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Situation I -- Nurse Caria is assigned in the emergency unit meeting. Varied opportunities that developed her nursing skills.
1. A 17-year old is admitted following an automobile accident He is very anxious, dyspneic, and in severe pain. The left chest wall moves in during inspiration and balloons out when he exhales. The nurse understands these symptoms are most suggestive of:
a. Hemothoraxb. Flail chestc. Atelectasisd. Pleural effusion
2. A young man is admitted with a flail chest following a car accident. He is intubated with an endotracheal tube and is placed on a mechanical ventilator (control mode, positive pressure). Which physical finding alerts the nurse to an additional problem in respiratory function?
a. Dullness to percussion in the third to 5th intercostals space, midclavicular lineb. Decreased paradoxical motionc. Louder breath sounds on the right chestd. pH of 7.36 In arterial blood gases
3. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system (Pleur-evac). To ensure that the system functions effectively the nurse should:
a. Observe for intermittent bubbling in the water seal chamberb. Flush the test tube with 30 to 60 ml of NSS 4 to 6 hoursc. Maintain the client in an extreme lateral positiond. Strip the chest tubes in the direction of the client
4. The nurse enter the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodge from the chest. The most appropriate nursing intervention is to:
a. Notify the physicianb. Insert a new chest tubec. Cover the insertion site with new petroleum gauzed. Instruct the client to breath deeply until the help arrives
5. A 71-year old is admitted to the hospital with congestive heart failure. She has shortness of breath and a +3 - 4 peripheral edema. The care plan to reduce the client's edema should include nursing strategies for:
a. Establishing limits on activity
b. Fostering a relaxed environmentc. Identifying goals for self cared. Restricting IV fluids
Situation 2 - Oxygen is the most vital physiologic need for survival.
6. Mr. Sison, 65 years old has been smoking since he was 11 years old. He has long history of emphysema. Mr. Sison is admitted to the hospital because of a respiratory infection, which has not improved with outpatient therapy. Which finding would the nurse expect to observe during Mr. Sison's nursing assessment?
a. Electrocardiogram changesb. Increased anterior-posterior chest diameterc. Slow labored respiratory patternd. Weight-Height relationship indicating obesity
7. Mr. Sison is ordered oxygen via nasal prongs. The nurse administering the oxygen via the low-flow system recognizes that this method of delivery:
a. Mixes room air with oxygenb. Delivers a precise concentration of oxygenc. Requires humidity during deliveryd. Is less traumatic to the respirator tract
8. Which statement by Mr. Sison indicates that client teaching regarding oxygen therapy has been effective?
a. "I was feeling fine so I removed my nasal prongs."b. "I've increased my fluids to six glasses of water daily."c. "Don’t forget to come back quickly when you get me out of the bed; I don't want to be without my oxygen for too long." d. "My family was angry when I told them they could not smoke in my room."
9. Supplemental low-flow oxygen therapy is prescribed for a man with emphysema. Which is the most essential for the nurse to initiate?
a. Anticipate the need for humidification b. Notify the physician that this order is contraindicated c. Place client in high Fowler's position d. Schedule nursing care to allow frequent observations of the client
Situation 3 - Mr. Silverio, 56 years old, has had significant problem with alcohol abuse for the past 15 years. His wife brings him to the emergency department because he is increasingly confused and is coughing blood. His medical diagnosis is cirrhosis of the liver. He has ascites and esophageal varices.
10. Assessment of Mr. Silverio would reveal all of the following, except:
a. Bulging flanksb. Protruding umbilicusc. Abdominal distensiond. Bluish discoloration of the umbilicus
11. Which laboratory value would the nurse expect to find in a client as a result of liver failure?
a. Decreased serum creatinine b. Decreased sodium c. Increased ammonia d. Restricted sodium
12. The major dietary treatment for ascites calls for:
a. High proteinb. Increased potassiumc. Restricted fluidsd. Restricted sodium
13. A Sengstaken-BIakemore tube is inserted in an effort to stop the bleeding. Base on this information, the first action the nurse should take is to:
a. Deflate the esophageal balloonb. Encourage him to take the deep breath c. Monitor his vital signs d. Notify the physician
14. Because the detoxification of alcohol damages tissues a high-calorie diet, fortified with vitamins should be encouraged to protect Mr. Silverio's:
a. Liver b. Kidneysc. Adrenals d. Pancreas
Situation 4 - Rape is one of the most tragic things that could happen to anyone especially with young girls. Incidence such as these could develop into a crisis situation involving not only the rape victims but also their families.
15. This type of crisis could be an example of which of the following?
a. Combination of developmental and situational
b. Situational c. Emotional d. Developmental
16. Noemi, a staff nurse in the emergency room, realizes that she has an important role to play as a patient advocate to rape victims. To demonstrate this role, she takes note of one of the responsibilities?
a. Since this is a legal case, call the press about the incidence of rape b. Perform thorough physical assessment and documenting objectively all the evidences of rape c. Ask the patient to stay in one isolated room first to provide privacy while attending to other patientsd. Provide emotional support first and postponed physical assessment when patient is already calm
17. Which of the following is a form of active, focused, emotional environmental first aid for patients in crisis?
a. Attitude therapy b. Psychotherapy c. Crisis intervention d. Re-motivation technique
18. Which of the following is true with regards to crisis?
a. Crisis is self-limitingb. After crisis, the individual always return to a pre-crisis state or condition c. Crisis always result in adaptive behavior d. The person in crisis is not susceptible for any help
19. If help is not provided in a crisis situation, an individual may spontaneously resolve in negatively or positively by returning to pre-crisis state, usually within which of the following duration?
a. 2-3 weeks b. 3-4 weeks c. 1-2 weeks d. 4-6 weeks
Situation 6 - One Important fact that will guide the nurse in the practice of the profession is her knowledge of the nursing law.
20. The nurse practice Act of 1991 regulates the practice of nursing in the Philippines. Which of the following statements about this Act is true?
a. This Act delineates the practice of nursing and midwiferyb. It was enacted in November 1991c. The primary purpose is to protect the publicd. The Act defines the practice of nursing in the Philippines
21. When a nurse starts working In a hospital but without a written contract, which of the following is expected of her?
a. She's not bound to perform according to the standards of nursing practice b. Provides nursing care within the acceptable standards of nursing practice c. She's not obligated to provide professional service d. The employer does not hold the nurse responsible for her action
22. A patient, G8P5, refused to be injected with the 3rd dose of Depoprovera. Thenurse insisted inspite of the patients refusal and forcibly injected the contraceptive. She can be sued for which of the following?
a. Misrepresentationb. Assault and Battery c. Malpractice d. Negligence
23.A patient has been in the ICU for 2 weeks. The relatives have consented to a "Do not resuscitate order," When the patient develops a cardiac arrest, the nurse will carry out which of the following actions?
a. Only medication will be givenb. All ordinary measure will be stoppedc. Basic and advance life support will not be given d. Mechanical ventilation and NGT will be stopped
24. When a patient falls from bed, which of the following is your immediate action?
a. Report to the head nurse and calls someone to help b. Determine any injury or harm c. Refer to the resident on duty d. Put back patient to bed
Situation 7 - Ms. May Mansur encountered vehicular accident on her way to the office and he remains conscious. Police officers brought her to the hospital.
