PREBOARDS 2_ NP 5 Flashcards by Justine Mae Palomata

Situation – Patients taking antipsychotic drugs are informed about potential adverse effects by nurses Dan. She advises people to report rather than stop taking their drugs. The teachings that follow have to do with patience.

Which APPROPRIATE health lesson should be emphasized when taking anti-anxiety medications like benzodiazepines?

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1 punto
A. The root of the issue can be addressed with anti-anxiety medications.
B. Since alcohol amplifies its effects, the patient is not allowed drink it with the meds
C. Without a doctor’s permission, a patient can stop taking a medicine abruptly.
D. Because of his slow response time, the patient can still drive.

B. Since alcohol amplifies its effects, the patient is not allowed drink it with the meds

Benzodiazepine are anxiolytics and depresses CNS. Alcohol are also depressants.

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Which APPROPRIATE HEALTH TEACHING should the nurse stress when someone is taking an anticonvulsant like lithium?

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1 punto
A. Time of last dose must accurate so that blood level monitoring be accurate.
B. Patient can take drugs even without food intake.
C. Patient will not experience polyuria and polydipsia.
D. Patient will have constipation, thus he has to increase fluid intake.

A. Time of last dose must accurate so that blood level monitoring be accurate.

Lithium - mood stabilizing drug. For manic episodes in bipolar disorder. Taken with meals since it’s GI irritant

Taken 900-3600 mg daily
Thera range: 0.6 - 1.2

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Of the following, which DOES NOT denote extrapyramidal symptoms (EPS) Haldol?

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1 punto
A. Acute dystonia
B. Akathisia
C. Dystonia
D. Increased libido

D. Increased libido

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4.The patient frequently presents as agitated, worried, and restless with stiff posture and a lack of spontaneous motions. Which of the following best sums up this patient’s strong desire to move around?

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1 punto
A. Withdrawal
B. Dyskinesia
C. Dystonia
D. Akathisia

D. Akathisia - “makati” siya = desire to move around

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Which APPROPRIATE health lesson should the nurse emphasize when someone is taking an SSRI (Selective Serotonin Reuptake Inhibitor)?

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1 punto
A. Aged cheese might be acceptable.
B. The medication should be taken by the patient in the morning.
C. Nuts are acceptable.
D. Diets low in tyramine can reduce blood pressure.

B. The medication should be taken by the patient in the morning.

We do not give SSRI in the morning if it causes drowsiness to the patient.

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Situation – Rheumatoid arthritis has been found in both of Feli’s hands and knees, a 65-year-old housewife.

A patient who visited the clinic reported experiencing the first signs of rheumatoid arthritis. What will the patient interview’s nurse-focused assessment entail?

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1 punto
A. Bigger nodules
B. Lower extremity stiffness in the morning
C. restricted range of motion in upper extremity joints
D. Hand joints that are malformed

B. Lower extremity stiffness in the morning - due to inactivity

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Patient Bel laments that she was unable to complete home tasks and that walking hurt her knees. The MOST SUITABLE nursing diagnosis is…

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1 punto
A. Self-care deficit related to increasing joint pain.
B. Activity intolerance related to fatigue and joint pain.
C. Disturbed body image related to fatigue and joint pain.
D. Ineffective coping related to increased joint pain.

B. Activity intolerance related to fatigue and joint pain.

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Which of the following does the nurse identify as having the LOWEST priority in the care plan for the patient who is experiencing the acute phase of rheumatoid arthritis?

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1 punto
A. maintaining joint functionality
B. avoiding joint malformation
C. alleviating pain
D. keeping up the routine task

D. keeping up the routine task - we alter their routines, less stressful ways to keep up with their routine

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9.Coagulopathy is a side effect of long-term nonsteroidal anti-inflammatory drug (NSAID) treatment in an osteoarthritis patient. What is most likely the cause of the coagulopathy?

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1 punto
A. reduced platelet adhesion
B. inhibited conversion of thrombin
C. reduced production of vitamin K
D. destroying factor VIII

A. reduced platelet adhesion - anti-platelet interferes with platelet prostaglandin synthesis

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10.A patient with osteoarthritis is being taught about lifestyle modifications by a nurse. When the nurse says she will ___, she knows the patient has understood the lesson.

