NURSING PRACTICE V – Care of Clients with Physiologic and Psychosocial Alterations (Part C)

GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 questions.
2. Write the subject title “COMPREHENSIVE NURSING PRACTICE I” on the box provided.
3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your
answer.
4. AVOID ERASURES.

SITUATION 1 - Mr. Lazo, a 78 year old male was admitted to the hospital to rule out any injury that may have resulted
from a fall while going up the stairs of his home. He has no recollection of what caused him to fall. While in the
hospital, Mr. Lazo exhibited mental status changes including disorientation and confusion.

1. Which of these questions would the nurse ask to gather data about Mr. Lazo’s orientation status?
a. Ask client the brothers’ and sisters’ names, children’s and grandchildren’s names.
b. Ask client to repeat 6 to 7 digits forward.
c. Ask client’s name, address, current location, date, time, and year.
d. Name 3 objects (e.g. table, spoon, shirt) and have client repeat the three objects. Ask client to repeat them again after 5
minutes.

2. In order to prevent complications for which Mr. Lazo may be at risk, which of these will the nurse prioritize in planning and
outcome identification? Mr. Lazo will:
a. Will maintain existing ability to perform activities of daily living
b. Remain safe and free from further injury
c. Will follow varied schedules of activity and rest
d. Demonstrate decreased anxiety levels

3. Prior to the fall accident, the wife noted Mr. Lazo’s changes in sleeping and eating habits getting irritated easily and lacking
interest in usually pleasurable things. The nurse infers correctly a possibility of the presence of:
a. Obsession b. Anxiety c. Depression d. Social isolation

4. All of the following nursing interventions are appropriate for Mr. Lazo EXCEPT:
a. Use calendars, sign and labels as needed c. Encourage clients to talk about past events
b. Offer activities that challenge creativity and innovation d. Limit client-decision making

5. Mr. Lazo became agitated and combative when the nurse approached him to help him with morning care. The nurse utilizes
validation technique by saying:
a. “ You need something to calm you down” c. “ It is time to get dressed ”
b. “ You need restraint for safety” d. “ You seem upset “

SITUATION 2 - Georgina is a 28 year old, female patient admitted to the psychiatry unit with a diagnosis of chronic
undifferentiated schizophrenia. She described herself as “Binibining Pilipinas Universe” and her mission is to represent
the country and be an ambassador of good will for the Filipino people. She was observed to be talking a lot and
laughing by herself. Her thoughts were incoherent and disorganized. She was also aloof in relating with others.

6. Georgina’s claim of being “Binibining Pilipinas Universe” is a/an:

a. Delusion b. Imagination c. Obsession d. Illusion

7. The nurse interprets Georgina’s thought of being an ambassador of good will for the Filipino people as a/an:
a. Attempt to overcome low self-esteem c. Personal vision that is realistic and laudable
b. Mechanism to connect with reality d. Regressive behavior

8. Which of these interventions would NOT be therapeutic in decreasing Georgina’s anxiety?

a. Listen to her thoughts and feelings. c. Do not challenge her deception.
b. Joke about her thoughts to help her feel at ease. d. Simply accept her behavior.

9. Which of the following is a PRIORITY intervention for the nurse?

a. Activity therapy b. Milieu therapy c. Behavior modification d. Relationship therapy

10. In order to assist Georgina to cope and be prepared for discharge, it is BEST for the nurse to focus on:
a. Insight into personal problems c. Skills for maintaining daily living
b. Attitudes of society towards the mentally ill d. Awareness of interpersonal interactions.

SITUATION 3 - Maria, 67 year old, has a history of mental illness in her middle age and treatment for “early
menopause”. Medications were given for depression which brought her into remission. She functioned fairly well but
was prone to paranoid ideation, social isolation and became severely anxious when stressed. She was brought to the
hospital due to profound depression with mood changes manifested by little sleep, high energy, hysterical laughter,
and bizarre behavior.