25. You have to observe for increase intracranial pressure. Which of the following is not a sign of increased intracranial pressure?
a. Headacheb. Vomiting c. Vertigo d. Changes on the level of consciousness
26. Which of the following drug may be given to reduce increase intracranial pressure?
a. Scopalamineb. Lanoxin c. Coumadin d. Mannitol
27. Since she medicated to reduce increased intracranial pressure. What nursing measure must be done to prevent further complication?
a. Encourage her to observe bed restb. Check blood pressure every shift c. Observe complete best rest d. Measure intake and output
28. In what manner would you be able to assess accurately her motor strength?
a. Observe how he talksb. Instruct her to squeeze her hands c. Allowing him to stand alone d. Pricking her skin with pin
29.Which of the following activities would cause her a risk in the increase of intracranial pressure?
a. Coughing b. Readingc. Turning d. Sleeping
Situation 8 - Basic Psychiatric concepts a nurse should be aware of...
30. Mental experiences, operate on different levels of awareness. The level that best portrays one's attitudes, feelings, and desire is the:
a. Conscious b. Unconscious c. Preconscious d. Foreconscious
31. The ability to tolerate frustration is an example of one of the functions of the:
a. Id b. Ego c. Superego d. Unconscious
32. In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. This normally accomplished through the use of:
a. Affective reactionsb. Ritualistic behaviorc. Withdrawal patterns d. Defense mechanisms
33. Sublimation is a defense mechanism that helps the individual:
a. Act out in a reverse something already one or thoughtb. Return to an earlier, less mature stage of developmentc. Exclude fro the conscious things that are psychologically disturbingd. Channel an acceptable sexual desire into socially approved behavior
34. An example of displacement is:
a. Imaginative activity to escape realityb. Ignoring unpleasant aspects of realityc. Resisting any demands made by othersd. Pent-up emotion directed to other than the primary source
Situation 9 - Joan, age 34, is hospitalized because of alcoholism.
35. Joan denied that she has a problem with alcohol. The nurse understands that Joan uses denial for which of the following reasons:
a. To reduce her feelings of guilt b. To iive up to others' expectationc. To make her seem more independentd. To make her look better in the eyes of others
36. Joan appears suspicious of others and blames them for her personal problems. The nurse understands the client is using this behavior because which of the following difficulties?
a. In telling the truthb. Meeting an ego ideal c. With dependence and independenced. In identifying who is creating the problem
37. When thinking about alcohol and drug abuse, the nurse is aware that:
a. Most polydrug abusers also abuse alcohol b. Most alcoholics become polydrug abusersc. Addictive individuals tend to use hostile abusive behaviord. An unhappy childhood is a causative factor in many addictions
38. The most important factor in rehabilitation of a client addicted to alcohol is:
a. The availability of community resources b. The accepting attitude of the client’s familyc. The client's emotional or motivational readiness d. The qualitative level of the client's physical state
39. Joan asks if attendance of Alcoholics Anonymous is required. Which of the following would reflect the nurse's reply?
a. "You'll find you need their support."b. "Do you have feelings about going to these meetings?" c. "No its best to wait until you feet you really need them."d. "Yes, because you will learn how to cope with your problem."
Situation 10 - Nurse Medie has been encountering schizophrenic and different psychotic disorders. .
40. A male client who has delusions of persecution and auditory hallucination is admitted for psychiatric evaluation after stabbing a friend. Later a nurse on the unit greets the client by saying, "Good evening. How are you?" The client who has been referring to himself as "man," answers, "The man is bad." This is example of:
a. Dissociation b. Transference c. Displacement d. Reaction formation
41. A disturb client starts to repeat phrase that others have just said. This type of speech is known as:
a. Autism
b. Echolalia c. Neologism d. Echopraxia
42. Projection, rationalization, denial, and distortion by hallucinations and delusions are examples of a disturbance in:
a. Logic b. Association c. Reality testing d. The thought process
43. The major reasons for treating severe emotional disorders with tranquilizers is to:
a. Reduce the neurotic syndrome b. Prevent secondary complication c. Prevent destructiveness by the client d. Make the client more amenable to psychotherapy
44. The nurse recognizes that dementia of the Alzheimer's type is characterized by :
a. Aggressive acting out behaviorb. Periodic remissions and exacerbations c. Hypoxia of selected areas of brain tissue d. Areas of brain destruction called senile plaques
Situation 11 - Aisa, is a 4-year old with severe anemia. She is seen by the nurse in the clinic.
45. In addition to weakness and fatigue, which of the following problems should the nurse expect Aisa to exhibit?
a. Cold, clammy skin b. Increased pulse rate c. Elevated blood pressure d. Cyanosis of the nail beds
46. Which of the following problems associated with anemia best explains why Aisa becomes dizzy during periods of physical activity?
a. An inflammation of the inner earb. Insufficient cerebral oxygenation c. A sudden drop in blood pressured. Decreased level of serum glucose
47. Aisa is to receive a liquid iron preparation. Which of the following directions would be appropriate for the nurse to teach Aisa's mother?
a. Administer this at least an hour before meals b. Explain that loose stools are common with ironc. Have Aisa take the diluted iron preparation through a straw d. Avoid giving Aisa orange or other citric juices with the iron preparation
48. Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion?
a. Serum hepatitisb. Allergic response c. Pulmonary edema d. Hemolytic reaction
Situation 12 - Eric Pineda is admitted to hospital to have his urethra dilated by the physician. A urinary retention catheter is inserted following the procedure.
49. A routine urinalysis is ordered for Mr. Pineda. If the specimen cannot be sent immediately to the laboratory, the nurse should:
a. Take no special action b. Refrigerate the specimen c. Store on dry side of utility roomd. Discard and collect a new specimen later
50. The nurse understands that the structure that encircles the male urethra is the:
a. Epididymis b. Prostate gland c. Seminal vesicled. Bulbourethral gland
51. The nurse can best prevent the contamination from Mr. Pineda's retention catheter by:
a. Perineal cleansing b. Encouraging fluids c. Irrigating the catheterd. Cleansing around the meatus periodically
52. When Mr. Pineda, who has urinary retention catheter in place, complaints of discomfort in the bladder and urethra the nurse should first:
a. Notify the physicianb. Milk the tubing gentlyc. Check the patency of the catheter d. Irrigate the catheter with prescribed solutions
53. Mr. Pineda experiences difficulty in voiding after his indwelling urinary catheter is removed. This is probably related to:
a. Fluid imbalanceb. Mr. Pineda's recent sedentary lifestylec. An interruption in normal voiding habits d. Nervous tension following the procedure
Situation 13 - Helen Alcantara is admitted to hospital with complaints of hematuria, frequency, urgency, and dysuria.