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1 punto
A. refuse to attend school
B. skip exercising
C. reduce weight
D. Limit caffeine intake

C. reduce weight

Problem: stress at weight bearing joints

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Situation –Rona, 18, and her friend came to the clinic to be evaluated for depression. She has several worries about contracting COVID 19 and passing away. She consumes less food and snores noisily. She hasn’t had a bath in a week, and she frequently speaks about her missing mother, who passed away from a COVID 19 infection.

11.Working with depressed Rona, the nurse should be aware that a person’s __________ is most strongly associated with depression.

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1 punto
A. recalling her formative years
B. stages of life
C. having experience a sense of loss
D. interacting with others in an unsatisfactory manner.

C. having experience a sense of loss

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12.To prevent long-term depression, early detection and treatment are crucial. NOT among the preventive measures is _________.

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1 punto
A. medicine used alone as therapy.
B. ensuring a secure home life
C. communicating honestly and openly.
D. fostering a strong sense of self-confidence, self-resilience, and self-worth.

A. medicine used alone as therapy.

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13.For the purpose of treating her depression, Rona was admitted to the hospital. Which antidepressant is USED MOST OFTEN?

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1 punto
A. Norframin
B. Elavil
C. Prozac
D. Tofranil

C. Prozac (Fluoxetine)

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How long should the patient continue taking the antidepressants to prevent a relapse of their depression?

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1 punto
A. Six month to two years
B. two months to 1 year
C. one year to three years
D. one to three months

A. Six month to two years

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Three days following Rona’s hospitalization, the nurse saw that she had taken a bath, dressed in fresh clothes, and brushed her hair. What is the NURSE’S APPROPRIATE REACTION to Rona’s altered behavior?

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1 punto
A. “Something about you has changed today. Which is it?”
B. “Oh. You finally put on a clean dress, and it makes me so happy.
C. I noticed that you are dressed neatly and that you have combed your hair.
D. “Good, that you’re wearing a tidy dress, and your hair is brushed.

C. I noticed that you are dressed neatly and that you have combed your hair. = observations

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Situation – Only when it is within the boundaries of their nursing practice and nursing knowledge can nurses give their patients the information they need to give informed consent. The patient’s acknowledgment and acceptance of medical treatment is known as consent.

What form of consent permits to assume APPROPRIATE medical treatment in an emergency when a patient is unable to give consent for life-saving treatment.

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1 punto
A. implied consent
B. Informed consent
C. Express consent
D. Involuntary Consent

A. implied consent

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Which of the following constitutes necessary elements of informed consent?
I. explanation of procedures and alternatives to the procedures
II. discussion of potential risks and benefits of the procedures
III. confirmation that the patient understands the risks, benefits, and any alterations

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1 punto
A. I, III
B. I, II
C. II, III
D. I, II, III

D. I, II, III

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Without a patient’s consent, treatment can be considered __________, which is characterized as unwanted and intentional touching.

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1 punto
A. battery
B. slander
C. Negligence
D. tort

A. battery

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Who is responsible for obtaining informed consent?

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1 punto
A. Nurse Manager
B. Anesthesiologist
C. Physician
D. Midwife

C. Physician

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Bioethical issue should be described as ______________.

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1 punto
A. The withholding of food and treatment at the request of the patient in a written advance directive given before a patient acquired permanent brain damage from an accident.
B. the physician makes all the decisions of client management without getting the input from the patient.
C. After the patient gives permission, the physician discloses all the information to the family for this support in the management of the patient.
D. a research project that included all regular employed personnel and not treating all the casual employed to compare the outcome specific drug therapy

B. the physician makes all the decisions of client management without getting the input from the patient.

Bioethical issue: conflict between 2 principles

AUTONOMY VS. BENEFICENCE

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She was instructed to file an incident report (IR) by her head nurse. The head nurse requested Nursed Ema submit an IR in order to __________.

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1 punto
A. note patterns from incidences in the same unit.
B. Place it in Nurse Rosie’s 201 file
C. document immediately the incident
D. evaluate Nurse Rosie’s performance

C. document immediately the incident

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Which of the following is NOT a part of the IR?

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1 punto
A. Who was / were involved?
B. What daily medications are given to the patient?
C. What happened?
D. Who witnessed the incident?

B. What daily medications are given to the patient?

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What instruction is IMPORTANT in regards to incident reports (IR)?

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1 punto
A. not entered into the patient’s record
B. included in the file for Nurse 201.
C. in the nurses’ station, filed
D. submitted with the hospital’s records department.

