NURSING PRACTICE V- Care of Clients with Physiologic and Psychosocial alterations (PART C)

Situation 1 Nick, a 35 year old employee was admitted to the hospital because of behavioral problems at the office. He
started to be bossy, claiming that he is the manager on the unit. On admission he was diagnosed to be having Bipolar
disorder, manic phase.
1. Nicks condition is primarily a problem of:
A. affect
B. perception
TTS: true option

C. thought
D. conscience

2. A therapeutic environment for Nick is:

A. minimal environmental stimuli
B. strict isolation and withholding privileges
TTS: True option

C. no limitation on his activities

D. well lit and basically colored room

3. During socialization Nick was provoked, became furious, started shouting and making personal demands. A
therapeutic intervention of the nurse is:
A. Take him away from the group until he manages to have control of himself
B. Restrain him and put him on isolation to protect other patients.
C. Prevent him from becoming more furious by giving extra PRN dose of sedative
D. Respond with, Nick, we dont favor anyone. Everybody in the ward is on equal footing.
TTS: True option
4. Therapeutic use of self is essential in relating with psychiatric patients. This is BEST demonstrated by the nurse in:
A. sympathizing with the miserable feelings of Nick
C. engaging Nick in productive activity
B. suppressing her own feelings towards Nick
D. engaging Nick in introspective thinking
TTS: true option
5. The nurse may recommend discharge when Nick:
A. easily finishes projects given to him during occupational therapy
B. takes his medications without reminding him
C. demonstrates skills in activities of daily living
D. complies with hospital rules and regulations
TTS: Umbrella
Situation2 The nurse considers factors related to safety effectiveness in the planning and delivery of the nursing
services
6. The nurse notices that the comatose client starts to lighten. She is aware that without protection, the client could fall or
be injured. Which of the following is the LEAST intervention?
A. Restrain the client to prevent from falling
C. Keep the side rails up on the bed
B. Give adequate support when turning or moving
D. Protect the clients head
TTS: priority-least
7. Following hip replacement after 24 hours the client asks for assistance onto the bedpan. She is placed in an orthopedic
bed and to facilitate the use of the bedpan, how should the nurse assist the client?
A. Pull on the trapeze to lift the pelvis extending both legs
B. Lifting the pelvis off the bed and turn gently toward the operative side
C. Assist the client in lifting the pelvis
D. Elevate the pelvis using a trapeze involving the unaffected upper extremity and unoperated leg.
TTS: true option
8. Bert, an elderly client, is to be discharged after sustaining a sprain from fall while negotiating the last step of the stairs.
The daughter asks how to promote safety in the stairways and hallways in the home. The nurse recommends extra
lighting at the stairways and suggests repainting the hallways with:
A. red and yellow
C. blue and green
B. black and white
D. cream and white
TTS: true option
9. Emma, 32 years old has problem with the olfactory nerve. They live in a thickly populated area and is concerned for the
safety of her 3 young children. What measure should the nurse recommend for home safety?
A. install additional lighting for visibility
C. Participate in fire prevention training
B. Mild water heater temperature
D. Install a smoke detector device
TTS: true option; D- client has a problem with the sense of smell-hazard is fire
10. Lola Andang, 76 years old is living alone. Her married daughter visits her from time to time. She can do activities of
daily living with limited assistance and seems to be independent physically. Which of the following measures should be
recommended to reduce sensory deprivation?
A. Encourage acquaintances to come to the house for a chat
B. Redecorate the house and provide a separate room
C. Provide pictures of family members
D. Invite friends often to share meals at home
TTS: True option; A&D- socialization