54. Mrs. Alcantara's signs and symptoms would most likely be associated with:
a. Pyelitis b. Cystitis c. Nephrosis d. Pyelonephritis
55. Mrs. Alcantara has a higher risk of developing cystitis than does a male. This isdue to:
a. Altered urinary pH b. Hormonal secretions c. Position of the bladder d. Proximity of the urethra and anus
56. The family of an elderly, aphasic client complain that the nurse failed to obtain a signed consent before insertion of indwelling catheter to measure hourly output. This is an example of:
a. A catheter inserted for the client's benefitb. A treatment that does not need a separate consent form c. Treatment without consent of the client, which is an invasion of rightsd. Inability to obtain consent for treatment because the client was aphasic
57. When caring for a client with continuous bladder irrigation, the nurse should:
a. Monitor urinary specific gravityb. Record urinary output every hourc. Subtract irrigant from output to determine urine volume d. Include irrigating solution in any 24 hour urine tests order
58. When urinary catheter is removed, the client is unable to empty the bladder. A drug is used to relieve urine retention is:
a. Carbachol injection b. Neosporin GU irrigant c. Bethanecol (Urecholine) d. Pilocarpine hydrochloride (Pilocar)
Situation 14 - Arman Adriatico is admitted to hospital with extensive carcinoma of the descending portion of the colon with metastasis to the lymph nodes.
59. The operative procedure that would probably be perform to Mr. Adriatico is a (an):
a. lleostomyb. Colectomy c. Colostomyd. Cecostomy
60. The primary step toward long-range goals in Mr. Adriatico's rehabilitation involves his:
a. Mastery of techniques of ostomy careb. Readiness to accept an altered body function c. Awareness of available community resourcesd. Knowledge of the necessary dietary modifications
61. When teaching Mr. Adriatico to care for a new stoma, the nurse should advice him that irrigations be done at the same time every day. The time selected should:
a. Be appropriate hour before breakfastb. Provide ample uninterrupted bathroom use at home c. Approximate Mr. Adratico's usual daily time for eliminationd. Be about halfway between the two largest meals of the day
62. When performing the colostomy irrigation, the nurse inserts the catheter into the stoma:
a. 5cmb.10cm
c.15cm d.20cm
63.Mr. Adriatico should follow a diet that is:
a. Rich in protein b. Low in fiber content c. High in carbohydrate d. As close to normal possible
Situation 15 - Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.
64. A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
a. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional helpb. Gently raise Mr. Gabatan to a sitting position to see if the pain eitherc. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and coverhim with any material available d. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
65. Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
a. Upper extremities are paralyzedb. Lower extremities are paralyzed c. One side of the body is paralyzed d. Both lower and upper extremities are paralyzed
66. The nurse recognizes that the major early problem for Mr. Gabatan will be:
a. Bladder control b. Client education c. Quadriceps setting d. Use of aids for ambulation
67. The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
a. Active exercise b. Deep massage c. Use of tilt board d. Proper positioning
68. Rehabilitation plans for Mr. Gabatan;
a. Should be left up to Mr. Gabatan and his familyb. Should be considered and planned for early in his care c. Are not necessary, because he will return to former activitiesd. Are not necessary, because he will probably not able to work again
Situation 16- Karen Boltron, age 16, is withdrawn and non communicative. She spendsmost of her time lying on her bed.
69. Which nursing intervention would be the most appropriate way to help Karen accept the realities of daily living?
a. Assist her to care for personal hygiene needs b. Encourage her to keep up with school studies c. Encourage her to join the other clients in group singing d. Leave her alone when these appears to be a disinterest in the activities at hand
70. Which is the best plan of nursing intervention to encourage Karen to talk:
a. Try to get her discuss feelingsb. Focus oh non threatening subjects c. Ask simple questions that require answersd. Sit and look magazines with her
71. Which of the following is an important aspect of nursing intervention when caring for Karen?
a. Help keep her oriented to realityb. Involve her in activities throughout the day c. Encourage her to discuss why mixing with other people is avoidedd. Help her understand that it is harmful to withdraw from situations
72. One day Karen suddenly walks up to the nurse and shouts. "You think you're so damned perfect ad good. i think you stink," Which response should the nurse make?
a. "You seem angry with me." b. "Stink? I don't understand." c. "Boy, you're in a bad mood." d. "I can't be all that bad, can I?"
73. On being discharged, a client with psychiatric problems should be encouraged to:
a. Go back to regular activities b. Call the unit whenever upsetc. Continue in an after care situationd. Find a group that has similar problem
Situation 17 - Danny Dasigao, age 63, has an obsessive-compulsive behavior disorder. He believes that the doorknobs are contaminated and refuses to touch them except with the tissue.
74. Which intervention should the nurse make when dealing with Danny's fear of doorknobs?
a. Supply rim with paper tissue to help him function until his anxiety is reduced b. Explain to him that this idea about doorknob is part of his illness and is not necessaryc. Encourage him to scrub the doorknobs with a strong antiseptic so he does not need to use tissues d. Encourage him to touch doorknobs by removing all available paper tissue until he learns to deal with the situation
75. Which stimulus is possibly motivating Danny to use paper towels to open doors?
a. He is using the method to punish himself b. He is listening to voices telling him that the doorknobs are unclean c. He wants to unconsciously control unacceptable impulses or feelings d. He has a need to punish others by carrying out an annoying procedure
76. Which action by the nurse would most likely decrease Danny's anxiety?
a. Explore with him the nature of his anxiety b. Stimulate him to express his ritualistic actions regularlyc. Encourage him to participate in his therapeutic plan of care d. Provide him with an environment that is both supportive and non-opinionated
77. Which intervention should be included in Danny's initial treatment plan?
a. Deny his time for the ritualistic behavior b. Give a schedule for the ritualistic behavior c. Determine the purpose of the ritualistic behavior d. Suggest a symptom substitution technique to refocus the behavior
78. The most appropriate way to decrease a clients anxiety is by:
a. Avoiding unpleasant objects and eventsb. Prolonged exposure to fearful situationc. Acquiring skills with which to face stressful events d. Introducing an element of pleasure into fearful situations
Situation 18 - Jennifer Yadao, age 16, is admitted with the diagnosis of anorexia nervosa. She has lost 10 kg in 5 weeks. She is very thin but excessively concerned about being overweight. Her daily intake is 10 cups of coffee.