A. not entered into the patient’s record

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Which one of the following would demonstrate that the nurse intervention fulfilled the standards of care for falls?

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1 punto
A. Utilizing the nursing process in providing safe, quality nursing care.
B. Performing health history
C. Carrying out the Doctor’s order
D. Performing physical assessment

A. Utilizing the nursing process in providing safe, quality nursing care.

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25. Which of the following is the best source of factual information if the fall investigation continues? * 1 punto A. incident report B. Nurse’s note in the chart C. Anecdotal record D. process recording

A. incident report

Situation 6 – Dementia has been identified in 70-year-old retired teacher Mrs. Dana. Her 24-year-old granddaughter resides with her. When she visits the OPD for her checkups, Nurse Shen takes care of her. 26. Mrs. Dana must be aware that the MOST prevalent chronic condition that results in injury in elderly people is___________? * 1 punto A. rheumatic fever B. Hip fracture C. gallbladder D. urinary tract infection

B. Hip fracture

27. Nurse Shen should be aware that the MOST prevalent psychological disorder affecting old people is _____. * 1 punto A. depression B. sleep disturbances C. decreased appetite D. inability to concentrate

A. depression

28. Which of the following contributes to dementia the MOST in elderly people? * 1 punto A. Parkinson’s Disease B. Alzheimer’s Disease C. Amyotrophic Lateral sclerosis D. Multiple sclerosis

B. Alzheimer’s Disease

29. Which of the following symptoms is COMMON to Alzheimer's disease-related presenile and senile dementias? * 1 punto A. Increases Appetite B. Loss of Short-term memory C. Inappropriate behavior D. Inability to provide self-care

B. Loss of Short-term memory - earliest sign of alzheimer’s

30.Which nursing intervention should be part of this patient's care plan if the dementia patient is experiencing "sundown syndrome"? * 1 punto A. Maintain consistent schedule and sequence of daily activities. B. Integrate patient’s cultural preferences into the care provided. C. Serve warm beverage and snack in the early evening D. Provide opportunities for the patient to learn and to practice new skills.

A. Maintain consistent schedule and sequence of daily activities. - so they are still oriented to time and their scheduled activities

31. The best description of bulimia is a/ an _________. * 1 punto A. disorder of the unknown origin associated with starving oneself. B. pathological disorder of binging and vomiting C. phobic disorder of fear of obesity D. eating disorder associated with vomiting

B. pathological disorder of binging and vomiting

32. What condition has a lower chance of developing Nima? * 1 punto A. Hyperkalemia B. Tooth Decay C. Gastric Ulcer D. Rectal Bleeding

A. Hyperkalemia = It should be hypokalemia since they are vomiting, electrolyte imbance.

33. Which of the following conditions may lead to death in bulimic patient like Nima? * 1 punto A. Hypokalemia and cardiac arrythmias and arrest B. Metabolic Acidosis and Renal failure C. Hyponatremia and circulatory collapse D. Hyponatremia and congestive heart failure

A. Hypokalemia and cardiac arrythmias and arrest

34.A patient who is bulimic frequently has hormonal alterations. In Nima, which of the following changes would be anticipated? * 1 punto A. Delayed Thyroid stimulating Hormone response to Hormone replacement Therapy. B. Increased production of Follicle Stimulating Hormone C. Hypopituitarism D. Decreased Adrenocorticotropic Hormone in response to cortisone.

A. Delayed Thyroid stimulating Hormone response to Hormone replacement Therapy. Due to decrease metabolic rate.

35. The anti-depressant amitriptyline is the medication of choice for treating Bulimia. What is this medication's MOST Common side effect? * 1 punto A. Anticholinergic Effects B. Cholinergic Effects C. Urinary Frequency D. Diarrhea

A. Anticholinergic Effects

Situation 8 – According to his diagnosis, Mr. Damian has chronic schizophrenia. 36.Which of the following should Nurse Anakin NOT encourage Mr. Damian and his family to do to avoid lapses in Mr. Damian's schizophrenia? * 1 punto A. Keep any troubling side effects of medications with nurses B. Practice stress reduction technique C. To follow the medication regimen accurately D. Participate Regularly in any other forms of treatment.