Situation 3 Nurses encounter situations in which they must make decision based on the determination of what is right
and wrong. Professional nursing actions are both ethical and moral.
11. Mrs. Miriam, a middle aged, obese woman seeks medical help often for recurring lower back pain. She does not lose
weight in spite of medical advice. Which of the following questions should the nurse ask the client?
A. What do you think will happen to you when you dont follow medical advice?
B. Arent you bothered about your condition?
C. Are you considering other courses of action?
D. Is it difficult to follow the medical advice?
TTS: Priority-assess
12. A 75 year old frail woman had cervical disk disorder. Conservative management did not work and the client requires
surgery. The client insisted that she does not want surgery, but the family and surgeon insisted. The staff nurse
assigned to her decided not to help in the preparation of surgery. Using caring based on reasoning which of the
following justify the refusal of the nurse in the preparation of surgery?
A. I empathize with the client because of her age and fear of not surviving the surgery.
B. I strongly feel that surgery will cause her more suffering and probably will not survive and feel the family may have
even feel guilty later.
C. I feel that my responsibility with the client is protecting her rights and meeting her needs.
D. I support the client since she has the right to decide on her medical treatment and management.
TTS: True option; D- client advocacy through support of the clients decision
13. A community health nurse in her home visits encountered a 58 year old woman who was depressed and tearful. She
was hospitalized before with glaucoma. She knows that she could be of help to the client by staying and talking to her
longer for another hour. However, she still has two clients to visit; one of them is Nelson who is in plaster cast of the
leg and needs a great deal of teaching and the other a 60 year old female, hemiplegic needing assistance in
performing activities of daily living. Which of the following is the appropriate action of the nurse?
A. weigh the facts carefully in order to divide her time justly among her clients
B. tell the client she will come back after attending to the other clients
C. ask one of the family members to attend to the client
D. stay with the client to prevent further depression
TTS: true option; C- passing the buck
14. Mrs. Marsha, a 40 year old professional was confined after suffering mild stroke. She has been critical of the care she
received which she regarded as not of high quality. The following actions of the nurse are appropriate in addressing
the complaints EXCEPT:
A. provide client with knowledge of what constitutes good care
B. provide client with list of her rights
C. ask the client what her expectations are
D. give a list of evaluation criteria and ask the client to respond
TTS: False option
15. The nurse demonstrates ethics of care when she plays the role of a
A. teacher
C. guidance counselor
B. care provider
D. clients advocate
TTS: true option
Situation 4 Following are situations that are a concern for records management of nurses.
16. A delusional patient said, I have no head, no stomach. The nurse would record this in which part of the mental
status?
A. Content of thought
C. Characteristics of talk
B. Emotional state
D. Sensorium or orientation
TTS: true option
17. For proper documentation and accountability of all entries to the clients chart, it is important for the nurse to inspect
that:
A. all notes must have signature and title of person making entry
B. the staff must not abbreviate SOAP
C. the nurse implements the use of problem-oriented progress notes
D. clients problems in the medical record must bear the date of entry and numbers of clients problems.
TTS: true option
18. Which of the following statements about Processing Recording is NOT true?
A. It provides data from which nurses can assess their own behavior in interactions with clients
B. It is a tool for assessing nurse-client interactions
C. It is an important means of communication between nurses or nursing students and their clinical
supervisors/instructors about their peer relationships.
D. It acquaints the student/ nurse with rudimentary applied research skills
TTS: False option
19. Data: Client is pacing, crying, waving his hands, yelling at the nursing staff and other patients. In the problem- oriented
progress notes this data would be noted under:
A. Assessment
B. Objective
C. Subjective
D. Plan
TTS: True option

20. In order for the process recording to be an effective learning tool for nurses, data should be:
A. unedited and comprehensive
C. brief and simple but focused on essentials
B. salient points that are summarized
D. edited and comprehensive
TTS: Opposing options A&D
Situation 5 In todays health care environment, nurses are increasingly accepted as essential members of the
interdisciplinary health care team.
21. The nurse is working in a tertiary hospital for almost a year. In order to effectively participate and lead a health care
team, she must have which of the following traits?
A. Courteous and respectful to the health team and members
B. Committed in the exercise of duties and responsibilities to clients and co-workers
C. Knowledge of the most effective and reliable, evidence based approach to care
D. Good interpersonal relationship with clients and families and the health team
TTS: True option
22. A staff nurse consulted a more experienced nurse and other health care providers whether aggressive ambulation
expedites the patients recovery or it requires too much energy. While this approach is extremely common, she is likely to
obtain clinical answers that are:
A. scientific
C. tradition based
B. evidence based
D. routine
TTS: True option
23. An experienced nurse is new in the work setting. Given this situation, what should the nurse do to conform to the
institutions expectations?
A. Pursue post graduate course to enhance skills and competence
B. Participate in the in-service education program offered by the institution
C. Attend seminars, conference and national convention related to the nursing profession
D. Learn new values, skills, attitude and social rules
TTS: true option
24. Image makers provide the greatest number of visual images of nurses at work such as angel of mercy, love interest
particularly to the physician, naughty nurse, handmaiden to the physician, etc. Changing nursings image in the public
eye will not be easy. Which of the following strategy/strategies is/are needed to change nursing image in the mind of
image makers?
1. Restriction of the term nurse to mean licensed RN
2. Involvement in the political processes that shape their profession
3. Increased effort to publicly praise and value nursing
4. Emphasize the contribution of nursing to patients, particularly on the desired health outcomes
A. 1, 3 and 4
C. 1, 2, 3 and 4
B. 3 only
D. 2 only
TTS: SATA(+)
25. Nurses naturally work to effect policy in the work place. Which of the following action/s can nurses take to increase
their influence in policy setting?
1. Be a member of a nursing organization
2. Write lobbying letter
3. Participate in coalitions of organizations
4. Get to know their elected officials
A. 1, 2, 3 and 4
C. 1, 3 and 4
B. 3 only
D. 1 only
TTS: SATA(+)
Situation 6 Leonardo is a survivor of tragic accident wherein his wife and child drowned when their boat sank due to
stormy weather. Within the next 6 months from the accident, he was observed to be detaching himself from others, unable
to sleep and concentrate and frequently would just be quiet and stare
26. He tells you, It is my fault. What kind of father and husband am I? he is expressing:
A. depersonalization
C. inappropriate effect
B. guilt
D. cognitive disturbance
TTS: True option
27. The nurse can best intervene by mobilizing the clients relatives, friends and people to provide:
A. Spiritual support
C. social support
B. material support
D. medical support
TTS: True option
28. A therapeutic attitude the nurse can convey to the client while he talks about his loss is:
A. sympathy
C. passivity
B. acceptance
D. optimism
TTS: True option
29. The nurse encourages the client to communicate and socialize because internalized hostility can lead to:
A. depression
C. physical assaultiveness
B. verbal assaultiveness
D. amok

