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Situation 1: Vilma, age 25, has been readmitted for uncontrolled blood sugar levels. The nursing team included the mental health nurse who integrated a healthy lifestyle program in addition to monitoring her blood sugar levels, staying on her prescribed diet, doing regular exercise, stress reduction, and smoking cessation program. 1. Vilma casually and unaffected says that she cant be bothered with monitoring her blood sugar level. The nurse interprets this behaviour as: A. realistic attitude because she can maintain the ability to be cool B. adaptive coping because she is expressing her feelings and thoughts directly C. Ineffective coping because she is ignoring or refusing to acknowledge a distressing reality D. negative because she is showing thought disturbance 2. Vilma claims that cant be so bad because it keeps her cool and helps calm her nerves. She is using the defenseof: A. sublimation B. rationalization C. displacement D. intellectualization 3. The attending nurse feels frustrated and irritated with Vilmas behaviour. It is BEST for the nurse to do: A. self-awareness B. self-aasertion C. self-control D. self-denial 4. In order to master positive coping skills, the nurse encouraged Vilma to practice sublimation by: A. avoiding thinking about disturbing problems and feelings C. turning to others for helps and support B. anticipating concequences of her actions and considering realistic solutions D. engaging in relaxation and hobbies 5. The nurses goal in teaching Vilma about healthy lifestyle is for Vilma to develop: A. awareness B.insight C. maturity D. responsibility Situation 2: A 60 year old male client is observed by his family to be forgetful, with pronounced personality changes and sometimes becomes violent. He begins to wander and this poses a serious safety problem. He is diagnosed with Stage II Alzheimers Disease. 6. The nurse is preparing a plan of care. Safe nursing care is ensured for the client when he is: a. participative c. oriented to reality as much as possible b. familiar where he is d. able to recall meaningful past experiences 7. The care of the client with Alzheimers Disease at home proved to be challenging to the family as cognitive functioning continues to deteriorate. The following nursing actions should serve as guide to the family to preserve cognitive function EXCEPT: a. provide a low-stimulating environment c. set limits b. call his name and tell him where he is d. talk to the client and ask him to tell stories about his past 8. The physician prescribed Exelon (Rivastigmine) 1.5 mg BID. The family asks the nurse the benefit of this drug for the client. The nurse responds accurately when she states that the medication: a. enhances the likelihood that the client will remember what to expect. b. makes the client feel more in control and not agitated c. promotes a feeling of security and improves cognitive function. d. raises the acetylcholine level in the cerebral cortex to improve cognition function 9. The nurse is doing full documentation of her nursing care. Which of the following include full documentation? a. ability to interact with others, medications given and side effects, strategies employed to enhance social interactions. b. visits of the family, health teachings, periods of interaction done, what the patient can and cannot do. c. discussing things that are of interest with the client, medications given and side effects, food intake and rest periods. d. medications given and side effects, responses to teachings given to the family and significant others and outcomes of all interventions done. 10. The client has impaired social interaction and communication related to reduced cognitive abilities. The outcome criteria set by the nurse is that the client will: a. use appropriate language c. continue to socialize with others b. have a reasonable and appropriate conversation with one person d. manifest appropriate behaviour. Situation 3: When nurses are considering issues on control, shame and stigma, surrounding the subject of mental illness, one of the primary considerations should be nurses own sensitivity in recognizing signs of mental health problem. Ethics pervades good practice. The following situations apply 11. A client is brought to the hospital by his officemates because he kept on blaming his immediate superior of getting him fired from his job. Ethical problems may arise when diagnosing psychiatric clients because of: a. subjectivity b. lack of expertise c. inadequate staffing d. inappropriate diagnostic procedures 12. The nurse is administering psychotropic medication to the client. The client refused to take the medication. Which of the following situations would guide the nurse where a client refuses medications? a. may refuse the medications only if his attending physician agrees. b. cannot refuse his medication regardless of his medical diagnosis c. need a ourt order to allow the client to refuse his medication d. can refuse this medication if he has not been deemed incompetent by formal legal proceedings 13. Which of the following is a basic safeguard to ethical practice by the nurse providing care to clients with borderline personality disorders who are extremely provocative and manipulative? a. applying person centered approach c. observing human to human relationship b. practicing self-awareness constantly d. seeking clinical expert opinion 14. The client verbalizes to the nurse about thoughts of threatening to kill his wife The nurse is in dilemma whether to tell the wife about this conversation. Given this situation which of the following is the appropriate action of the nurse? a. weigh carefully the situation by viewing it as a dilemma between disclosing confidential information or warning appropriate authorities b. alert immediately the proper authorities regarding the threat to safeguard the safety of the wife c. keep the information to herself and be vigilant on the action of the client to protect the wife d. tell the wife to be very extra careful as her life is in danger. 