A. Keep any troubling side effects of medications with nurses

37. Pick one nursing technique that Nurse Andeng should not do. * 1 punto A. Speak in a low, calm tone of voice B. Let him interact with you while hallucinating C. Maintain a non-threatening stance, keep a physical distance D. Maintaining safety for herself and Mr. Dacs

B. Let him interact with you while hallucinating We should orient them back to reality

38. Pick the LEAST nurse intervention while speaking with Mr. Damian. * 1 punto A. “Please let me know if I can be helpful”. B. Check his order PRN medication. C. “ I’ll let you sit here quietly and I will be at the nurse station D. “ I’m just checking in with you to see if there is anything you need right now”.

C. “ I’ll let you sit here quietly and I will be at the nurse station - can be a hazard since the client will be left alone

Situation – Nursing research is conducted to answer a question or resolve problems on the relevance of the nursing profession ________. 39. The nurse developed the following hypothesis: Elderly women receive less aggressive treatment for terminally ill spine patients than younger women. Which variable would be considered to be dependent variable? * 1 punto A. Degree of treatment received B. Age of the patient C. Use of patient treatment D. Type of complication being treated

A. Degree of treatment received Age = IV

40. The following are considered steps in the qualitative research process EXCEPT? * 1 punto A. Sample B. Literature review C. Hypothesis D. Data collection

C. Hypothesis (quanti)

41. Which of the following is an example of a PRIMARY source in a study. * 1 punto A. A doctoral dissertation that critiques research articles in area of attention deficit disorder. B. A textbook of medical-surgical nursing C. A journal article about the effectiveness of bitter gourd in reducing blood glucose. D. A published commentary on the finding of another study

C. A journal article about the effectiveness of bitter gourd in reducing blood glucose. Other choices are secondary

42. What is the best source to use when conducting a level ONE systematic meta-analysis of the literature? * 1 punto A. An electronic database and doctoral dissertations B. An electronic database C. doctoral dissertations D. The Cochrane Statistical method

D. The Cochrane Statistical method = reviews evidences = meta analyses

43. Which type of research allows researchers to be neutral observers? * 1 punto A. Quantitative research B. Ethnographic research C. Case studies D. Qualitative research

D. Qualitative research Key: Neutral Observers

Situation: Mrs. Rochelle’s condition requires that a general surgery must be performed on her. 44. Mrs. Rochelle tells the nurse that she does not want to know about surgery. What would be the best response of the nurse. * 1 punto A. “I must go over certain information with you”. B. “You are right; do not worry yourself tonight”. C. “You sound quite concerned about your surgery”. D. “Well, I could talk to your son about this instead”.

C. “You sound quite concerned about your surgery”. = making observations

45. What should the nurse do before giving pre-operative teaching to the patient? * 1 punto A. determine Mrs. Rochelle’s anxieties, level of understanding and expectations. B. Research the surgical procedure so as to give step-to-step explanation C. Schedule teaching to begin 2-3hours before surgery. D. Give Mrs. Rochelle general information because specifics might be threatening

A. determine Mrs. Rochelle’s anxieties, level of understanding and expectations.

46. While doing health teaching to MRS. Rochelle, the attending nurse can BEST recognize that her patient is learning by ____. * 1 punto A. demonstrating a positive change in her behavior. B. Constant verbal reaffirmation that she understands C. her ability to repeat what was discussed D. nonverbal acknowledgement that she understands, such as nodding.

C. her ability to repeat what was discussed

47. The nurse prepares Mrs. Rochelle for discharge. What would be the nurse’s MOST important instruction post cataract surgery to her patient? * 1 punto A. Avoid the use of laxatives B. Use an eye shield at night C. Avoid touching the eye dressing D. Curtail most heavy activities

B. Use an eye shield at night Curtail means restrict or reduce

48. After discharge, Mrs. Rochelle attends the eye clinic for follow – up visit. When she receives the cataract glasses, it is important that the nurse advice her that _________. * 1 punto A. daily eye drops are required with eyeglasses B. magnification by the lens is only about 10 percent C. objects will appear closer than they really are D. her peripheral vison will be increased

C. objects will appear closer than they really are - to prevent risk for injury and fall

Situation – Marcus, 41-year-old carpenter met a vehicular accident to work. He suffered head injury, responsive and admitted at intensive care unit for close monitoring and management. 49. During nursing assessment, Marcus speaks in a rambling manner and repeats words spoken to him. Which part of the brain is MOST likely to be affected ? * 1 punto A. Broca’s Area B. Foramen Magnum C. Brodmann’s Area D. Wernicke’s area

D. Wernicke’s area Broca’s Aphasia: Expressive Aphasia - the client understands what is said but can’t communicate verbally Wernicke’s Aphasia: Receptive Aphasia - the client is unable to comprehend spoken words but can communicate verbally but without any sense

50. The physician orders computerized transversed axial tomogram (CAT) scan. Nursing preparation of the patient for this procedure includes: * 1 punto A. Explaining the vital signs will be monitored for 2 hours after the examination. B. Explaining that the spinal tap will be done so that a radioactive isotope can be injected. C. Telling patient that a radiopaque dye is injected into an artery in the arm D. reassuring that the CAT scanning in a noninvasive procedure.