TTS: True option; Similar options C&D

30. The patient is having a:
A. Post traumatic stress disorder
B. psychotic breakdown
TTS: True option

C. developmental crisis
D. personality dysfunction

Situation 7 Increasing problems of substance abuse continue to challenge the competencies of professional nurses.
31. The comprehensive Dangerous Drugs Act (RA No. 9165) challenges the nurse in his/ her role as a/an:
A. Advocate
B. Therapist
C. Counselor
D. Health educator
TTS: true option
32. The nurse is conducting Parent Education Classes. Aware of the scope of nursing practice he/she recognizes the
necessity to network with other agencies to discuss this area:
A. Communication skills appropriate for different ages
B. Constrictive discipline
C. Normal and defiant child and adolescent behavior and development
D. Legal implications of illegal use
True option
33. Which of these characteristics has the LEAST potential success of treatment of drug dependency?
A. An addict who has reached bottom pit level of self-disgust and who wants help
B. An individual who became dependent on a drug before or during the teen years
C. Individuals who have access to support from intact family groups
D. A person who began taking the drug of choice for recreational or experimental reasons
TTS: priority-least
34. The BEST model of drug abuse prevention supports:
A. programs focusing on means of dealing with problems and frustration of adolescents
B. Mandatory basic education transformation of society
C. An Integrated program requiring development of both intellectual and affective health
D. The medical treatment of drug abuse utilizing less addictive drugs
TTS: true option
35. Clients says, I am not a substance user. I take drugs only when I am under stress. What defense mechanism is the
client employing?
A. Repression
B. Substitution
C. Compensation
D. Denial
TTS: true option
Situation 8 Consumers of health care requires improvement in health care. Nurses must deliver activities and behaviors
and do the right things well and continue to strive to do better to meet and satisfy the diverse needs of clients.
36. Nurse Ethel observes the client with glaucoma while he instills eye drops. The client looks up to the ceiling and instills
the correct number of drops at the middle of the eyeball. The technique used by the client in the instillation of the
medication is:
A. correct as this spreads the medication over the eyeball
B. aimed to protect the eyeball from injury
C. allowed so that the client is less likely to blink
D. incorrect because it may damage the cornea
TTS: true option
37. The client had cataract surgery. Shortly after, he complains of nausea. Which of the following courses of action should
be given priority by the nurse?
A. Administer the prescribed antiemetic
B. Give ice chips to relieve nausea
C. Assure the client that this is expected following surgery
D. Report the complaint to the attending physician
TTS: Priority- independent nsg intervention first
38. The members of the nursing team were discussing about the activity of the client treated with detached retina during
the nursing rounds. Which of the following statements serves as guide for the client during the rehabilitation phase?
A. The client may resume his activity with moderation the day after the treatment
B. The client may indulge in normal activities after the treatment
C. The client may be restricted in bed for one week
D. The client may resume gradually her usual activities within 5-6 weeks
TTS: true option
39. During the nursing conference, Nurse Ella shares with the team the concerns of the wife of a client with Menieres
disease. She is concerned about the change in the husbands social activities. To assist the wife in adjusting to the
present situation, the team should:
A. plan the course of action with the husband
B. create an atmosphere of sense of belonging for the couple
C. assist the wife to accept the condition of the husband
D. explain to the wife that her husband is experiencing social isolation related to attacks of vertigo