79. Which nursing intervention should the nurse initially perform for Jennifer? a. Explain the value of good nutritionb. Compliment her on her lovely figure c. Try to establish a relationship of trust d. Explore the reasons why she does not eat
80. Which stimulus is the most likely cause of Jennifer's disorder?
a. Allow self-esteem b. Feelings of unworthinessc. Anger directed at the parentsd. An unconscious fear of growing up
81 Jenifer is to be placed on behavior modification. Which is appropriate to include in the nursing care plan?
a. Remind frequently the client to eat all the food served on the tray b. Increase phone calls allowed the client by or a per day for each pound gained c. Include the family with the client in therapy sessions two times per week d. Weigh the client each day at 6:00 A.M. in hospital gown and slippers after she voids
82. Another patient, Kara, 17 years old, is also diagnosed with anorexia nervosa. You have been assigned to sit with her while she eats her dinner. Kara says to you, "My primary nurse trusts me. I don't see why you don't." Your best response is:
a. "I do trust you, but S was assigned to be with you."b. "It sounds as if you are manipulating me." c. "OK. When S return, you should have eaten everything."d. "Who is your primary nurse."
83. Which observation of the client with anorexia indicates that the client is improving?
a. The client eats meals in the dining roomb. The client gains one pound per week
c. The client attends group therapy sessionsd. The client has a more realistic self-control
Situation 19 - Mr. Pascua is pacing about the unit and wringing his hands. He is breathing rapidly and complains of palpitations and nausea and he has difficulty focusing on what the nurse is saying. •
84. Mr. Pascua is experiencing a high degree of anxiety. It is important to recognize if additional help is required because:
a. If the client is out of control, another person will help to decrease his anxiety level b. Being alone with an anxious client is dangerous c. It will take another person to direct the client into activities to relieve anxietyd. Hospital protocol for handling anxious clients requires at least two people
85. He says he is having a heart attack but refuses to rest. The nurse would be Interpret his level of anxiety as:
a. Mild b. Moderatec. Severed. Panic
86.What should the nurse include in the care plan to Mr. Pascua when he is havinga panic attack?
a. Calm reassurance, deep breathing and modication as ordered b. Teach Mr. Pascua problem solving in relation to his anxiety c. Expiam the physiologic responses of anxietyd. Explore alternate methods for dealing with the cause of his anxiety
Situation 20 - Joel is a toddler who has classical hemophilia.
87. Which of the following statements is true regarding Joel's disorder?
a. Hemophilia is an autosomal dominant disorder in which the woman carriesthe traitb. Hemophilia follows regular laws of Mendelian inherited disorders such as sickle ceil anemiac. This disorder can be carried by either male or female but occurs in the sex opposite that of the carrier d. Hemophilia is an X-linked disorder in which the mother is usually the carrier of the illness but is not affected by it
88. Joel has some internal bleeding. At which of the following sites is the most
common for the child with hemophilia to bleed?
a. Joints b. Intestines c. Cerebrum d. Ends of the log bones
89. Which of the following blood products is most likely to be given to Joel?
a. Albuminb. Fresh frozen plasma c. Factor VIII concentrate d. Factor II, Vll, IX, X complex
90. Joel's parents ask if-their other children will be affected by the disorder. Which of the following statements should guide the nurse in her response?
a. All the girls will be normal and the other son a carrier b. All the girls will be carriers and one half the boys will be affected c. Each son has a chance of being affected and each daughter a 50% chance of being a carrierd. Each son has 50% chance of being affected or a carrier, and the girls will be all carriers.
91. A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:
a. Call the physicianb. Slow the flow ratec. Stop the blood immediatelyd. Relieved the symptoms with an ordered antihistamines
Situation 19 - Mr. Villa who was admitted to the respiratory floor with COPD. The nurse finds him extremely restless, incoherent, and showing signs of acute respiratory distress. He Is using accessory muscles for breathing and Is diaphoretic and cyanotic.
92. The best initial action by the nurse is to:
a. Administered oxygen as ordered b. Assess vital signs and neural vital signs c. Administered medication which has been ordered for paind. Call respiratory therapy for a prescribed ABG (arterial -blood gas) analysis
93. An order is written for oxygen by nasal cannula at 2 liters per minute. Which assessment is most useful in assessing the adequacy of the oxygen therapy?
a. Respiratory rateb. Color of mucus membranesc. Pulmonary function testsd. Arterial blood gases
94. Mr. Villa needs frequent monitoring of arterial blood gases. Following the drawing of arterial blood gasses it is essential for the nurse to do which of the following?
a. Encourage the client to cough an deep breath b. Apply pressure to the puncture site for 5 minutes c. Shake the vial of blood before transporting it to the lab d. Keep the client on bed rest for 2 hours
95. The nurse is interpreting the results of a blood gas analysis performed on an adult client. The value include pH of 7.35, pC02 of 60, HC03 of 35. and 02 of 60. Which interpretation is most accurate?
a. The client is in metabolic acidosisb. The client is in compensated metabolic alkalosisc. The client is in respiratory alkalosisd. The client is in compensated respiratory acidosis
Situation 20 - The nurse is assigned in a counseling clinic about preventive measures for cancers.
96. Cancer is the second major cause of death in this country. What is the first step toward effective cancer control?
a. Increasing governmental control of potential carcinogensb. Changing habits and customs that predispose the individual to cancerc. Conducting more mass screening programsd. Educating public and professional people about cancer
97. In order to educate clients, the nurse should understand that the most common site of cancer for a female is the:
a. Uterine cervix b. Uterine body c. Vagina d. Fallopian tube
98.A client has just completed a course in radiation therapy and is experiencing radio-dermatitis. The most effective method of treating the skin is to:
a. Wash the area with soap and warm water b. Apply a cream or lotion to the areac. Leave the skin alone until it is clear d. Avoid applying creams or lotion to the area
99.A client with cancer that has metastazised to the liver is started on chemotherapy- His physician has specified divided doses of the antimetabolite. The client asks why he could take the drug in divided doses. The appropriate response is:
a. " There really is no reason your doctor just wrote the orders that way." b. "This schedule will reduce the side effect of the drug." c. "Divided doses produce greater cytotoxic effects on the diseased cells." d. "Because these drugs prevent cell division, they are more effective in divided doses,"
100. A client has possible malignancy of the colon, and surgery is scheduled. The rationale for administering Neomycin preoperatively is to:
a. Prevent infection postoperativelyb. Eliminate the need for preoperative enemasc. Decreased and retard the growth of normal bacteria in the intestinesd. Treat cancer of the colon
Situation 1. The following pertains to some concepts and principles of community health nursing that a nurse must apply in carry out CHN services.