D. reassuring that the CAT scanning in a noninvasive procedure.

51. The physician orders to observe for EARLY signs of increased intracranial pressure which includes ______________. * 1 punto A. Elevated temperature and decerebrate posturing. B. Restlessness and change in level of consciousness C. Rising blood pressure and bradycardia D. Widening pulse pressure and dilated pupils

B. Restlessness and change in level of consciousness

52. All of the following signs indicate increased intracranial pressure aside from: * 1 punto A. Decreased level of consciousness B. Papilledema C. Tachycardia D. Vomiting

C. Tachycardia

53. The nurse noticed the dressing is wet. Which action by the nurse can be safely used to determine if the drainage contains cerebrospinal fluid (CSF). What should the attending nurse do? * 1 punto A. Blot the drainage with sterile gauze pad and look for a clean wet around the spot of blood. B. obtain a negative reading for a sugar after testing the CSF with Test Tape. C. Gently suction the ear and send the specimen to the laboratory. D. Swab the orifice of the ear with sterile applicator and the specimen in the laboratory.

A. Blot the drainage with sterile gauze pad and look for a clean wet around the spot of blood. = known as the Halo sign > CSF leakage

Situation – Nurse Managers participate in quality improvement projects to increase awareness and achieve better performance of nursing team. 54. A professional practice system that manages clinical care of patients across a continuum using managed care concepts and tools is called __________. * 1 punto A.Modular nursing B. Differentiated practice C. Case management D. Primary nursing

C. Case management Modular = primary + team nursing

55. What is the outcome of having sound clinical care management by professional health care team? * 1 punto A. It diminishes collegiality between health care providers B. It decreases patients’ length of stay C. It increases cost of hospitalization D. It contributes to duplication of services

B. It decreases patients’ length of stay

56. During a staff meeting, the nurse manager presents his own analysis of problems and proposals for action to the staff, inviting critique. Which answer indicates the manager’s leadership style? * 1 punto A. Laissez faire B. Participative Leadership C. Autocratic D. Democratic

B. Participative Leadership Key: inviting critique’s but the ultimate decision is still with the manager

57. Which of the following is often associated with the concept of decentralized decision making in management? * 1 punto A. Team Nursing B. Interdisciplinary Model C. Shared Governance D. Primary nursing

C. Shared Governance - everyone will be one of those who can be held accountable if something happened

58. Some decisions are best made by the group rather than by the nurse alone. What is the advantage of group decision making? * 1 punto A. Promote collective contributions of idea B. Different ideas and opinions C. Individuals’ opinions are influenced by others D. Dependency is fostered

A. Promote collective contributions of idea

59. Which of the following strategies would the nurse instruct the patient to prevent relapse? * 1 punto A. Report changes in sleeping, eating and mood. B. Block Hallucinations during daily activities C. Take additional medications on days when Mr. Rollan “feeling bad”. D. Take stress Management Class

A. Report changes in sleeping, eating and mood.

Situation – Mr. Dacs is Diagnosed to have Chronic Schizophrenia. 60. Which of the following identified ability of Mr. Dacs that effectively participate in rehabilitation? * 1 punto A. Ability to concentrate B. Ability to think C. Ability to talk D. Ability to listen

A. Ability to concentrate Warning signs of Schiz -Insomnia - inc. fear and anxiety - absent mindedness

Situation – Mrs. Lao, 75 years old, is in the clinic for the treatment of acute closed-angle glaucoma. 61. The physician would like to measure the intraocular pressure with a tonometer. While preparing patient for her examination, the nurse informs the patient that ________. * 1 punto A. After the examination, a slight pain will be experienced B. Before the examination, an oral medication will be given C. It is painless procedure that has no side effects D. During the ocular fundoscopy, atropine eye drop will be instilled.