TTS: true option

40. The staff nurse performs ear irrigation on a client for removal of cerumen. What relevant information should the staff
nurse share with the client at the start of the procedure?
A. Experience a feeling of fullness, warmth and occasional discomfort when the fluid comes in contact with tympanic
membrane.
B. Any medication needs to be withheld after the procedure and the physician must be notified.
C. ear irrigation requires cooperation from the client to facilitate the introduction of the solution
D. Assume lying position on the unaffected side after the procedure to facilitate drainage
TTS: True option; client will cooperate when he knows what to expect of the procedure
Situation 9 Antonia, the mother of two children was cooking dinner and wondering why her husband was so late. Then
she received a telephone call from the police notifying her that her husband had just been pulled from the river. Witnesses
say her husband jumped from a bridge in the locality,
41. Antonia, together with her children walked a 10 block way to the funeral home to meet the medical examiner to identify
the body of her husband. Without a tear, she became focused on attending to her children and simply signed the
necessary paperwork. She is in the state of:
A. Integration
B. Shock
C. Recovery
D. Reality
TTS: True option
42. In the following weeks after the death of her husband, Antonia struggled not only with finances but with confusion and
rage in response to her husbands actions and abandonment. The nursing diagnosis is:
A. spiritual distress
B. disturbed self esteem
C. powerlessness
D. social isolation
TTS: true option
43. Unable to handle her emotions, Antonia hurls anger and explosive outbursts toward those who are helpful to her.
This behavior is an example of:
A. sublimation
B. reaction formation
C. displacement
D. introjections
TTS: true option
44. Hostility is distinct from anger in that the former is:
A. compatible with love
B. growth-promoting
TTS: True option

C. destructive

D. ego syntonic

45. During nurse-patient interactions with Antonia, when she actively works out her rage, which of the following is NOT
therapeutic?
A. Ask Antonia to describe what is the hardest part of the death for the family
B. Assure that the death of husband is not her fault
C. An encouragement toward normalcy must be communicated
D. The nurse should be non-reactive
TTS: false option
Situation 10 To produce a beneficial effect on eye medications, the nurse should make sure that the amount of
medication reaches the ocular site of action in sufficient concentration.
46. The nurse in the EENT unit is preparing the 8:00 AM medication. She is fully aware that topical administration of
ocular medication results in how many percent rate of absorption?
A. 21 % to 25 %
B. 10 % to 16 %
C. 16 % to 20 %
D. 1 % to 7 %
TTS: True option; it is 2-10%; closest is option D
47. The nurse is preparing ocular medications for topical route of administration. The most common ocular medications
are administered through instilled eye drops and applied ointments. What is advantage of ointment application from
instillation of eye drops?
A. Self administration, ease of absorption and decreased risk of contamination
B. Extended retention time and provides a higher concentration
C. easy to administer with reduced adverse reaction
D. Promotes efficiency, safety and distribution of solution evenly
TTS: true option; Options C&D have similar thoughts
48. The nurse is to administer eye ointment to the patient. Which of the following guides the nurse in the administration of
the ointment?
A. Administer during nap time or bedtime
B. Inform the relative of the action of the drug
C. Explain the procedure to the patient
D. Check medical conditions that would contraindicate the use of the drug.
TTS: true option
49. Common ocular medication include topical anesthetic. In the application of topical anesthetics, the nurse MUST
instruct the patient which of the following measure?
A. Place the fingers on the sides of the nose to prevent medication from draining
B. Place the patient in supine position with the head slightly hyper extended
C. Close both eyes, gently move eyes
D. Refrain from rubbing the eyes to prevent corneal damage
TTS: true option

