radiation resistant linen must be used
 B. No special handling techniques are required for linens or equipment
C. Rubber gloves must be used while in contact with the bed linen and Ms. Amor
D. Linen and equipment should not be removed from the room until it is free from radiation contamination

Rationale:
Because patients receiving internal radiation emit radiation while the implant is in place, contacts with the health care team are guided by principles
of time, distance, and shielding to minimize exposure of personnel to radiation.
Internal radiation therapy (which is also called brachytherapy; does not use radiation beams aimed from a large machine. Instead, the radiation
source is usually sealed in a small holder (called an implant). The implant is placed very close to or inside the tumor. It’s placed so that it harms as
few normal cells as possible. The radioactive material may be left in the body for only a short time, or it may be left there permanently. In implant
radiation therapy, the positioning of the device is critical to the effectiveness and safety of the treatment. Although the cervical cancer receives the
highest radiation dose, the surrounding organs, such as the rectum and bladder, are also exposed to some radiation. Radiation injury to the rectum,
bladder or bowel can occur and may cause pain or bleeding with urination or passage of stools. Less commonly, some patients will develop a fistula,
which is an abnormal connection between the rectum or bladder and the vagina. At times, additional surgery may be necessary for repair of fistulas
or other radiation injury

INTERNAL RADIATION
TYPE SEALED/BRACHYTHERAPY UNSEALED
RAD SOURCE Radium, iridium, cesium Radioisotope, radionuclide
 Intracavitary RT for uterine/cervical cancer is placed for  Iodine 131 (PO for Grave’s disease & thyroid
24-72 hours (usually cesium 137 or radium 226) cancer)
 Interstitial RT is in the form of beads, needles, seeds,  Alrontium chloride 89 (IV for relief of painful
ribbons, or catheters directly implanted in the tumor. bony metastases)
(usually iridium 192, iodine 125, cesium 137, gold 198,
or uranium 222)
LOCATION Sealed radiation source placed in a cavity or adjacent to cancer Source of radiation is given PO, IV, or instilled in a body
site cavity
 Used for both intracavitary and interstitial therapy
MANAGEMENT  Douche, enema, perineal prep, with Foley catheter  The source is not confined completely to one
before insertion of cervical radium body area, and it enters body fluids and
 Low-fiber diet and/or anti-diarrheals (ex. eventually is eliminated via various excreta,
diphenoxylate/Lomotil) for 2-4 days to prevent which are radioactive and harmful to others.
dislodgement in cervical implants, etc.  Most of the source is eliminated from the body
 Flat/supine position, logroll technique to prevent within 48 hours; then neither the client nor the
dislodgement excreta is radioactive or harmful.
 Never handle radium directly, even with gloves; use  Radiation is excreted in urine,
long-handled lead/steel forceps/tongs (beta to gamma perspiration/sweat, tears, vomitus, and
radiation) feces/stool 8 days in radioactive iodine, and 14
 Always face client when rendering care, otherwise the days in radioactive phosphorus (due to
portion uncovered by the lead apron will be exposed to systemic circulation)
radiation  Careful handling of gowns, dressings, utensils,
 Keep linen in room until source of radiation are & linens
completely accounted for  Client may use disposable utensils and plates
 Non-exposure/prohibition of pregnant women and  Always use gloves and gowns (alpha to beta
children (both staff and visitors; consequence is radiation) when handling body fluids
retarded growth in children and teratogenic effect to the  ►Hand washing should be done before and
unborn child) after removal of gloves
 ►Children <16 years old should not be permitted to  The client is also instructed to rinse the sink
visit. with copious amounts of water after tooth
 There is NO radiologic contamination of brushing and to flush the toilet several times
excretions/secretions/serum after each use (to prevent radiologic
 Regular observation to ensure no dislodgement occurs; contamination of other people and the
still following the 30 minutes/8-hour-shift principle environment
 PSYCHOLOGICAL NI: to prevent feelings of isolation,  Any emesis/vomitus, especially that occurs
maintain contact with the client while keeping distance after ingestion of PO radioisotope, should be
from radiation exposure. Talk with the client from the covered with absorbent pads, and the
doorway of the room. radiation safety officer should be called
immediately.