11. Lithium was initiated. The nurse was effective in her health teaching when the client remarked:
a. I need to lessen my calorie and salt intake but have enough fluids
b. I need to have regular diet with adequate sodium and fluid intake
c. I should restrict my salt and fluids
d. I should sweat a lot with exercise to reduce my body fluids
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12. Maria claimed that she had been hearing frightening motorcycle noises, angry voices and sounds of rushing floor water. The
priority need at this point is:
a. Trust b. Love and belongingness c. Self-esteem d. Safety and security

13. Maria was started an antipsychotic medication. The following are effects of haloperidol EXCEPT:
a. Akathisia c. Control the affective symptoms
b. Pseusoparkinsonism d. Voices decreases in both intensity and content

14. The nurse watches for early lithium toxicity. Which of the following must be part of health teaching?
a. Seizures and anuria c. High fever and tachycardia
b. Fine tremors, nausea , vomiting and diarrhea d. Shuffling-gait and restlessness

15. When agranulocytosis is noted, antipsychotic medication should be withheld and the patient is watched for:
a. Changes in sensorium b. Involuntary muscle movement c. Hypertension d. Signs of infection

SITUATION 4 - Mr. Jolo, a 35-year-old married driver, experienced fatigue, visual disturbances, and episodic
paresthesia in various parts of his arms and legs. He later developed spastic paralysis of the legs. His physician says he
has multiple sclerosis.

16. The nurse in assessing the client should address the following behavior associated with the disease?
a. Client’s coping c. Client’s plan for the future
b. Client’s lifestyle d. Client’s actual and potential problems

17. The client is concerned about his fluctuating physical condition and generalized weakness. Which of the following is the
PRIORITY nursing invention for this client?
a. Teach measures for activity limitation c. Have an immediate family member stay with him
b. Space activities throughout the day d. Bed rest and restriction of activities

18. The nurse should expect client with exacerbation of multiple sclerosis to experience:
a. Mental retardation b. Sudden burst of energy c. Diplopia and nystagmus d. Resting tremors

19. Mr. Jolo is experiencing bladder incontinence, which of the following should the nurse include in the plan of care?
a. Limit fluid intake to 1,200 ml per day c. Establish a regular voiding schedule
b. Insert an indwelling catheter d. Administer prophylactic antibiotic as ordered

20. The nurse is preparing Mr. Jolo for discharge from hospital to home. Which of the following is the appropriate instruction?
a. Keep active, less stressful activities and avoid fatigue c. Observe quiet, inactive lifestyle and regular exercise
b. Learn to use walking aids in anticipation of future disabilities d. Maintain, good health habits regular exercise

SITUATION 5 - Roger, 24 years old, sustained fracture of the right tibia and fibula following a motorcycle accident. The
physician ordered application of long leg cast.

21. The physician applied the cast to immobilize the fractured leg. The plaster of pairs cast is damp and the client verbalized that his
leg feels very hot. What should be the appropriate action of the nurse?
a. Reassure the client that it is a common effect after the application of the cast.
b. Elevate the limb to facilitate drying of the cast.
c. Tell the client that he will experience feeling hot for several hours as the moisture evaporates and the cast hardens.
d. Notify the physician as the cast is constricting the legs, causing so much pressure.

22. To facilitate the drying of the long leg cast, the nurse should do which of the following measures?
a. Elevate the affected leg on a bed board c. Place the bed in a cool place
b. Instruct the client to assume one position d. Expose the cast fully to the air

23. The nurse is assessing the client with long leg cast. She noticed that the client’s toes are pale, cool and capillary refill is delayed
for five seconds. How should the nurse interpret this finding?
a. The nerves in the toes are threatened c. The finding is normal for this recovery time period
b. Stasis of venous blood in the toes d. Decrease of arterial blood soppy in the toes

24. Several hours after the application of the long leg cast, the nurse notices that the client’s toes are edematous. The nurse refers
her observation to the attending physician. The physician decided to bivalve the cast. The client asks the nurse what the
procedure is. The nurse explains to the client that this procedure is done by:
a. Splitting the cast near the toes to relieve constriction c. Splitting and spreading the cast on each side
b. Placing the client’s leg in a dependent position d. Cutting the cast and reapply after 24 hours