1. Community heatlth nursing is a field of nursing which utilize
1. Knowledge about the history and philosophy of public health practices2. Concepts of epidemiology and bio-statistics3. Principles of leadership and management 4 Principles of social change
a. 1, 2, 3 & 4 b. 1 & 2 C. 2 & 3 d. 1,2 & 3
2. Which of the following features should the nurse incorporate in her practice of community health nursing (CHN)?
1. CHN is oriented to population2. CHN emphasize health3. CHN involves interdisciplinary collaboration4. CHN promotes client participation in determining their own health
a. 1, 2, 3 & 4 b. 3 & 4 onlyc. 1 & 2 only d. 1, 2 & 3
3. In order to strengthen community participation in health activities in the community, which of this following should be done by the Public Health Nurse?
1. Identify the existing and potential leaders of the community2. Form a core group for health3. Formulate action program for health4. Tell the community leaders what to do for their health problems
a.1 & 3 b.3 & 4c.1 & 2d.2 & 3
4. Which of the following characterize Primary Health Care?
1. Essential health care accessible and acceptable to individual and families in the community2. The cost of care is affordable to community and country3. The setting is in tertiary hospitals 4. Require; health personnel and specialized training
a. 1 & 4 b. 3 & 4c. 1 & 2 d. 2 & 3
5. Which of the following statements about the PHN’s role in the community is/are correct?
1. The PHN will only enjoy her work if she accepts her role and is able to perform that role2. The PHN is a community health nurse if she is able to establish rapport with the community officials and members 3. The PHN wish only give bedside nursing care4. The PHN can walkthrough mud, work under stress and eat with the people in the barangay
a.1 & 2 b.3 & 4
C. 2 & 3 d. 1, 2 & 4
Situation 2. Cynthia Payas at 30 weeks of gestation has been admitted to the labor room. She says she been having moderate contractions every 3-5 minutes lasting almost a minute. Her membranes are placed.
6. From the nurse's assessment findings of Leopold maneuvers TS revealed a soft, rounded mass, irregular nodules on Cynthia's right side and a hard prominence on her right, just above the symphisis. Which of the following best describe the fetal presentation and position?
a. ROPb. LOA c. LSAd. RSP
7. Health teaching during the prenatal period emphasize the expectant mother's need to go to the hospital when:
a. Contractions are 5-10 min, apart lasting 30 seconds and are felt as strong as menstrual cramp.b. Contractions are 5 min. apart lasting 60 seconds and in increasing intensity c. Contractions are 3-5 min. apart with rectal pressure and bloody show d. contractions are 2-3 min apart lasting 90 seconds and membranes have ruptured
8. The nurse continues with her admission assessment. Which location should the nurse anticipate finding the fetal heart tones?
a. above the umbilicus on her left side b. above the umbilicus on her right sidec. below the umbilicus of Mona's left side d. below the umbilicus of Mona’s right side
9. The nurse assessed the frequency, duration and intensity of Cynthia's contractions. Which of the following techniques should the nurse use?
a. Holding the finger and palm over the area below the umbilicus b. Moving of her ringers of one hand over the uterus pressing into the muscle c. Spreading the ringers of one hand tightly over the handd. Indenting the uterus in several places during and between contractions
10. During labor, when positioning a client on lithotomy, the nurse should
a. Make sure the legs are safety strapped on the stirrupsb. Put her on semi-ceiling position first
c. Gradually lift one legs after the other d. Put up hef client's leg together
Situation 3. An early childhood febrile syndrome affecting the lymphodes was identified by the Public Health Nuse(PHN)
11. Cristina a three years old girl came to RHU due to fever unresponsive to antibiotics. During assessment, the nurse noticed that she has "strawberry tongue ". Which the following syndrome her diagnosis?
a. Karachi fever b. Igarashi feverc. Kawasaki feverd. Nagasaki fever
12. Upon assessment, you have observed that Cristina was irritable with mood changes and cervical lymphadenopalhy. What would you do to her?
a. Blame the mother b. Give medicationc. Divert bar attentiond. Spank her
13. When the doctor arrived, the mother wanted to bring her child to a tertiary hospital. Which level of bars would you put Cristina in?
a. fourthb. first c. second d. third
14. Which among the treatment below was ordered by the physician for Cristina's mother to buy from the "Botika sa barangay"?
a. Immunoglobuline b. Antihistaminec. Paracetamol d. Salicylatea
15. Susceptibility of the syndrome that Cristina was affected with, is from what ancestry?
a. Aryan b. Caucasian c. Asian d. America
Situation 4. Hearing, impairment appears to be common among elderly patients. But also occurs among children.
16. To assess the degree of hearing impairment of a 70-year-old client. Which communication approach would you initiate?
a. Use verbal communication and observe the responseb. Give message to client in writingc. Asks a family member about the client'sd. Post a sign "Patient deaf"
17. While you are mating your routine rounds you were told that there is a client in the 1CU who is in respirator and who lip-reads. To establish relationship with him, communication is best accomplished by:
a. Speaking slowly but aloudb. Writing messagesc. Gesturing while speakingd. Using simple "charade" approach or strategy
18. One of your client's has just undergone an ear surgery. Which of the following would be inappropriate in planning for his care?
a. Administration of anti-emetics and analgesics as orderedb. Daily irrigation of the ear canalc. Walking with assistance at least 24 hours after operationd. Teaching the patient to avoid sneezing, coughing and nose blowing
19. Which of the following conditions would an irrigation of the ear canal be appropriate intervention?
a. Foreign body in the ear canal b. Serious otitisc. Impacted cerumend. Tympanic membrane perforation
20. Children who have undetected hearing loss are likely to exhibit which of the following:
a. Indifference and lack of interest in the environmentb. Hyperactivityc. An increased interest in readingd. Hand gestures while speaking
Situation 5. As a professional nurse you take responsibility for personal & professional
growth
21. Regulation of nursing practice is mainly based on:
a. Board of Nursing resolutions and pronouncementsb Legal rules and principles governing nursing practicec. Standards of nursing practiced. Decisions made by the PRC relating the nursing practice
22. You are a graduate of new BSN curriculum feat aims to prepare a fully functioning nurse. Which of the following best describe this graduate?
a. Sensitive awareness to the health needs of society b. Collaboration with multi-sectoral groups c. Compassionate attitude to all those cared for d. Consideration of needs of patients and others
23. Accountability and responsibility in nursing practice is enhanced by utilization of
a. Assessment or appraisal tools b. Code of Ethics of nurse'sc. Records for care pland. The nursing process
24. The professional license is renewable every three years during which of the following periods?
a. Every April 15 of each year b. Every march 15 of each year c. Every January 20 of each year d. On or before one’s birth month
25. Which of the following Acts means that "Health Workers" are all persons engaged in health relate work regardless of their employment status?
a. Magna Carta of Public Health Workerb. Security of Tenure of regular employeesc. Discrimination Prohibitiond. Code of Conduct and Ethical Standard of Public Officials and Employees
Situation 6. Nurses provide care to individuals in the various stages of health & illness.