83. Teletherapy means distant treatment, and the source is external. This type of therapy is also called beam radiation. Mr. Eduardo is a patient
who had just received external beam radiation for treatment of his laryngeal cancer. The lower portion of his head as well as his neck received
exposure to radiation. In caring for Mr. Eduardo, which of the following should the nurse perform?
A. Informing the patient that excessive salivation can occur several hours to days post-exposure
B. Taking care not to remove the markings that indicate where the beam of radiation is to be focused
C. Using water only or mild soap with water on washing the irradiated area, with the use of a washcloth
D. All of the above

Rationale:
OPTION B: Markings are placed on the skin serve as guide which indicates where the beam of radiation is to be focused the next time the patient
receives radiation therapy. Water only or water with mild soap is used in cleaning the irradiated site. Use only the hands, not a washcloth, in cleaning
the skin to be gentler. After washing, dry the irradiated area with a patting motion rather than rubbing motion using a soft, clean towel. Xerostomia, or
dry mouth, can occur in patients receiving head and neck radiation because radiation can damage the salivary glands. (p. 491, Medical-Surgical
Nursing by Ignatavicius and Workman 5th edition, 2006)
84. A patient is suffering from neutropenia as a result of his chemotherapy. In addressing this problem, which of the following interventions should
you give the least importance? Select all that apply:
1. Do not allow the patient to change litter boxes or work with houseplants.
2. Change IV tubings every other day.
3. Do not reuse cups or glasses without washing
4. Use povidone iodine before any arterial puncture or venipuncture.
5. Use indwelling urinary catheters using strict aseptic technique.
6. Avoid rectal and vaginal procedures (rectal temperature, examinations, suppositories).
7. Avoid fresh fruits, raw meat, fish and vegetables.

A. 1, 2, 4
B. 1, 5, 6
C. 2, 4, 6
D. 2, 5

Rationale:
The use of indwelling catheters should be avoided because it can be a potential source of infection. Changing the IV tubings daily is needed to
prevent infection. The patient should not be allowed to come in contact with litter boxes or work in the garden or wit house plants as these as
potential sources of infection. Cups or glasses that the patient is using should not be reused without washing them first to prevent infection. (p. 497,
Medical-Surgical Nursing by Ignatavicius and Workman 5th edition, 2006)

Rather than every day, intravenous sites are changed every other day. Changing of sites for more than 72 hours promotes bacterial growth, but at
the same time, frequent changes would also increase the risk for infection due to the skin breaks brought about by the IV insertions. Rectal and
vaginal procedures disrupt membrane integrity, thus increases risk for infection. Fresh fruits, raw meat, fish and vegetables harbour bacteria that
could not be removed by washing alone. Povidone iodine is effective against many gram-positive and gram-negative pathogens. (Brunner and
Suddarth’s Textbook of Medical-Surgical Nursing 10th edition, page 335-336)

85. The clinic nurse prepares a teaching plan for the client receiving an antineoplastic medication. When implementing the plan, the nurse tells the
client:
A. To take aspirin (acetylsalicylic acid) as needed for headache
B. Drink beverages containing alcohol in moderate amounts each evening
C. Consult with health care providers before receiving immunizations
D. That it is not necessary to consult health care providers before receiving a flu vaccine at the local health fair

Rationale:
Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without a physician's or
health care provider's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to
avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side
effects.

86. Substance abuse has also been referred to as any use of substances that poses significant hazards to health. Which of the following
statements is not true regarding the factors implicated in the predisposition of a person to substance abuse?
A. An apparent hereditary factor is involved in the development of substance-use disorders.
B. Depression and an antisocial personality, although not predictive, have been commonly associated with substance abuse.
C. The person’s culture, which molds attitudes and influences patterns of consumption based on cultural acceptance, is also a predisposing
factor.
D. Using the psychodynamic approach, it has been noted that a person with a punitive id is more likely to abuse substances.