25. The nurse is preparing the client to ambulate. To prepare the client, the nurse should encourage the client to:
a. Sit up in bed for 30 minutes twice a day c. Practice sitting using a trapeze to strengthen muscles
b. Keep the affected limb in straight alignment d. Perform exercises in bed to strengthen the upper extremities

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SITUATION 6 - Pido, 70 years old, tripped and fell while going down the stairs. He was unable to get up due to a sharp
pain in his left hip and leg. After examination in the Emergency Room, he was diagnosed with a fracture of the neck of
the femur. He is scheduled for total joint arthroplasty.

26. The nurse is giving preoperative information for the client. The client asks the nurse regarding mobility especially in getting out
of bed. Which of the following should be the appropriate response of the nurse?
a. Sit before moving out of bed.
b. Get out on the operative side keeping leg straight out in front.
c. Lead with your feet when changing direction.
d. Use a high chair with supportive arms.

27. On the day post surgery, the client manifested a pyrexic response. The wife was bothered and asks the nurse why her husband
is having a fever. The nurse explains that the condition is:
a. an early infection occurring. c. part of the normal inflammatory process.
b. secondary to contamination. d. an indication of deep infection.

28. The client asks the nurse what position he should assume when sleeping. Which of the following positions is best for the client?
a. Back c. Prone with extremities supported with pillows
b. Side-lying either side d. Supine with pillow

29. The client is ready for discharge. The nurse is assessing his mobility and exercise. Which of the following should be the main
concern of the nurse?
a. Determining the living condition at home c. Need to maintain prescribed movement and therapy
b. Client’s knowledge of wound care d. Continue taking medication after discharge

30. The client is sent home on Coumadin. Which of the following should the nurse remind the client regarding the Coumadin
prescription?
a. Blood is to be drawn weekly or biweekly to monitor intake of Coumadin.
b. The physician may change the Coumadin prescription after blood tests are drawn to prevent excess bleeding.
c. Encourage the client to take the Coumadin prescribed to prevent excess bleeding.
d. Adhere to medical program for blood works and maintain Coumadin prescription.
SITUATION 7 - Nurse Linda is a young promising nurse who chose to start a professional career as mental health
psychiatric nurse. Part of her orientation and training as a beginning professional nurse is enhancing facilitative
personal characteristics.

31. Nurse Linda recognizes that therapeutic effectiveness is BEST acquired through?
a. Human relations laboratories c. Workshops like sensitivity sessions
b. Education in the behavioral sciences d. Knowledge and practice of specific interpersonal skills

32. Anne is a new client of Nurse Linda. She offers Linda a gift. Nurse Linda responds therapeutically by:
a. Clarifying client’s intent, “I wonder why you are offering me a gift.”
b. Reacting emphatically, No it is unethical to receive gifts from clients”
c. Citing a hospital policy, “It is against hospital policies.”
d. Accepting with an acknowledgement, “ I feel uncomfortable doing this but I don’t want to disappoint you.”

33. Who of the following clients must Nurse Linda refrain from “use of touch”?
a. Jacy who is aggressive and hostile c. Dina who is looking for a mother
b. Jim who is depressed with low level of energy d. Mico who has very low self-esteem

34. Resistance is often mistakenly seen as the client’s struggle against:

a. Change b. Self-awareness c. Responsibility for actions d. The nurse

35. Establishing a therapeutic contract is the goal of which phase of the nurse-patient relationship?
a. Orientation phase b. Working phase c. Pre-orientation phase d. Middle phase

SITUATION 8 - A 45-year-old male client has a progressive hearing impairment with history of ear infection. He is
admitted to outpatient surgery for tympanoplasty. The nurse is performing her initial assessment and found the client
well informed about the nature of surgery. However, the client appears somewhat anxious about the outcome of the
procedure.

36. The nursing diagnosis for this client is:

a. Risk for Infection related to outcome of surgery. c. Risk for Hearing Impairment.
b. Risk for Injury related to graft displacement. d. Risk of Activity Intolerance.