50. The nurse is assessing a patient receiving mydriatic drop. The patient is sweating, complains of blurred vision and
drowsiness. These manifestations are indicative of:
A. fear and anxiety
C. allergic reactions
B. overdose of the medications
D. systemic anticholinergic effect
TTS: true option
Situation 11- Many clients in a psychiatric unit receive antipsychotic medications, also referred to as Neuroleptics.
51. Clients may be shifted from typical to atypical antipsychotic medications because of its minimal extra pyramidal side
effects. A common extra pyramidal symptom that is very unpleasant and intolerable to clients is called akathisia. This
is:
A. upward rolling of the eyes
C. pill rolling movement of the hands
B. inability to sit or stand still
D. stiffening of the clients neck
TTS: true option; B- rephrased as pacing
52. Health instructions about Haldol (haloperidol) has been given to Lester while in the hospital and before discharge. The
client correctly understood the health techniques of the nurse when she says:
A. I will immediately report any episode of diarrhea or vomiting to my doctor.
B. I will drink about 2 liters of fluid daily and expect to urinate frequently.
C. I will wear long sleeve clothing and sun block when I go out.
D. I will avoid pizza, any food with cheese and processed meat.
TTS: True option; C- Haldol increases sensitivity to the sun
53. While giving Chlorpromazine (Thorazine) to client Miriam, the nurse remembers that she should stop giving the
medication when she observes this side effect:
A. shuffling gait
B. fine tremors
C. yellow sclera
D. facial grimacing
TTS: True option; B- shld be gross tremors
54. Another client in the ward, Benjie is given Thorazine (Chlorpromazine). This medication has several side effects.
Which side effect should cause the nurse to be MOST concerned?
A. Uncomfortable sun burns
B. Sore throat, fever, decreased white blood cell count
C. tremors, inability to stand still
D. low blood pressure upon getting up from bed
TTS: true option; B- rare adverse S/E
55. Clients on antipsychotic medications usually receive anti-parkinson drugs to reduce Parkinson like side effects. What
medication would the nurse expect the client to receive?
A. Cogentin (Benztropine)
C. Fluphenazine (Prolixine)
B. Nardil (Phenelzine)
D. Fluoxetine (Prozac)
TTS: true option
Situation 12- The following questions refer to nurses efforts to integrate in mental health community work.
56. The most important role of the nurse as a member of the team is to:
A. keeps a 24 hour watch for the patients
B. meets the needs for the physical well being of patients
C. carries out medical orders
D. coordinates the psychosocial care and management of clients
TTS: true option
57. Activity therapy is a treatment that utilizes which of the following?
A. Psychotherapy
B. Behavioral therapy
C. Somatic therapy
TTS: True option; B- under option A; C- self-awareness exercises

D. Millieu therapy

58. Which of these nursing actions belong to the secondary level of preventive intervention?
A. Providing mental health education to members of the community
B. Providing mental health consultation to health care providers
C. Providing emergency psychiatric services
D. Being politically active in relation to mental health issues
TTS: True option
59. When the nurse identifies a client who has an attempt to commit suicide the nurse should:
A. refer the matter to the police
C. call a priest
B. refer the client to the psychiatrist
D. counsel the client
TTS: true option; A,B,C are all passing the buck
60. The community health nurse was invited by the principal of an elementary school and was asked to give a talk to
parents. An appropriate topic would be:
A. The legal aspects of drug abuse
C. Marital crises
B. Discipline of children at home and alcohol
D. The problems of out of school youth
TTS: true option
Situation 13- The nurse assigned in the neurology unit is taking care of a patient with medical diagnosis of increased
intracranial pressure