Rationale:
The psychodynamic approach to the etiology of substance abuse focuses on a punitive superego and fixation at the oral stage of psychosexual
development (Sadock & Sadock, 2007). Individuals with punitive superegos turn to alcohol to diminish unconscious anxiety and increase feelings of
power and self-worth. Sadock and Sadock (2007) state, “As a form of self-medication, alcohol may be used to control panic, opioids to diminish
anger, and amphetamines to alleviate depression”
Choice A: An apparent hereditary factor is involved in the development of substance-use disorders. This is especially evident with alcoholism, less
so with other substances. Children of alcoholics are three times more likely than other children to become alcoholics (Harvard Medical School,
2001).
Choice B: Substance abuse has also been associated with antisocial personality and depressive response styles. This may be explained by the
inability of the individual with antisocial personality to anticipate the aversive consequences of his or her behavior. It is likely an effort on the part of
the depressed person to treat the symptoms of discomfort associated with dysphoria. Achievement of relief then provides the positive reinforcement
to continue abusing the substance.
Choice C: Factors within an individual’s culture help to establish patterns of substance use by molding attitudes, influencing patterns of consumption
based on cultural acceptance. Historically, a high incidence of alcohol dependency has existed within the Native American culture. Alcohol-
attributable deaths among Native Americans are approximately twice that of the U.S. general population (CDC). (Source: Essentials of Psychiatric
Mental Health Nursing by Townsend, 5th ed., p. 269-270)

87. Cannabis sativa is the hemp plant widely cultivated for its fiber and marijuana refers to the upper leaves, flowering tops and stems of the plant.
These parts contain delta-9-tetrahydrocannabinol, which is thought to be responsible for the psychoactive effects of marijuana. Which of the
following statements about this drug is not precise?
A. Overdoses of cannabis do not occur.
B. It can be used to treat nausea and vomiting due to chemotherapy.
C. Marijuana can be smoked or eaten.
D. Benzodiazepines are given to patients with severe withdrawal symptoms.
 Rationale:
Although some people have reported withdrawal symptoms of muscle aches, sweating, anxiety and tremors, no clinically significant or severe
withdrawal symptoms are identified. Choice A is correct. Overdoses of cannabis do not occur (Hall and Degenhart, 2005), although excessive and
long-term use can lead to delirium, psychoses and respiratory difficulties. Choice B is also correct. Two cannabinoids, dronabinol (Marinol) and
nabilone (Cesamet), have been approved for treating nausea and vomiting associated with chemotherapy. Choice C is also correct. Marijuana can
be smoked (rolling it in paper [called a “joint”] or using a bong) or eaten (usually baked inside brownies or cookies). (Source: Psychiatric Mental
Health Nursing by Videbeck, 3rd ed., p. 384-385)

88. You are interviewing a 19-year old male who is suspected of smoking marijuana. When determining whether this client has any problems with
memory, which of the following questions is the most appropriate to ask?
A. “Will you please repeat the days of the week backwards?”
B. “Who was the president before the current president?”
C. “What did you do yesterday?”
D. “Do you have any memory problems?”

Rationale:
The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. For example, if the nurse asks “Do you
have any memory problems?” (Choice D) the client may inaccurately respond with “no”, and the nurse cannot verify that. Similarly, if the nurse asks
“What did you do yesterday?” (Choice C) the nurse may be unable to verify the accuracy of the client’s responses. Therefore, the best answer is
Choice B (examples of other appropriate questions would be “What is the capital of ____?” or “What is your social security number?”). Choice A
assesses the ability to concentrate, not memory.
Source: Psychiatric Mental Health Nursing by Videbeck, 3rd ed., p. 156

89. You are conversing with Tamaki, the 20-year old son of the long-time alcoholic you had just admitted. He has been living in the same house as
his father and seems distraught about the situation, so you have decided to refer him to a support group. To which of the following should you
refer him to?
A. Alcoholics Anonymous
B. Alateen
C. ACOA
D. Children Are People