37. Which of the following nursing interventions is the MOST appropriate for the client following
tympanoplasty?
a. Side-lying position on operative side c. Flat on bed for 8 hours
b. Side-lying position on non-operative side d. Head slightly elevated

38. The client states he is dizzy and nauseated. Which of the following measures is the MOST appropriate in addressing the
problem?
a. Administer medication prescribed for vertigo. c. Assist when getting out of bed.

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b. Avoid noise and pressure changes. d. Stress importance of not blowing his nose.

39. The client is ready for discharge. When asked about knowledge of home self care to avoid an upper respiratory infection, the
client demonstrates understanding when he states that:
a. follow up check up must be complied with. c. blowing of nose of at least 1 week should be avoided.
b. medication must be taken as prescribed. d. side-lying position on either side should be observed.

40. In preparation for home self care, the nurse is teaching the client how to change dressing on the external ear. The expected
outcome is that the client should:
a. describe how dressing is changed accordingly. c. get a printed instruction on changing dressing.
b. change the dressing with the assistance of a family member. d. demonstrate dressing change correctly.

SITUATION 9 - Television and newspaper report that drug abuse is a serious social, economic and political problem in
our society. Nurses are continually challenged to play a role in abetting this problem in the community.

41. Street children are introduced early to harmful substances such as inhaling rugby. This observation underscores the need to
address the problem at its core. Nurses contribute BEST at the preventive level by promoting:
a. Social welfare for underprivileged families c. Responsible parenthood
b. Early childhood education d. Family planning

42. Teenagers who join fraternities and gangs are high risk groups for substance abuse. Which psychosocial need is BEST met
through peer counseling?
a. Recognition b. Self-esteem c. Belonging d. Security

43. Benjie is using Marijuana. Which of the following behaviors would be observed?
a. Watery eyes, rhinitis, sneezing, yawning c. Uses dark glasses to conceal bloodshot eyes
b. Appears drunk with staggering gait d. Appears alert and confident with dilated pupils

44. A college student client states that his addiction to morphine is due to a chemical imbalance. The nurse understands that
researches that point to biochemical theory of addiction support that drugs of abuse have in common, stimulation of which of
the following neurotransmitter?
a. Norepinephrine b. Serotonin c. Acetylcholine d. Dopamine

45. At the Emergency Room, a young guy was brought in and succurmbed to sudden heart attack. The parents reported that their
son had always been healthy. A report was made that substance use was positive. MOST commonly abused substance by this
age is:
a. Marijuana b. Steroids c. Cocaine d. Alcohol

SITUATION 10 – Mr. B was a post-operative patient who died from injuries sustained in a fall from his third floor
window. Apparently, he had tried to climb down on an improvised rope. At trial the nurse testified that during her last
evening visit with him, he had experienced an episode of tachycardia and hypertension, refusing all nursing care and
prescribed medication known to have adverse effects including confusion and anxiety. The nurse did not report to the
physician and testified also that when she passed by the patient at midnight, he appeared to be sleeping and did not
reassess has vital signs.

46. The nurse’s negligence includes:

a. Failure to document c. Failure to act as patient advocate
b. Failure to follow standards of care d. Failure to assess and monitor and failure to communicate

47. Failing to maintain a safe environment in this instance is a joint accountability of the nurse and the:
a. Nursing staff b. Doctor c. Hospital d. Security personnel

48. When the nurse testified that the patient appeared to be sleeping, which of these competencies did she fail to do?
a. Inspect b. Plan c. Analyze d. Observe

49. Full documentation of care on the patient’s chart in addition to being factual, accurate, and complete includes being:
a. Thorough b. Truthful c. Tidy d. Timely

50. When this incidence of fall is reviewed, what is the primary basis for considering this to be a nursing negligence?
a. Nurse practice act b. Nursing supervisor evaluation c. Nursing procedure manual d. Hospital rules and policies

SITUATION 11 - A non-experimental, one-group, pretest-posttest research design was used to evaluate the
effectiveness of a newly developed training program for nurses working with electroconvulsive therapy (ECT) for
psychiatric patients.