26. Which of the following are internal factors that influence health practices?
a. Family practices b. Norms of society c. Religious beliefs d. Developmental stage
27. Health-illness continuum refers to which of the following statements? A person
a. Can both be healthy or ill b. Is either healthy or sickc. Can be at the level of health & illnessd. Is either not healthy or not ill
28. One's ideas convictions and attitudes which influence his level of health is referred to as his:
a. Health beliefs b. Health habits c. health practice d. health perceptions
29. Health Beliefs Model states that one takes health action if:
a. Is consistent of his health beliefs b. Get support from familyc. Agree with the society's norms d. Will prevent his getting sick
30. Health action that keeps one's present level of health is referred to as:
a. Health enhancement b. Health promotion c. Death preventiond. Health maintenance
Situation 7.Cathy is in the early first trimester of her first pregnancy. ,
31. Cathy visits her gynecologist to confirm a suspected pregnancy. During the nursing history, she states that her last menstrual period began April 11. Cathy states that some spotting occurred in May 8. The Nurse calculates that her due date is:
a. January 10 b. January 18c. February 12d. February 15
32. Cathy asks the nurse why menstruation ceases once pregnancy occurs. The nurse's best response would be that this occurs because of the
a. Reduction in the secretion of hormones by the ovaries b. Production of estrogen and progesterone by the ovaries. c. Secretion of luteinizing hormone produced by the pituitaryd. Secretion of follicle-stimulating hormone produced by the pituitary.
33. The nurse is aware that the nausea and vomiting commonly experienced by many women during the first trimester of pregnancy is an adaptation to the increased level of
a. Estrogen b. Progesterone c. Luteinizing hormone d. Chorionic gonadothropin
34. The nurse in the prenatal clinic should provide nutritional counseling to all newly pregnant women because:
a. Most weight gain during pregnancy is fluid retentionb. Dietary allowance should not increase during pregnancyc. Pregnant women must adhere to a specific pregnancy dietd. Different sources of essential nutrients are favored by different cultural groups
35. Cathy is now in her 8 weeks of pregnancy and complains of having to go to the bathroom often to urinate. The nurse explains to her that urinary frequency often occurs because the capacity of the bladder during pregnancy is diminished by:
a. Atony of the detrusor muscleb. Compression by the ascending uterusc. Compromise of the autonomic reflexesd. Constriction of the ureteral entrance at the trigone
Situation 8. AIDS cases has been all over the country and yet only few are reported cases due to the stigma attach to it.
36. What is the causative agent in HIV/AIDS?
a. trichomonas vaginalisb. Human, T-cell lymphotrophio virus c. Treponema pallidumd. Chlamydia tranchomatis
37. A classic full blown AIDS case is identified by clinical manifestations such as:
a. Persistent generalized lymphadenopathyb. Sudden loss of weight, afternoon fever and general malaisec. Tumors and opportunistic infectionsd. Fever, weight loss, night sweats and diarrhea
38. Pulmonary complications are the most common problem in caring for AIDS patients. This is caused:
a. Kaposi's Sarcoma b. Filterable Virusc. Pneumonia Carnii d. Staphylococcus bacteria
39. The cause of death of most AIDS patients who develop multiple opportunistic infections is/are the following:
a. Weakened immune system impairs response to therapyb. AH of these (a, b, c) c. Weakened immune system impairs resistance to infectiond. Infection cannot be treated effectively
40. Implementation of the following activities can help prevent the transmission of AIDS through the blood.
1. Conduct public education campaign, with the aim of implementation self-deferral of blood donate who are risk of HIV infection2. Educate health care workers on the correct use of blood3. Conduct surveillance of women attending anti-natal clinics4. Use of condoms of those found to be infected with HIV
a. 1 & 2b. 3 & 4C. 1 & 3d. 2 & 3
Situation 9. One of the main fools of the nursing profession is the use of therapeutic communication. The following situation would require you of your communication skills.
41. A patient who is diagnosed to have terminal illness tells you. "I’m really scared. Am I dying?" What could be your most appropriate response?
a. "Tell me about what you think." b. "I'm sure you are scared; other clients in your situation feel the same way."
c. "You should be careful not to let your family know you're scared"d. "Why are you scared?"
42. The nurse assessing a male client who has been admitted for treatment of alcoholism. Which question by the nurse is least appropriate?
a. "How much do you think?"b. "What other drugs do you use?" .c. "How is your general health?"d. "Why do you drink so much?"
43. A 58-year-old male client tells the office nurse that his wife does not let him change his colostomy bag himself. Which response by the nurse indicates as understanding of the situation?
a. "Your wife's need to help you is a reality you should accept"b. "Do you think your wife might benefit from counseling?"c. "You feel you need privacy when changing your colostomy?"d. "Have you discussed the situation with your doctor?"
44. An 87 year old widow was hospitalized for treatment of chronic renal disease. She lives with her daughter and son-in-law and their family, who are very supportive. She is now ready for discharge. The doctor has ordered high carbohydrates, low-protein, low sodium diet for her and the family has asked for assistance in planning low-sodium diet meals. Which of the following choices best reflects the pre-discharge information the nurse should provide for the client's family regarding low-sodium diet?
a. Avoid canned and processed foods, do not use salt replacements substitute herbs and replaces for salt in cooking and when seasoning foods, call a dietitian for help. b. Use potassium salts in place of table salt when coking and seasoning foods, read the labels on packaged foods to determine sodium content, and avoid snacks food c. Limit milk and dairy products, cook separate meals that are low in sodium and encourage increased fluid intaked. Avoid eating in a restaurant, soak vegetables well before cooking to remove sodium, omit all canned foods, and remove salt shakes from table.
45. You are encouraging your patient for major cancer operation to verbalize her fears. She remarked," I am afraid to do". Your appropriate response is
a. "I know how you feel about your condition".b. "Don't worry, you are in good hands."c. "Let me call a chaplain to see you."d. "Let us asks your doctor about your operation."
Situation 10. You are assigned as a public health nurse to oversee the different health
activities in your community.