C. It is painless procedure that has no side effects Tonometry measures IOP N IOP = 10-21

62. Which symptoms are ASSOCIATED with acute closed angle glaucoma? * 1 punto A. Diplopia and Photophobia B. Blurred vision and colored rings around lights C. Episodic Blindness an no pain D. Sensation of curtain drawn across the vision field.

B. Blurred vision and colored rings around lights

63. The physician has prescribed pilocarpine one percent eye drop every six hours. The expected OUTCOME for this medication is to _______? * 1 punto A. Dilate the pupil by paralyzing the ciliary muscle B. Prevent dryness of cornea and conjunctiva C. Promote drainage of aqueous humor form anterior chamber D. Reduce inflammation of the iris and choroid

B. Prevent dryness of cornea and conjunctiva It is a miotic

64. The physicians recommend peripheral iridectomy to relieve intraocular pressure. He prescribed meperidine Hydrochloride (Demerol) 50mg and Atropine Sulfate 0.3mg IM as preoperative medications. The nurse should_____. * 1 punto A. recognize the atropine sulfate is given preoperatively to dilate the pupil. B. recognize this as a usual preoperative medication and administer it. C. realize that the atropine sulfate is being given to dry up secretion D. notify the physician and question the order

A. recognize the atropine sulfate is given preoperatively to dilate the pupil.

65. Which of these nursing diagnoses should the nurse give PRIORITY for an elderly patient who has impaired vision due to glaucoma? * 1 punto A. High risk for injury B. Impaired Physical Mobility C. Grooming self-care deficit D. Feeding Self-care Deficit

A. High risk for injury

Situation: Keith, an 18-year old boy, developed the habit of sniffing rugby because he wants to do things that his peers from the neighborhood do as well. He is not going to school anymore and does not participate in productive activities with other people. He is enrolled in a rehabilitation center. 66. The predisposing factor in Keith’s case is his _____. * 1 punto A. Socio-economic status B. Occupation C. Parental upbringing D. Community influence

D. Community influence

67. Volatile Substance abuse is considered the most dangerous among abused psychoactive substances because of the risk of ________. * 1 punto A. Violence B. Developing schizophrenia C. Irreversible damage to the bone marrow, brain, liver, kidney D. malnutrition

C. Irreversible damage to the bone marrow, brain, liver, kidney Volatile substance abuse = inhalants

68. The nurse heard Keith saying, “My mother visited me last night and smiled at me.” This is a manifestation of____. * 1 punto A. auditory hallucination B. visual hallucination C. delusion D. reaction formation

B. visual hallucination

69. Substance abuse affects not only the user but also the other people the user interacts with. Which of the following is the MOST APPROPRIATE diagnosis in the care of Keith? * 1 punto A. Impaired Social Interactions B. Impaired Parenting C. Dysfunctional family processes D. Ineffective coping

A. Impaired Social Interactions

70. Severe intoxication to volatile substances may lead to unconscious or even death. The PRIORITY nursing intervention in caring for patient is monitoring the__________. * 1 punto A. mental status B. neurological functions C. nutritional status D. AST and ALT levels

A. mental status

Situation – Kelly, a 25-year old evening-shift cashier of Altamart 24-hour convenience store, was sexually abused by a jeepney driver while on her way home from work one evening. She was brought to the E.R with bruises all over her body. She was crying uncontrollably and appears to be anxious. 71. Which of the following therapeutic communication should nurse Michael say for Kelly? * 1 punto A. “You are upset, calm yourself first Glory. I can’t understand you”. B. “Can you identify your abuser?” C. “Something terrible, and horrifying happened to you” D. “Would you like to relate to me what happened?”

D. “Would you like to relate to me what happened?”

72. In providing nursing care for Kelly during her acute stress reaction to rape trauma, Nurse Michael may apply, which of the following? * 1 punto A. Physical Assessment B. Collaborate with community agency C. Crisis intervention techniques D. Normal reactions to a devastating event.