51. Subjects were selected because they happen to be available for participation in the study. The process used is:
a. Random sampling b. Convenience sampling c. Probability sampling d. Purposive sampling

52. The study was approved by the Health Service Ethics Committee. Prior to completing questionnaire at the start of the training
program, the consent would be provided by:
a. Nurse supervisors b. Patients undergoing ECT c. Hospital medical director d. Nurse participants

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53. An evaluation questionnaire included 14 True-False items which measured Nurses’ knowledge of key components of providing
assistance in an ECT procedure. In this study, participants’ knowledge were measured:
a. Solely after the training b. Solely before the training c. Before and after the training d. In the middle of the training

54. Six items of the evaluation questionnaire used a 10 point scale (ranging from not all confident to very confident) to measure
nurses’ perceived level of confidence with setting up an appropriate ECT machine.
a. Interval scale b. Ordinal scale c. Ratio scale d. Nominal scale

55. Table: Changes in Participants’ Knowledge Before and After the ECT Program (N=92). In the Table where N=92, N=92 means:
a. Percentage of nurses responding correctly in the post-test
b. Number of nurses who participated in this study.
c. Number of nurses currently working in the field of ECT.
d. Percentage of nurses who completed both pretest and posttest questionnaires.

SITUATION 12 - A 10-month-old infant is brought to the hospital due to high fever. The mother told the nurse that the
infant’s fever subsided a day before. Examination done by the attending physician revealed a definitive diagnosis of
acute otitis media.

56. The nurse is taking history. The infant displays discomfort by crying constantly, fussy behavior and pulling the left ear. Which of
the following information gathered by the nurse would support the admitting diagnosis?
a. Sudden rise of temperature to 39°C c. Irritable and unable to consume scheduled feedings
b. Had colds and low grade fever for number of days d. Pain and itchiness of the ear canal

57. The nurse explores measures used by the mother in comforting the infant to develop teaching strategies. The nurse cautions her
mother to place the infant in which of the following position?
a. Sitting b. Side-lying on the affected ear c. Side-lying on the unaffected ear d. Supine

58. The nurse observes the mother bottle feeding the infant in supine position. Which of the following should be the BEST
appropriate action of the nurse?
a. Praise the mother in promoting feedings of control and enhancing self-esteem.
b. Counsel on the risk encountered in the situation by telling the mother that the position allows milk to enter the Eustachian
tube.
c. Call the attention of the mother to observe the regular feeding schedule and emphasize correct position during feeding.
d. Provide support as needed and assist in reinforcing positive behaviors and increasing motivations and hope.

59. The infant was screaming out few lines, then nap for short period and slept the whole night. This can be interpreted as:
a. Effect of analgesic and antibiotic medication c. Exhaustion from continuous crying
b. Increased pain or a sudden relief of pain d. Improvement in the condition of the infant

60. The nurse educates the mother on management of the infant in the event of acute episode by stressing which of the following?
1. Importance of completing the course of antibiotics 3. When to seek medical care
2. Observing common complications 4. Presence of serous effusion

a. 1 and 3 b. 1, 2 and 3 c. 2 and 3 d. 1 only

SITUATION 13 - Karen, a 19 year old nursing student, faints in the Ladies Room of the University Bookstore. A staff
person discovers her and calls an ambulance. En route to the Emergency Department, she drifts in and out of
consciousness. Her blood pressure, 70/42 mmHg, is barely audible; pulse 62bmp, erratic and difficult to palpitate.
When she arrives at the ED, an IV of 1,000 D5W is started. Karen is conscious but weak.