Rationale:
Alcoholics Anonymous (AA) is a major self-help organization for the treatment of alcoholism. The self-help groups are based on the concept of peer
support—acceptance and understanding from others who have experienced the same problems in their lives. The only requirement for membership
is a desire on the part of the alcoholic person to stop drinking. Each new member is assigned a support person from whom he or she may seek
assistance when the temptation to drink occurs.
AA is the support group for the alcoholic himself. Alateen is a support group for teenage children with an alcoholic parent. Adult Children of
Alcoholics is the support group for adults who grew up in a home with an alcoholic. Children Are People is the support group for school-age children
with an alcoholic family member.
Source: Essentials of Psychiatric Mental Health Nursing by Townsend, 5th ed., p. 305-306

90. While interviewing Mori, a 24-year old shabu addict, he says that “pwede naman akong huminto kung gugustuhin ko” and “wala namang
sobrang samang dulot sa katawan ang shabu ” He also appears emaciated and his conjunctiva is pale. He was admitted due to a laceration on
his right arm after he got into a fight with a group of men while high on shabu. Based on the data you have gathered, which of the following
nursing diagnoses could be formulated?
1. Ineffective coping
2. Denial
3. Ineffective denial
4. Imbalanced Nutrition
5. Knowledge deficiency
6. Chronic low self-esteem

A. 1, 3, 4, 5
B. 1, 2, 4, 5
C. 1, 2, 3, 4, 5
D. 1, 2, 4, 5, 6

Rationale:
Ineffective coping: Abuse of chemical agents; destructive behavior toward others and self; inability to meet basic needs; inability to meet role
expectations; risk taking.
Ineffective denial: Makes statements such as, “I don’t have a problem with (substance). I can quit any time I want to.” Delays seeking assistance; does
not perceive problems related to use of substances; minimizes use of substances; unable to admit impact of disease on life pattern.
Imbalanced Nutrition: Loss of weight, pale conjunctiva and mucous membranes, decreased skin turgor, electrolyte imbalance, anemia, drinks alcohol
instead of eating.
Deficient knowledge: Denies that substance is harmful; continues to use substance in light of obvious consequences.
Denial is not a nursing diagnosis and there is not enough data to support the diagnosis of Chronic Low Self-esteem (Criticizes self and others, self-
destructive behavior, dysfunctional family background etc.)
Source: Essentials of Psychiatric Mental Health Nursing by Townsend, 5th ed., p. 299

91. Alcohol in various mixed drinks, beer, wine and liquor provides sedation, relaxation and the release of inhibitions. It acts as a depressant on the
CNS and the respiratory system; therefore the signs and symptoms of the effects of alcohol use are primarily neurologic. Which of the following
situations depict an example of alcohol abuse?
A. Ejay likes to go out every Saturday with his friends and drink at a nearby pub. He usually wakes up the next morning with a hang-over.
B. Jeff has the strong urge to drink at least three bottles of beer in the afternoon and a glass of scotch at night. He cannot sleep if he is unable
to do so.
 C. Julian experiences tremors and tachycardia if he goes for a long period without taking in alcohol.
D. Prince was put into jail a couple of days ago when he was caught driving under the influence (DUI) of alcohol.

Rationale:
Alcoholism and alcohol abuse are two entirely different conditions. Alcoholism, or alcohol dependence syndrome, is a disease wherein the person
has a strong need or compulsion to drink alcohol and experiences a physical dependence to alcohol (experiences withdrawal symptoms after alcohol
use is stopped). Therefore, Choices B and C are examples of alcoholism.
Alcohol abuse exists when a person does NOT have a strong craving or physical dependence to alcohol, but has problems regarding alcohol use,
like when a person experiences legal problems due to inappropriate alcohol use (as in Choice D).
Choice A is normal behavior and does not indicate an alcohol-related problem.
Source: Medical-Surgical Nursing by Ignativicius and Workman, 5th ed., 99-100