46. While you were going over the record of Mrs. Uy who missed her prenatal appointment date. Her review of the family folder showed the following: GR-II, PARA II; with slight edema; BP=150/100. Mra. Uy eldest son in underweight is sick of H-fever. Nurse Linda planned a home visit. Which of the following would you give priority in planning her for the family?
a. Mrs. Uy's eldest son who is sick with H-feverb. Mrs. Uy pre-eclampsia c. Nutritional status of Mrs. Uy’s eldest sond. Family potential threat of cross-infection from H-fever
47. The midwife refers to you a family who fails to take action regarding a sick member of the family despite her suggestions. In helping the family decide on what actions to take you will.
1. Explain the consequences of inaction2. Identify the courses of action open to the family and resources needed for each3. Discuss the consequences of each course of action available4. Influence me family to act on what you think is best for the situation
a. 1 & 4b. 2, 3 & 1 c. 2 & 3 d. 4 only
48. Elisa is on her 1 1/2 month pregnancy. Her first child 3 1/2 months old. She asked you if she should stop breastfeeding her first baby since she is now pregnant. Your response should be the following. EXCEPT:
a. Breastfeeding during pregnancy is not harmful to either of the babies.b. Sudden weaning can be harmful and can make the older child illc. Breast milk is only valuable until the child is 4 months oldd. She can start giving solid foods in preparation for weaning when her child is 4 to 6 months old
49. Which of the following statements is correct regarding Community Health Nursing (CHN)?
a. Professional growth and development of the PHN is the responsibility of the Department healthb. Provision of CHN care is not any way affected by policies of the agency where the Nurse workc. The PHN worked with community 19 for 6 years can solely determine the health needs of the community
d. Evaluation of the health status of individuals and families should be done in consultation with them
50. In developing capability of people to assume more responsibility for their health, which of the following statements would you consider most important?
a. Lead-lag in the health activitiesb. Organizing me community for healthc. Identifying health problems with the peopled. Making medicine available
Situation 11. Demographic profile of the elderly population is important in the nursing profession and it is therefore important to know the basic facts about it
51. According to the definition of UN and WHO elderly people are who belong to the age bracket of
a. 60 years old and aboveb. 65 to 74 years oldc. 85 years old and aboved. 75 to 84 years old
52. There are four classifications of elderly, which age group do old-old person, belong
a. 55 to 60 years old b. 65 to 74 years oldc. 75 to 84 years oldd. 85 years old and above
53. Factors that affect Reproductive health includes, except,
a. Socio-economicb. Status of Womenc. Status of Mend. Social and Gender Issues
54. Element of Reproductive Hearth is responsible for the sex education for students,
a. Men's Reproductive Health b. Adolescent Reproductive Health c. Family Planning d. V.A.W
55. Essential Tool used in Community Health Nursing, that saves time and effort,
a. Bag technique b. Public Health Bagc. BP Apparatus d. Thermometer Technique
56. Principles in Home Visit include, except
a. Home visit should have an objective or purpose.b. Planning of Home Visit should be flexible and practical.c. Planning revolves around the needs of the Nurse.d. Planning should revolve around the essential needs of the family,
57. Steps in Home Visit, which should be done initially?
a. Wash handsb. Greet Client or household c. Explain purpose of visits d. Ask about client's health status.
58. After home delivery, the Nurse should include in her health teaching
a. Circumcision of the Infant b. Immunizationc. Starting the infant on bottle feeding d. Breast feeding of infant
59. In giving tetanus toxoid immunization for pregnant women, the first dose should be given.
a. Second Trimesterb. 3rd Trimesterc. 1 year after deliveryd. as early as possible during pregnancy
60. The legal mandate that supports the PHC act
a. LOI 949b. PD 996c. E.O 51d. RA7180
61. Requirements to be a Public Health Nurse Includes
1. Filipino citizen2. BSN, RN3. Masters degree in Nursing4. 3 years as a C. I
a. 1, 3 b. 3, 4c. 1, 2 d. 2, 4
62. Which of the following statements best explain the concept of people empowerment?
a. People are the health beneficiariesb. People themselves are health resourcesc. People can demand health servicesd. People are our partners in health
63. As a PHN you also have an active role in disease surveillance sod epidemiology of disease in the community. Among others you also do the following.
1. Immediately inform the rural health physician of any unusual increases cases in the community disease.2. Conduct epidemiological investigation on all reported outbreaks 3. Request the midwife to graph weekly disease incidence cases in the municipality 4. Assist in the planning and implementing disease control measures during outbreak
a. 1, 2 & 4b. 2 & 4 c. 1 & 4d. 3 & 4
64. The habitual presence of a disease or infectious agent within a given geographic area is:
a. Epidemic b. Endemicc. Pandemic d. Sporadic
65. Measures the frequency of occurrence of new cases of a certain disease during a given period of time
a. Prevalence rate b. Endemic
c. Fatality rate d. Mortality rate
Situation 13. Theories regarding the aging process were formulated in order to guide the health care profession in their care of the elderly patient.
66. Theories proposed to explain aging are organized as:
a. Fully explanatory and partially explanatory b. Complete and incomplete c. Genetic, biochemical and sociopsychological d. Known and unknown
67. In the "Wear and Tear" theory of aging continued use of the body is supposed to lead to worn out parts, similar to the breakdown and wearing out ®f old machinery. This could not explain aging because:
a. Continued use has little effectb. Nothing over wears out completely c. The human body can’t be compared to machineryd. Greater use leads to improvement in some systems such as muscles
68. The "Somatic Mutation Theory" states that low doses of radiation accelerate aging. The theory has been criticized for three reasons. Which of the following is not of the reasons why this theory explains little about the aging process.
a. Sunscreens are now available to block out fee harmful ultraviolet raysb. The effect of the sun occurs mainly in dividing cells while the effects of aging are seen mainly in calls that no longer dividec. The number of cells that undergo mutation is too small to account for overall aging.d. Most cells contain mechanisms for the repair of DNA
69. Which of the following explains that the critical factor in framing old age concerns is how well persons function in regards to activities of daily living?
a. The functional capacity theory b. The activity theoryc. the disengagement theoryd. the personal meaning theory
70. The view of the older people "Withdraw" from the soclety is:
a. The adics theory b. The disengagement theoryc. The parling theory
d. The absence theory
Situation 14. Mrs. Castro is one-week post partum. She visits health center because of fever and intense pain over the episiotomy site.
71. What will be first action of the nurse?
a. Assess for signs of anemia b. Determine nutritional statusc. Ask for the possibility of sexual intercourse d. Elici: history of delivery
72. Upon inspection the nurse observes an edematous episiotomy site. Which of the following intervention will you first apply?
a. Administer antimicrobials as ordered b. Expose the wound to perilightc. Cleanse the episiotomy with iodine solutiond. Give oral analgesic
73. Upon inspection the nurse observes an edematous episiotomy site. Which of the following herbal plants can be used to related perineal infection?
a. Lagundib. Banana Leavesc. Herba Buenad. Guava Leaves
74. Breast engorgement can also cause temperature elevation, but does not last longer than how many hours?
a. 48 hoursb. 12 hours c. 10 hoursd. 24 hours
75. Which of the following is an anti-inflammatory drug?
a. Metoprotol succinate b. Mefenamic Acidc. Meperidine hydrochlorided. Mefhylergonovine oaaleate
Situation 15. The Department of Health implements various health programs and projects in order to achieve its goals and objectives. As a Public Health Nurse you are one of the implementers of these programs at the municipal level.