61. Karen admitted to the nurse that, “she took about a handful of laxatives over the course of 6 hours…” to which the nurse
responded, “ That’s not too bright. The chart says you’re a nursing student. You should know better than that, hmm?” This
approach is:
a. Accepting because she is just stating an information from her chart
b. Encouraging client to use her judgment appropriately
c. Simply a matter of fact attitude
d. Not therapeutic because she is admonishing

62. Karen is diagnosed to have Bulimia Nervosa. This is characterized by binging and a typical behavior is:
a. Excessive anxiety of hospitalization and encountering health practitioners that probes into her private life.
b. Eating larger amounts of food than most people do under similar time and circumstances
c. Uncontrolled urge to seek secondary gain from other people
d. Eating unusual and non-nutritive kinds of foods and substances

63. A nurse counselor talked to Karen after her emergency needs have been attended to. Which of the following questions should
the nurse avoid?
a. How often are you moving your bowels?
b. Have you tried to make yourself thrown up to relieve yourself of stomach distress?
c. Why do you take laxatives to feel thinner or to lose weight?
d. Do you sometimes take something to move your bowels along?

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64. Clients like Karen conceal their illness because of:

a. Pretending to seek help b. Fear of being judged c. Uncontrolled urge d. Non-threatening nature

65. The long term goal of the nurse counselor is:

a. Educate on personal and mental hygiene c. Develop trusting relationships
b. Increase self-esteem essential to health d. Educate on proper food servings and dietary requirements

SITUATION 14 - Ash, a 35-year-old man, had undergone an exploratory laparotomy and segmental small-bowel
resection to treat an intestinal obstruction. His first postoperative assessment showed that he’s somewhat anxious,
agitated and not easily reassured or calmed. The patient was tremulous, anxious and showing increasing agitation.
Staff suspected alcohol withdrawal.

66. When assessing Ash, the nurse notes polyneuropathy and skin changes. The nurse knows these are results of deficiency of:
a. Vitamin B b. Vitamin K c. Vitamin A d. Vitamin C

67. The staff suspected alcohol withdrawal. Which of the following cluster of symptoms should be noted as withdrawal symptoms?
a. Seizures, hallucination, illusions, autonomic arousal and panic
b. Agitated, confused, frightened, combative and can’t be calmed down
c. Generalized tonic-clonic seizures
d. Elevated vital signs, irritability, anxiety, restlessness and anorexia

68. Prompt treatment of alcoholism is essential. The nurse’s vigilance starts when:
a. There is slightly elevated pulse, blood pressure and body temperature
b. Signs of irritability, restlessness and anxiety are observed
c. A history of alcohol use is revealed on assessment
d. At most eight hours from the time the patient last drank alcohol

69. The nursing staff ensures Ash’s safety during treatment. While giving nursing care, Ash verbalized fearing a presence of snake
around him. Which of the following approaches is LEAST therapeutic?
a. “We are not going to leave you alone until your vital signs become stable.”
b. “This is rolled up belt to restrain you temporarily. It can’t hurt you.”
c. “When your alcohol levels fall, you may perceive things that aren’t really there, and these may frighten you.”
d. “There is no snake here, you are in hospital.”

70. The health team is discussing a plan of treatment of Ash. After providing him with the necessary information about his illness,
the MOST important aspect to consider in his rehabilitation is:
a. Commitment and motivation for treatment c. Ability to refrain from drinking for brief periods
b. Total physical health d. Support from his family

SITUATION 15 - It is the first day of Orientation of new nurses at the Psychiatry Ward. The supervising nurse
emphasizes that it is the responsibility of all members of the interdisciplinary team to safeguard patients’ records from
loss of destruction or from people not authorized to read it.

71. It is unethical to tell one’s friends and family members data about patients because doing so is a violation of patient’s rights to:
a. Informed consent b. Confidentiality c. Civil liberty d. Secrecy

72. The nurse must see to it that the written consent of mentally ill patients must be taken from:
a. Law agencies b. Social worker c. Doctor d. Parents or legal guardian

73. In an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has
to be correctly written and signed by the physician within:
a. 24 hours b. 48 hours c. 12 hours d. 36 hours

74. To facilitate identification of persons and relationship, the family nurse utilizes this diagrammatic representation of members of a
family and their relationships.
a. Kardex b. Flow chart c. Genogram d. Algorithm

75. The MOST significant events the nurse records regarding psychosocial well-being are:
a. The patient’s sleeping, eating, and elimination patterns
b. The behavior patterns and interpersonal interactions of the client
c. Somatic treatments, medications and their effects
d. Signs and symptoms and physical appearance

SITUATION 16 - Ms. Corpuz, the psychiatric nurse at the family section of the Out-Patient Department follows up
families of discharged schizophrenic patients. These follow up visits provide opportunities for psychosocial treatment
of patients and their families.