92. Simon, a 54-year old gardener, was brought in to the ED at 8 am this morning after fracturing his right leg. Surgery subsequently took place. He
was alert and responsive while in the PACU, and his vital signs were stable, therefore he was transferred to a private room by 2pm. By 9 pm, he
was clearly agitated, even though he does not complain of pain. You have decided to ask Mr. Simon regarding his usual alcohol intake. He
replied, “I have 4 or 5 drinks at night but I only do it because I need to relax after working so hard during the day.” The primary defense
mechanism the client employed is:
A. Denial
B. Rationalization
C. Intellectualization
D. Projection

Rationale:
Rationalization is the act of excusing one’s own behavior to avoid guilt, responsibility, conflict, anxiety or loss of self-respect. Denial is the failure to
acknowledge an unbearable condition or the failure to admit the reality of the situation or how one enables the problem to continue. Intellectualization
is the separation of emotions of a painful event from the facts. Projection is the unconscious blaming of unacceptable inclinations of thoughts on an
external object.
Source: Psychiatric Mental Health Nursing by Videbeck, 3rd ed., p. 51

93. After interviewing the client and his SO, you suspect that the client is an alcoholic. Which of the following assessment findings would lead you
to conclude that the client is experiencing major alcohol withdrawal signs/symptoms?
A. Restlessness, anxiety, low-grade fever and diaphoresis.
B. Somnolence, hypotension and tachycardia.
C. Tremors of the entire body, heart rate greater than 100 bpm and vomiting.
D. Confusion and inability to recognize familiar objects or people.

Rationale:
Alcohol withdrawal can be evaluated by categories according to severity. They can be classified into minor withdrawal, major withdrawal or life-
threatening withdrawal. Choice A depicts minor withdrawal. Choice B is incorrect, as withdrawal symptoms include difficulty sleeping, increased
blood pressure and tachycardia. Choice D is classified under life-threatening withdrawal.
Additional major withdrawal symptoms include hallucinations (auditory or visual), diastolic pressure above 100 mmHg and pronounced diaphoresis.
Source: Medical-Surgical Nursing by Ignativicius and Workman, 5th ed., 100

94. Mr. Simon is now undergoing detoxification under medical supervision. Upon looking at his medication orders, which of the following orders
would you question?
A. diazepam (Valium), a benzodiazepine
B. atenolol (Tenormin), a beta-blocker
C. doxazosin (Cardura), an alpha-1 adrenergic blocker
D. dextroampethamine sulfate (Dexedrine), a stimulant

Rationale:
When the client is experiencing withdrawal from alcohol- or another depressant- the goal is to prevent the client from harming himself or others. The
HCP often prescribes medications to calm and sedate the client; hence a stimulant is not given. Also, Dexedrine is normally given to clients with
narcolepsy or ADHD. Diazepam (Valium) and chlordiazepoxide (Librium) are commonly given to manage withdrawal symptoms. Beta-blockers and
alpha-1 adrenergic blockers are given to decrease the pulse rate and blood pressure.
Source: Medical-Surgical Nursing by Ignativicius and Workman, 5th ed., 100
Lippincott’s Nursing Drug Guide by Karch, 2007 edition, p. 374

95. Upon entering Mr. Simon’s room one afternoon, you noticed that he is looking at and swatting his arms, trying to remove something that isn’t
there. You suspect he is having a visual hallucination, which can be experienced by people undergoing alcohol withdrawal. At this point, which
of the following would be an appropriate statement?
A. “Oh my god, what’s that on your arms?!”
B. “I don’t see anything, but you must be frightened.”
C. “There is nothing on your arms, Sir. You are just seeing things.”
D. “What are you seeing on your arms?”

Rationale:
Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client’s response towards
reality. The initial action of the nurse is to determine what the client is seeing or hearing and elicit a description of the hallucination, therefore the best
answer is Choice D. Choice A is non-therapeutic and only reinforces the hallucination and increases the client’s anxiety. Choice B is therapeutic, but
it is not what should be said initially. Choice C is also non-therapeutic.
Source: Psychiatric Mental Health Nursing by Videbeck, 3rd ed., p.293

96. Neurotransmitters that have been implicated in the etiology of aggression and violence include decrease in serotonin, and increase in
norepinephrine and dopamine. Which of the following is true of abuse?
 A. It is characterized solely by inflicting physical pain.
B. The rate of reported abuse remains constant.
C. Abuse has economic implications.
D. Abuse includes inflicting damage to a person by himself.