C. Crisis intervention techniques

73. Kelly’s physical assessment is complete and physical evidence has been collected. After three days, Nurse Michael noted Kelly to be withdrawn, confused and at times physically immobile. How should Nurse Michael interpret this behaviors? * 1 punto A. Evidence that the client is a high suicide risk B. Signs of depression C. Indicative of the need for longer hospital admission D. Normal reactions to a devastating events

D. Normal reactions to a devastating events

74. Emergency care to be given for rape victims as follow: I. If victim calls the hospital, tell her not to take a bath, wash or change clothes, just go directly to the hospital. II. Provide privacy and be judgmental. III. Stay with the victim, focus on physical safety and emotional security. IV. Assist on pelvic examination to collect evidence as semen stains. * 1 punto A. I, III, IV B. I, II, III C. II, III, IV D. I, II, IV

A. I, III, IV

75. Nurse Michael wanted to become a patient advocate of rape victims. Which of the following RESPONSIBILITIES should she note? * 1 punto A. Isolate the patient first to provide privacy while attending to other patients B. Call the press since this a legal case C. Perform thorough physical assessment and document objectively all evidence of rape. D. Postpone the physical examination until the patient is calm

C. Perform thorough physical assessment and document objectively all evidence of rape. Physical exam should be done right away

Situation – Head Nurse Milo ensures teamwork and collaboration in her to achieve efficient shared decision-making and open communication to provide safe patient care. 76. A nurse returns from vacation and finds a new model of I.V pump attached to her patient. How should the nurse proceed? * 1 punto A. Read the I.V. pump manual before caring for the patient . B. Refuse to care for the patient C. Inform the charge nurse and ask her to provide a teaching session about how to use pump. D. Use the pump because it is somewhat like the old pumps on the unit.

A. Read the I.V. pump manual before caring for the patient .

77. A nurse caring for 76-year old female patient requires insertion of a central venous catheter. Who is responsible for obtaining informed consent? * 1 punto A. Physician who will insert the catheter B. Charge Nurse C. Attending Physician D. The Nurse assisting with the procedure

A. Physician who will insert the catheter

78. A nurse reports that a patient coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the patient, in which the physician participating in the team rounds writes the order. This is an example of collaboration of client care ______. * 1 punto A. with the ancillary care providers. B. between the physician and the dietary department C. with risk management team because of risk aspiration D. among members of the multidisciplinary group.

D. among members of the multidisciplinary group. = collaboration among the multidisciplinary group

79. Before delegating to the new nurse the task of giving a shower to the paraplegic elderly , the charge should FIRST ensure that the new nurse ___________. * 1 punto A. Has received the assignment during endorsement time B. Is supervised at all times C. Has demonstrated competency for the task D. Provides companion to the patient

C. Has demonstrated competency for the task

80. Which of the following task would be APPROPRIATE for the nurse to delegate to nursing aide. * 1 punto A. Assist a new postoperative patient to the bathroom B. Teach a patient on how to administer discharged medications C. Change a center line dressing D. Assist the patient during meal time.

C. Change a center line dressing RN scope - unstable or unpredictable patients -post-op 24-48 hrs pt -IV drip meds - Admissions -Sterile procedures Do not delegate what you EAT - Evaluation -Assessment -Teaching

Situation – Mr. Julio, 45 years old, is admitted to the hospital in semi-conscious state diagnosed with cerebrovascular accident. 81. The nurse obtained history of patient’s present illness from his family. What significant information can the nurse gather from the patient’s family? * 1 punto A. Consistent Hypertension and dizziness B. Palpitations and hypotension C. Family history about illness D. Emotional response form past illness

A. Consistent Hypertension and dizziness = hypertensive emergency

82. The PRIORITY nursing care for Mr. Julio during the acute phase is to _________. * 1 punto A. Provide sensory stimulation B. Maintain Respiratory And Cardiac Function C. Prevent Contracture And Deformities D. Maintain Optimal Nutrition

B. Maintain Respiratory And Cardiac Function

83. Part of nursing care plan is to observe Mr. Julio for signs of increased intracranial pressure. Which of the following clinical manifestations would indicate this condition? * 1 punto A. tachycardia and drop in blood pressure B. Bradycardia and rising in blood pressure C. Bradycardia and drop in blood pressure D. tachycardia and rising in blood pressure

B. Bradycardia and rising in blood pressure

84. Which of the following positions will be MOST APPROPRIATE to Mr. Julio’s care? * 1 punto A. head of bed elevated in a lateral position B. head of bed elevated in supine position C. right lateral position D. left lateral position

B. head of bed elevated in supine position - to dec ICP and facilitate venous drainage

85. Mr. Julio’s wife is very upset and asks if there is any hope to recover from his condition? Which of the following is the MOST APPROPRIATE reply by the nurse? * 1 punto A. “You must be patient, let’s hope for the best outcome”. B. “ You should never lose hope”. C. “It is too soon to tell what the outcome will be”. D. “ Actually, manifestation may even get worse”.