76. To ensure maximum participation of family members in follow up sessions with Ms. Corpuz, which of these elements of effective
family intervention is basic?
a. Family social support c. Training in problem in problem solving
b. Improvement in family communication d. Mutually agreed upon goals

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77. The primary goal of psychosocial treatment for families of discharged psychiatric patients is:
a. Provide gainful employment c. Provide education on medication management
b. Ameliorate poverty and social ills in the community d. Enhance coping efforts and reduce stressful life events.

78. Which of the following is a cultural factor that is a barrier to avail of family intervention?
a. Resources and time c. Shame and stigmatization
b. Unresponsive government policies d. Traditional practices

79. All of these are within the scope of the generalist nurse’s role, EXCEPT:
a. Social skills training c. Family therapy
b. Individual and family assessments d. Health education on psychotropic drugs

80. Cognitive behavior principles are utilized in psychosocial treatment. In such intervention, patient who are rehabilitating from
schizophrenia are:
a. Taught to unlearn maladaptive behaviors through desensitization.
b. Assisted to work through their unconscious internal conflicts.
c. Taught to reframe psychotic symptoms as coping attempts rather than signs that they are crazy or week.
d. Made to recognize the importance of psychotropic drugs to combat delusions and hallucination.

SITUATION 17 - The community health nurse spearheaded an educational collaborative activity to address the
increasing drug and alcohol problems in the community. An initial organizational meeting was called which was
attended by a barangay official assigned to community health and peace and order, resident representatives from the
community, Parents-Teachers Association, Church/Parish Pastoral Council and the barangay social worker. The
following questions apply.

81. During the initial meeting which of the following activities will the nurse introduce first which MOST likely will interest and
motivate the attendees to engage in collaborative activities?
a. Alarming dangers of drug and alcohol use c. Values Formation program
b. Planning for a summer sportfest d. Lecture forum on increased awareness of unhealthy lifestyle

82. A survey is necessary to assess the prevalence and incidence of substance abuse. The community members assisted in asking
respondents to be surveyed who are at MOST risk to substance abuse and these would be the:
a. Adults b. Adolescent c. Older children d. Elderly

83. A self-help support group with educational and caring approach for alcoholics is:
a. Halfway homes b. Detoxification programs c. Psychiatric rehabilitation d. Alcoholics anonymous

84. The MOST effective education and preventive measure for drug abuse is:
a. Regular advocacy meetings to include families, store, restaurant and bar owners
b. Leaflets and brochures for mass dissemination
c. Family enrichment programs
d. Activity workshops for out of school youth

85. In coordination with the Parents-Teachers Association, the nurse organized parent education classes. She recognizes the
necessity to link with other agencies to discuss this area:
a. Stress management
b. Recognition of deviant child and adolescent behavior
c. Legal implications of illicit drug use
d. Parent effectiveness training

SITUATION 18 - Joe, 30 years old was admitted to Psychiatry Ward because of changes in behavior such as neglect of self
care, withdrawal from relations with people, talking to himself and beliefs that he is being persecuted. He has been
diagnosed with Schizophrenia disorder.

86. Nurse Gina was assigned to take care of Joe. She approached and greeted Joe and sat with him to start an interaction. He
moved back to distantiate himself and evaded eye contact. Nurse Gina recognized that in order to establish a nurse-patient
relationship, it is important for Joe to have:
a. Self – confidence b. Self – worth c. Rapport d. Trust

87. Nurse Gina observed that Joe kept mumbling unintelligible words which made no sense to her accompanied with inappropriate
facial grimaces as if he is talking to someone. He claims he is in a prison camp. Nurse Gina interprets these behaviors as:
a. Depersonalization b. Anhedonia c. Lack of insight d. Ambivalence