Rationale:
 Abuse is the maltreatment of ONE PERSON BY ANOTHER.
 It may include VERBAL, PHYSICAL, EMOTIONAL, FINANCIAL & MORAL abuse.
 Abuse has an effect on a country’s GDP (WHO).
 The rate of reported violence is increasing.

97. Battering is a pattern of coercive control founded and supported by physical and/or sexual violence or threat of violence of an intimate partner.
Which among the following statements does not characterize a battered woman?
A. “It was my fault because I didn’t cooked anything for dinner.”
B. “I am only staying in this relationship for the sake of our children.”
C. “I can’t seem to understand him.”
D. “I failed to perform my role as a wife.”

Rationale:
Battered women are characterized by low self-esteem as exemplified in letter D. They often accept the blame for the batterer’s action as shown in
letter B. And they often adhere to sex-role stereotypes as shown in letter D.
They often have an understanding that the batterer is more powerful than them – “male dominance” leading to a phenomenon called “learned
helplessness”.

98. There are three phases of the battering cycle. Which of the following is true of the acute battering incident?
A. This is characterized by actions of the batterer as becoming extremely loving, kind and contrite.
B. This is the shortest phase of the battering cycle.
C. This is the least violent phase of the cycle.
D. Minor battering incident will occur in this stage.

Rationale:

Tension Building Phase

 The woman senses that the man’s tolerance for frustration is declining.
 The man becomes angry with little provocation.
 Minor battering incidents may occur in this stage.
 The women may stay away from him so not to trigger explosion of the building tension. However, she may be misinterpreted by the man
and may think that she is rejecting him leading to further escalation.
Acute Battering Incident
 The most violent and the shortest, usually lasting up to 24 hours.
 By the end of the incident, the batterer cannot understand what happened only that he lost control over his behavior.
 May begin with the batterer wanting to teach her a lesson.
 The woman feel that her only option is to find a safe place to hide.
Honeymoon Phase
 The batterer becomes extremely loving, kind and contrite.
 He promises that the abuse will never happen and ask for forgiveness.
 The woman has a desire to believe on what the batterer is saying, and that he will change.
 However, in most instance, the batterer begins again.

99. RA 9262 is the law protecting women and children from violence. The nurse is suspecting that Bogart, an 8-year old child is being abused. What
would be the best way for the nurse to proceed with this information?
A. As a healthcare worker, bring Bogart to the hospital and obtain a medical certificate, and then report the incident to the police station.
B. Check Bogart again in a week and see if there are any new bruises.
C. Meet with Bogart’s parents and ask them how Bogart got the bruises.
D. Initiate paper work to have Bogart placed in foster care

Rationale:
Any suspicious case of violence must be reported immediately as this warrant immediate attention and may endanger the life of the patient.

Letter B: This is wrong because IMMEDIATE ACTION IS NEEDED.

Letter C: This may not be appropriate because the parents may deny how Ejay got the bruises especially if they are the ones inflicting them.
Letter D: This is a least priority action.

100. Rape is the expression of power and dominance by means of sexual violence. Kikay, an 18-year old girl, was physically abused and raped after
refusing the sexual advances of her boyfriend after coming from a party. Kikay was left beaten in the parking lot. As a nurse, your priority
nursing intervention for the patient is:
A. Help her to bathe and clean herself
B. Provide physical and emotional support during evidence collection
C. Provide her with a written list of community resources for rape victims
D. Discuss the importance of a follow-up visit to evaluate for sexually-transmitted diseases

Rationale:
Letter A: This is wrong because evidence of the rape may be wash off.
Letter B: This is the appropriate action for now and once completed, that is the time when we can help the patient bathe and clean herself.
Letter C: This is a list priority action.
Letter D: This is also a list priority action.