C. “It is too soon to tell what the outcome will be”.

Situation – Patient safety remains to be a global health care challenge. There are basic principles of infection control. These include standard precaution and transmission based precaution questions. 86. Which of the following is considered the MOST important in infection control? * 1 punto A. Personal protective clothing B. Prevention of infection associated with catheter C. Safe use and disposal of sharps D. Hand hygiene of health care staff

D. Hand hygiene of health care staff

87. Which mode of infection transmission is due to splashes of blood/body fluids into the mucosa or contamination of non-intact skin with infected blood and body fluids? * 1 punto A. ingestion B. airborne C. inoculation D. direct/Indirect contact

C. inoculation

88. Which mode of infection transmission is due to microorganism being transferred to other patients from contaminated equipment and via the hands of nurses. * 1 punto A. ingestion B. Airborne C. inoculation D. Direct/Indirect contact

D. Direct/Indirect contact

89. What mode of transmission is due to contaminated food and water being consumed? * 1 punto A. inoculation B. direct/indirect contact C. ingestion D. airborne

C. ingestion

90. Which of the following is NOT a standard precaution? * 1 punto A. respiratory isolation B. Injection safety C. personal protective equipment D. Hand hygiene

A. respiratory isolation - droplet prec

Situation – Reall, 6 years old, was diagnosed as having autism since she was 1 year old. 91. What behavior will nurse Bret observe as characterized by Reall? * 1 punto A. Inappropriate behavior, poor attention span with impulsivity B. Negativistic, hostile and defiant behavior C. Failure to develop interpersonal skills D. Anxiety-induced involuntary stereotypical motor movements

C. Failure to develop interpersonal skills

92. At her age, Reall is in what stage of social development? * 1 punto A. Initiative vs. Guilt B. Trust and Mistrust C. Industry vs. Inferiority D. Autonomy vs, shame & doubt

A. Initiative vs. Guilt

93. Nurse Bret recognizes which of the following as a COMMON behavioral sign of autism? * 1 punto A. Clinging behavior toward parents B. Early language development C. Indifference to being hugged or held D. Creative imaginative play with peers.

C. Indifference to being hugged or held

94. The BEST nursing intervention that Nurse Bret can use to provide trusting relationship with a patient with autism is to ___________. * 1 punto A. Convey warmth through touch B. Early language Development C. Explain to the child activities and routines D. Provide a structured environment

D. Provide a structured environment

95. Which pharmacologic treatment is APPROPRIATE for Reall’s temper tantrum, aggressiveness, self-injury, and stereotyped behavior ? * 1 punto A. Clonidine (catapres) B. Naltrexone (ReVia) C. Clomipramine (Anafranil) D. Haloperidol (Haldol)

D. Haloperidol (Haldol)

Situation – The nurse abides with ethico-moral principles. 96. When the nurse placed the patients in the restraints before using other methods of intervention, she/he violated the patient’s rights to ______________. * 1 punto A. Receive confidential and respectful care B. Provide informed consent C. Receive treatment in the least restrictive environment D. Refuse treatment

C. Receive treatment in the least restrictive environment

97. Which of the following actions is a violation of psychiatric patient rights? * 1 punto A. Paranoid patient with delusion about his family is told that if he makes a will, it not be valid. B. The nurse confiscated the cellphone from the patient’s room and told him it is being locked in the vault C. Staff members confiscated written letters done by patients addressed to local newspaper. D. Patient is paid minimum wage for helping the hospital kitchen.

C. Staff members confiscated written letters done by patients addressed to local newspaper.

98. Which of the following is NOT covered in Patient’s Bill Of Rights? * 1 punto A. Refusal to treatment B. Informed Consent C. Right to Treatment D. Civil Commitment

D. Civil Commitment

99. A patient has been advised by the psychiatrist that he needs inpatient hospitalization. The patient agrees, signs the admission forms, and agrees to receive treatment. What type of admission is this? * 1 punto A. Formal B. Voluntary C. Informal D. Involuntary

B. Voluntary

100. Disclosure of client information beyond the interdisciplinary team without consent of the client is a breach of ___________. * 1 punto A. Confidentiality B. Beneficence C. Duty D. Veracity

A. Confidentiality