88. The multidisciplinary team shared observations of Joe and discussed plans for treatment. Nurse Gina anticipates that from
evidenced based practice, the MOST likely treatment plan to be initiated is:
a. Behavior modification b. Relationship therapy c. Demotivation therapy d. Pharmacotherapy

89. A socialization program is scheduled for the day. A therapeutic intervention of Nurse Gina is:
a. Minimize environment stimuli and have Joe engage in a less stimulating activity
b. Present the plan for the day and have Joe decide
c. Have a friendly patient invite Joe to the Socialization program to overcome his withdrawal from social relations

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d. Refer the matter to the occupational therapist

90. A therapeutic attitude in dealing with Joe is by being:

a. Lenient and have no demands c. Passively friendly with him
b. Actively friendly with him d. Simply objective and businesslike

SITUATION 19 - The onset of schizophrenia has a profound impact on an individual self-concept. A nursing team
organized a pilot study to initiate therapeutic intervention to help individuals who are recovering from a first episode of
psychosis work out a positive self-concept.

91. Participants for the pilot group were recruited for a first episode experience of psychosis at a university medical center which is
located within close proximity to the university campus. The sampling of this group membership is:
a. Systematic b. Random c. Stratified d. Convenience

92. The nature of the group was supportive and interaction-oriented. Discussions focused on:
a. Self-disclosure b. Development issues c. Past relationship d. The “here and now”

93. In eliciting the meaning of the experience of a first episode of psychosis, it is BEST to have group members share emotional
experiences by:
a. Prescribing a structure to focus c. Following the group leader perspective
b. Allowing for elaboration of the experience d. Offering alternative explanations

94. Having hope and building confidence in one’s self is BEST achieved by:
a. Feeling good b. Thinking positively c. Experiencing success d. Acceptance of other

95. The female nurse leading the pilot group for clients with a first episode experience of psychosis was asked by one of the male
participants to go out to dinner. Which response of the nurse would be MOST professional?
a. Accept the invitation with caution not to let anyone know it because it is against the policy
b. Explain that because of her role she considers it against professional boundaries to go out
c. Say, “Ok, maybe sometime,” and maintain this simply a possibility
d. Tell the client that she is dating someone else.

SITUATION 20 - Mr. Iris, a 25-year-old construction worker, had convulsive movements with loss of consciousness in
the construction site. After the episode, he was rushed to a nearby hospital. He is diagnosed with epilepsy with
generalized seizures. He was hospitalized before due to an accident while at work.

96. Nurse Vernard is conducting physical assessment. Which oh the following activity is the LEAST considered nursing behavior?
a. Prepare for diagnostic evaluation c. Assess the client’s life style and occupation
b. Identify the client’s daily activities d. Assess the client’s family relationship for evidence of tension.

97. The nurse should observe which of the following clinical manifestation as the FIRST indicator of seizure?
a. Clenched jaw c. Shallow and irregular breathing
b. Eyes rolled upward d. High pitched cry

98. The nurse should observe which of the following manifestation during the generalized seizures?
a. Facial grimace with patting and smoking
b. Loss of consciousness , dilated pupils, and muscular stiffening or contraction
c. Jerking movements of all extremities
d. Vacant stare with a brief loss of consciousness

99. The client had seizure attack in the hospital. The nurse should take the following seizure precautions, EXCEPT:
a. Restrain the client c. Keep an artificial airway at the bedside
b. Place the client in a flat, side lying position d. Prevent the tongue from obstructing the airway

100. Upon awakening during the episodic attack, the client asks the nurse what cause his seizures. Which of the following should
the nurse include as the cause of the seizures?
a. Trauma
b. Tumor of the brain
c. Vascular diseases
d. Withdrawal from drugs

END OF EXAMINATION.

PASS YOUR ANSWER SHEET TO THE PROCTOR AND HAVE THIS QUESTIONNAIRE SIGNED FOR VALIDATION. KEEP THIS
QUESTIONNAIRE IN PREPARATION FOR RATIONALIZATION.

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 NURSING PRACTICE V – SET A

PROCTOR’S NAME & SIGNATURE