61. An intracranial pressure monitor is in place and the patient is becoming lethargic. The nurse noted the intracranial
pressure is high. Which of the following should be the immediate action of the nurse?
A. Turn the patient to his left side with back unsupported with pillows
B. elevate the legs at 15 degrees with a pillow under the head
C. Elevate the head of the bed to 30 degrees
D. raise the head of the bed to 90 degrees and the head supported with pillows
TTS: True option; C- 30 degrees will promote venous return; head shld not be lower that the body.
62. The nurse is monitoring intracranial pressure of the patient. Which of the following nursing assessment would identify
the earliest indication of increasing intracranial pressure?
A. widening pulse pressure
C. cyanosis and hypotension
B. change in level of consciousness
D. Increased body temperature
TTS: Priority-earliest; Option A can lead to option B
63. The nurse completed a nursing assessment. Which of the following data concludes that the patient is showing signs of
increased intracranial pressure?
A. Decrease in pulse pressure, increased heart rate and irregular breathing pattern
B. Dilatation of the pupil, decreased blood pressure and increase in level of consciousness
C. Increase in heart rate and respiratory rate and decreased level of consciousness
D. Slowing of the heart rate, increase in pulse pressure and irregular breathing pattern
TTS: opposing options A&D
64. In preparing for the plan of care, the nurse should prioritize which of the following nursing and medical measures?
A. High backrest to prevent Valsalva maneuver and promote venous drainage
B. Turning every 2 hours with log rolling movement to maintain proper position
C. elevating the head of the bed and keeping the head in proper alignment
D. proper positioning and frequent change in position
TTS: Priority; A- maintain HOB at 30 degrees; B- ok but C is more appropriate in decreasing ICP; D- avoid frequent
position changes-can increase ICP
65. The nurse plan of care includes preventing environmental stimuli that may stimulate an increase in intracranial
pressure. Which of the following measures should the nurse include in the nursing care plan?
1. Keeping light on low setting
2. Keeping noise at a minimum
3. Providing a calm and restful environment
4. Having a cooling blanket available
A. 1, 2, 3 and 4
B. 1 and 2
C. 1, 2 and 3
D. 2, 3 and 4
TTS: SATA(+)
Situation 14 The stress of hospitalization can lead to difficulties between nurses and patients. Following are situations
that nurses presented during a monthly nursing circle.
66. Neil asked the nurse to have an out on pass privilege for the week-end but his request was not granted by the nurse.
He remarked, I thought you really liked me. A therapeutic response of the nurse would be:
A. Say, I understand, you feel bad but of course, I like you.
B. Say as a matter of fact, Your behavior did not meet criteria for out on pass privilege.
C. Ignore Neils remark
D. Be transparent and express disapproval openly: You upset me with your remark.
TTS: therapeutic com.
67. The dynamics of behavior underlying manipulative behavior explain that it is a behavior of:
A. sense of security and control
B. exhibiting uncooperative and hostile behavior
C. reducing patients anxiety
D. sensing fear of other people
TTS: Umbrella; Option A can lead to option B
68. Victoria, an elderly client idealizes some nurses as terrific, The best, or so understanding, but refers to others as
mean, incompetent, or indifferent. This behavior can be understood by the staff as:
A. avoiding taking responsibility for her own behavior and underlying feelings
B. an understandable behavior of an elderly that must not be taken seriously
C. an invitation to have a social and intimate relationship with the nurse
D. immature and childish behavior
TTS: true option
69. A patient with delirium touches the nurse inappropriately. The therapeutic response of the nurse would be to:
A. Ask for the patients name and if whether he is aware where he is.
B. removes the patients hand while saying calmly. Im the nurse and this is a hospital.
C. say nothing and just go on with the usual nursing interventions
D. say her name, Im Cathy, and Im your nurse.
TTS: Therapeutic com.
70. The staff nurses have differing emotional reactions to the use of limit setting. Some staff views it as unprofessionally
punitive and uncaring. The MOST appropriate approach to address this nursing concern is through:

A. counseling with the nursing supervisor

B. nursing conference
TTS: true option

C. seminar-workshop
D. brainstorming session

Situation 15- Mrs. Samson is an 85 year old woman who has been hospitalized due to a urinary tract infection and
dehydration. She has Alzheimers disease, osteoporosis and a tendency to wander. She has an IV in her left forearm,
which was difficult to establish. Concerned that Mrs. Samson might pull out her IV and wander off the floor, the staff is
considering the possibility of using restraint on her.
71. The staff is considering the possibility of using restraint on Mrs. Samson; however she repeatedly declares that she
does not want to be restrained. The staff is faced with an ethical dilemma of autonomy versus:
A. beneficence
B. Veracity
C. fairness
D. Justice
TTS: Similar options C&D
72. With a history of osteoporosis and a tendency to wander, which of the following should be priority?
A. request for a sitter
C. prevention of fall
B. Wheelchairs privilege
D. provision of a bedside commode
TTS: Priority-safety/umbrella
73. Which of the following would be LEAST likely appreciated by Mrs. Samson?
A. Playing a table board game
C. Going through family picture album
B. Singing to or with her
D. Listening to old familiar music
TTS: Priority-least
74. The nurse aims at highest level of self care. Which of the following will the nurse minimize?
A. Providing mouth swabs
C. Using clothing with buttons and zippers
B. Hand and body lotion
D. Labeling clothing items
TTS: True option
75. Mrs. Samson has a dietary privilege of food preferences. Which question is MOST effective to communicate with her?
A. Which way would you want your egg done? Scrambled? Sunny side up? With vegetable mix? Or boiled?
B. Do you want fried or boiled egg?
C. How would you want to have your egg done?
D. What is your favorite egg recipe?
TTS: true option; limit options; make options very simple.
Situation 16 Nurse Kim engaged clients in a group experience for medication education. Students are paired with
clients to play a game and exchange knowledge about medications and disorders. Participants play with a game board
and color-coded game cards with bear questions on five categories namely: Antipsychotic medications, Antidepressants,
mood stabilizers, antianxiety medications and medications for drugs of abuse.
76. An opening comment about the purpose of the group encouraged clients to gather around the table and select small
toy cars to move playfully around the racetrack game board. The aim of this affective learning approach is for the
clients to:
A. meet diverse learning needs
B. satisfy clients level of functioning
C. share common feelings about the medications
D. maximize the likelihood of compliance
TTS: true option
77. One objective of their group experience is for the clients to describe the impact of these medications on their
symptoms and day to day activities. Immediate discussion and interaction about daily life situations utilizes the
principle of:
A. Reinforcement
B. Appropriateness
C. efficiency
D. flexibility
TTS: true option
78. Which of the following client behaviors demonstrate that interpersonal learning occurred?
A. One of the client advised another client that he should get a pill box so he would remember to take the
medications
B. clients shared a sense ofwe-ness
C. Clients said that they were all in the same boat
D. One client said, I feel that way.
TTS: True option; interpersonal means relationship with other people
79. One client shared her very infrequent experiences with alcohol, which she knew were contraindicated with her
medications and quietly stated, I dont want anyone to repeat this. This experience included which of these
therapeutic factors.
A. altruism
C. Imparting information
B. universality
D. group cohesiveness
TTS: true option; altruism means selflessness or opposite of selfish
80. Which of the following LEAST contribute to creating a therapeutic learning environment?
A. Heterogenous composition of participants
B. Use of alternative teaching strategies that fit the needs of the group
C. Development of pre-determined, absolute group goals

D. Flexibility in accommodating the number of players

TTS: Priority-least; C- absolute word absolute
Situation 17 A team of researchers is conducting a study on the effect of high dose corticosteroids in improving the
motor and sensory outcomes of patients with spinal cord injuries within 6 weeks if administered within 8 hours after injury.
The study covers a three month period.
81. On the basis of the nature of the investigation, which one of the designs listed below, would allow the researchers to
have the most confidence that the corticosteroids is effective in improving the motor and sensory outcomes of patients
with spinal cord injury:
A. quasi or semi-experimental design
C. experimental design
B. non-experimental design
D. retrospective-prospective study design
TTS: true option
82. Which of the following is present in conducting the above study?
A. experimental group
C. variables
B. subjects
D. control group
TTS: True option
83. The target participants of the intended study are homogenous in the variables being measured. In determining the
sample size, the researchers should include how many participants in this study?
A. 500
B. 10
C. 50
D. 100
TTS: True option/central tendency
84. In the above study, the researchers manipulate the variable under study. Which of the following variable is sufficient
for the effect to occur?
A. clients with spinal cord injury
B. injection of corticosteroids within 8 hours after injury
C. research methodology
D. motor and sensory outcomes patients with spinal cord injuries
TTS: true option
85. The manipulated variable to the experimental group is the:
A. improved recovery and lessen hospitalization period
B. questionnaire in gathering pertinent data
C. improved motor and sensory outcomes
D. injection of corticosteroids within 8 hours post spinal cord injury
TTS: true option
Situation 18 Jorge, a 19 year old, second year college student is seeking assistance in coping with school related
stressors and sleep disturbances. During the initial evaluation of the psychiatric nurse, he reports he is ashamed and
embarrassed by a mistake he made in his class oral report and feels like his classmates are going to look down on him.
He reports that he failed a practical exam a year ago. Although he has made up for this, he cannot get this out of his mind.
86. When the nurse asks Jorge to describe his physical experience, which of these assessment data are appropriate?
A. I do not know what to do
C. I feel helpless and depressed
B. I am tense, nervous and exhausted all the time.
D. I am worried and thinking a lot