76. The primary function of the Department of Health is the promotion, preservation or restoration of the health of the people through.
a. Regulation and encouragement of providers of health goods and servicesb. Provision and delivery of health servicesc. All of these except reduction of morbidity and mortalityd. Reduction of morbidity and mortality
77. In recent years, the government have given more emphasis of which of the following.
a. Rehabilitation b. Treatment of diseasec. Prevention of illnessd. Treatment and rehabilitation
78. In your campaign against sexually transmitted disease which of these groups are your target audience for health education?
a. Commercial social workers b. All of these groupsc. General populationd. Health workers and private practitioners
79. Knowing the policies if the National Family Planning Program which of these is the best contraceptive method to use for a couple who have already four children?
a. Use of IUD since she is still on her postpartum period b. Natural family planning method since her menstruation is still regular c. A method they will choose and use d. Tubal ligation as this is more permanent method
80. Under the National Center Control Program, the following are primary prevention measures implemented cancer of the mouth except
a. Avoidance of inverted cigarette smoking b. None of thesec. Improved dental hygiened. Avoidance of smoking and betel chewing
Situation 16. The Community Health Nurse prepares/participate in the preparation of the community health care plan.
81. In order to plan effectively, the nurse needs a -working knowledge on the
following, except
a. None of theseb. The way people view health and how they are using health care servicesc. Health status profile of the communityd. Data on quality assurance
82. In a rural health unit with full man power complement, the nurse's main contribution in the preparation of the total health care plan is the.
a. Preparation of the nursing component of the planb. Collation of the data on Health Statisticse. Identification of health problem of the barangaysd. Analysis of the community survey data
83. Which of the following statement would serve as a guide in the preparation, of the community health care plan?
a. Recommendation for action should be stated in quantifiable termsb. The formulation of criteria for evaluating the effectiveness of the plans must be an aspect of planning c. All of these statements d. Problems goals and objectives should be stated in quantifiable terms
84. Which of the following is a well-stated objective of a community health nursing care plan
a. To increase the number of mothers coming for prenatal check-up by 25% in 6 months time.b. To increase the number of home visits by 50%c. To increase the coverage for immunization in 1 year timed. To increase the number of children receiving food assistance
85. If the objectives of the health care plan is to decrease the number of children with parasitism: by 50% by the end of 2 years, which of these would be an appropriate evaluation indicator?
a. Number of children found positive for ascaris/ amebiasis/ hookworm, infection b. Number of children examined for parasitismc. Number of children who consulted for abdominal pain and anemiad. Number of children who were dewormed
Situation 17. Your head nurse participated a 2-weeks seminar. You were designated to be an officer-in-charge of your nursing unit.
86. In unit planning which of the following questions initiate the process?
a. How to schedule the activities? b. Who will do the planning?c. What is to be accomplished? d. Where to get unit supplies?
87. This is an example of data that should be analyzed when identifying missing needs.
a. Number of nursing staff b. Medical diagnosis of patientc. Ward supplies and materialsd. Patient classification
88. To accomplish the nursing unit work, you should first get information about:
a. Objectives of the unit c. Nursing budget b. Nursing service organizational chart d. Mission of the hospital
89. This is an example of a patient care unit objective
a. To ensure adequate unit supplies/materials b. To use the kardex system of charting c. To determine the number of nursing staff needed d. To provide safe nursing
90. Which of the following tools can be most helpful in the evaluation of staff performance?
a. Performance assessment b. Performance standardc. Performance auditd. Performance appraisal
Situation 18. Rebecca, a 2 year old and her Mother are consulting the community health nurse
91. The nurse observes Rebecca at play in the clinic. She realizes that at this age, Rebecca could be expected to exhibit which of the following?
a. Build houses with blocksb. Is extremely possessive of toys c. Attempts to stay within the hue when coloring
d. Amuses herself with a picture book of 15 minutes
92. When observing Rebecca, the nurse would expect her to engage in which type of play?
a. Parallel play b. Solitary play c. Competitive playd. tumbling play
93. Rebecca's mother asks the nurse when it would be appropriate to take her to the dentist for dental prophylaxis. What is the nurse most appropriate response?
a. Before starting school b. Between 2 and 3 years of age c. When Rebecca begins to lose deciduous teethd. The next time another family member goes to the dental
94. Rebecca's mother say's that Rebecca consistently says "no” every time she is offered fluids. Considering Rebecca's development, how could the nurse assist the mother to increase Rebecca's fluid intake?
a. Distract her with some foodb. Be firm and hand her the glassc. Offer her a choice of two things to drinkd. Let Rebecca see that she is making her mother angry
95. Rebecca is well and is to be discharged- Her mother asks the nurse why Rebecca persists in saying ''no'' to everything. The nurse explains to Rebecca's mother that this negativism is helping Rebecca to meet a 2 year old need for which of the following?
a. Trust b. Attention c. Disciplined. Independence
Situation 19. You are the nurse assigned in the nursery unit and your patients are of various ages.
96. Assessment an infant, the nurse knows that a pincer grasp nornally appears
a. At the same time as the palmar grasp b. Between 9 & 12 month of age
c. Between 5 & 7 month of age d. Along with the ability to "rake" objects toward themselves
97. In a child development, the period of negativism begins when the child
a. Can manipulate his or her parents b. Copies negative behavior of sibling. c. Is struggling between dependence and independence d. Is learning manual skills
98. The nurse is caring for a hospitalized toddler who was toilet trained home. He wets his pants. The best response to this situation is to say?
a. "Its okay, try not to wet your pants next time”b. "That's okay. Now lets get you cleaned up”c. "I know you understand how to use the toilet; what happened?"d. "Your mom told me you don't wet anymore; what's wrong?"
99. Which of the following behavior would a normal 18 moths old be likely to exhibit during the first few hours of hospitalization?
a. Crying loudly when parents leaveb. Readily accepting the nurse caring for himc. Showing considerable interest in new toyd. Sitting quietly in the comer of the cab, showing little or no interest in his surrounding
100. Evaluating a 1 month old infant normal developmental skills, the Nurse should observe that the infant
a. Actively follow movement of familiar persons with her eyesb. Responds to "No-No"c. Turns her head to a familiar noised. Discriminates between family and strangers