TTS: True option

87. Jorge admits that he has, always been wound up just like his father and that he has negative thoughts for himself.
He is having a problem of:
A. inferiority
B. mistrust
C. stagnation
D. role confusion
TTS: true option
88. The nurse teaches non-pharmacologic ways to induce sleep. Which of these would she caution Jorge to avoid?
A. warm milk
B. classical music
C. coffee after dinner
D. a warm bath
TTS: true option
89. Which of these describe the characteristic of free floating anxiety?
A. It is not conditioned by specific trigger
B. It creates panic
C. There is an easily recognizable stressor that provokes anxiety
D. It results in selective attention/inattention
TTS: True option; Free floating anxiety is severe, generalized & persistent, a precursor to panic
90. A generalized anxiety disorder is distinguished by:
A. experience of anxiety after exposure to a life threatening event
B. presence of excessive anxiety for a period of 6 months or more
C. irrational thoughts and actions
D. fear of losing control thus avoiding going out or avoids crowds
TTS: True option; A- PTSD; C- psychotic disorder; D- phobia
Situation 19- The nurse works in an institution that shelters street children. She encounters varied family histories and
presenting behavior patterns of these clients.
91. At night when the children are being prepared to go to sleep, the nurse hears from a frightened child, Ayaw ko
matulog mag-isa. May multo. (I dont want to sleep alone. There is a ghost!). The nurse conveys acceptance with
which of these response?
A. Gusto mo ikwento kung ano pa ang naiisip at nararamdaman mo? (Would you like to tell me more about your
thoughts and feelings?)
B. Talaga? Anong itsura ng multo? (Really? How does the ghost look like?)
C. Nakaktakot nga ang pakiramdam ng ganyan. (That must really be scary)
D. Huwag kang matakot, babantayan kita. (Dont be afraid. Ill keep watch over you.)
TTS: Therapeutic com.
92. Most street children come from broken families. The nurse is MOST therapeutic in meeting their needs by being a:
A. activity therapist
C. child therapist
B. mother surrogate
D. teacher
TTS: true option
93. With adequate rest, food, cleanliness, shelter, warmth and safety, the child:
A. Develops a sense of competence
C. Develops a separate identity
B. Acquire a sense of personal power
D. Learns to trust in self and in others
TTS: Umbrella option to options A&B
94. Preventive interventions for children at risk are BEST achieved through:
A. Family therapy for the dysfunctional families
B. non-government organizations and other workers paying attention to victims in conflict ridden communities
C. support and caring to children during family crisis situations
D. play and activity therapies for children
TTS: Priority-prevention
95. Vina was a frequent witness to domestic violence. Her father would always come home drunk and beat up Vinas
mother. As an effect of this experience she had nightmares, speechless for weeks, inability to sleep, tension and
palpitations lasting for more than a month. Vina is experiencing anxiety due to:
A. adjustment in growing up
C. an identifiable traumatic stress
B. fear of phobic proportion
D. imagined loss of parental love
TTS: True option
Situation 20- Mrs. Corteza, 65 year old, had an acute attack of pain, soreness and swelling on both knees. She is
diagnosed with rheumatoid arthritis.
96. Nurse Nerissa is assessing the client. Which of the following is MOST likely to be assessed?
A. Early morning stiffness
C. Joint for deformities
B. Nodules along the knees
D. limited motions of joints
TTS: Priority-most; RA is an autoimmune disorder- chronic inflammation of joints
97. The client is in the acute phase of rheumatoid arthritis. In addition to the prescribed medication; the physician orders
application of heat and cold to manage arthritis pain. Which of the following statements indicate that the client lacks
understanding in the application of heat and cold.
A. Cold application is applied for 20 minutes, then 20 minutes off
B. Hot water bag should be covered with flannel to prevent burns.
C. Heat and cold can be applied as needed.

D. heat producing liniments can be used while applying heat or cold.

TTS: false option; D- will increase heat and may cause burns
98. Nurse Nerissa is helping the client, who is immobilized by pain, towards self reliance and independence. The nurse
should approach the problem with which of the following:
A. Set a specific goal
B. Set a positive attitude toward an eventful outcome
C. need for a member of the family during the pain episode
D. recognize that little can be accomplished
TTS: True option
99. The nurse should know that a client with rheumatoid arthritis will most often have pain and limited movements of the
joints:
A. resulting from non-adherence to prescribed diet
B. after assistive exercise
C. because of inactivity upon awakening in the morning
D. during cold weather
TTS: true option; C- explanation to the most common sign which is early morning stiffness
100. To prevent deformities of Mrs. Corteza, the nurse includes in the nursing care plan:
A. Massaging the joint with oil liniment
B. Implementation of strictly prescribed diet
C. Performing isometric exercises twice a day
D. Alternate rest periods with active periods
TTS: true option; D- inactivity will lead to deformities
*** E N D ***

NOTE: Need to clarify answers for nos: 21,24,25,32,41,48,68,76.