15. The psychiatric diagnosing of clients is a morally charged issue and the assigning of diagnosis may be an ethical issue. The role of the nurse in diagnosing psychiatric patient is important because nurses are: a. knowledgeable in the field of psychiatry due to extensive clinical c. collaborators in the diagnostic process experience d. competent by virtue of their educational preparation b. planners of psychiatric nursing care Situation 4: Clients with manic disorders are often put on lithium therapy. The nurses undersanding of mood stabilizers will be very important in the management of clients taking the medication. 16. Before Lithium therapy begins, the nurse should make sure that the client has baseline data on clients: a. neurologic studies b. enzyme studies c. fluid and electrolyte studies d. renal studies 17. Which of the following instructions will the nurse teach the patient when collecting a 24 hour creatine clearance for the performance of prelithium workup? a. Sign this consent form and then collect your urine for the next 24 hours after discarding the first urine of the morning and keep refrigerating the clean 3-liter container between voidings b. Sign this consent form and collect your urine in a clean 3-liter plastic container for 24 hours. c. Collect all urine when you wake up and for 12 hours thereafter, then discard all collected urine, noting the time. Begin to collect all urine and refrigerate it for the the next 12 hours after your blood is drawn. d. Discard your first morning urine on awakening and then begin to time and collect your urine. Keep it refrigerated in a clean 3-liter plastic container. Your blood may be drawn atanytime during the collection. 18. Marita is prescribed Lithium Carbonate 1800 mg in divided doses daily. The clients blood lithium level is monitored regularly since lithium toxicity can be very dangerous to the client. The therapeutic range of lithium is:

a. 3.0 to 5.0 mEq/L b. 0.2 to 1.0 mEq/L c. 2.0 to 3.0 mEq/L d. 0.5 to 1.5 mEq/L 19. While taking Lithium, Marita is most likely to experience some common side effects of Lithium that are uncomfortable and ditressing. The nurse however, should be able to identify and be alert for signs of Lithium toxicity such as: a. increased urination, and increasing drinking c. severe vomiting, diarrhea, lack of coordination b. mild nausea, metallic taste, fatigue d. weight gain, acne, fine hand tremors 20. Signs of lithium toxicity are observed in Marita so Lithium is immediately discontinued and ordered resumed when it is safe. When teaching Marita about Lithium therapy, the following health instructions should be included EXCEPT: a. diet should include enough sodium and fluids c. blood lithium levels should be monitored regularly b. take Lithium before meals for ease absorption d. lithium is contraindicated during pregnancy Situation 5 Poor insight into mental illness is associated with poor adherence to treatment for individuals with psychotic illnesses. The psychiatric nursing team organized to develop a program to identify strengths and weaknesses in insight in order to promote beneficial change. The following questions apply. 21. Many nurses observe that patients poor insight into their illness and their inability to recognize the potential for recovery when taking their medication lead to poor adherence. Which of the following situations describe medical adherence? a. proper observance of adequate nutrition and healthy lifestyle. b. extent to which clients behaviour coincides with medical or health advice c. degree to which clients with schizophrenia acknowledge to the health team that they have a serious mental illness d. diligent monitoring of their signs and symptoms of disturbance 22. A group discussion on poor insight was conducted. Literature review of insight include all of the following factors EXCEPT: a. ability to recall recent and remote experiences c. acceptance of the need for treatment b. awareness of suffering from mental illness d. ability to appreciate that symptoms such as delusion are abnormal 23. A poor therapeutic alliance between the client and the nurse contributes to problems with effectiveness of therapeutic interventions. This underscores a priority for the nurse to be able to: a. develop a working relationship c. establish rapport with clients b. work out countertransference reaction d. ability to empathize 24. Which of the following symptoms of illness pose a very high risk for potential for violence? a. limited interest in grooming b. fair reality testing c. poor eye contact d. command hallucinations 25. When staff members perceptions of clients level of functioning vary markedly with the clients own self-perception, it is most likely that the client is minimizing his symptoms and employing: a. compensation b. rationalization c. denial d. projection Situation 6: Community problems of substance use were noted in ER admission cases. The following situations refer to different stages of patients hospitalization. 26. To manage alcohol withdrawal, which of these pharmacotherapeutic agents are commonly used? a. Librium (CHlordiazepoxide) and vitamin (thiamine) therapy c. Halperidol (Haldol) and calcium channel blockers b. Selective Serotonin Reuptake Inhibitors d. intravenous alcohol drip in decreasing doses 27. The alcoholic has low frustration tolerance. The nurse intervenes initially by: a. encouraging verbalization of client c. helping client utilize his support system b. assisting with development of constructive coping skills d. providing positive interpersonal experiences 28. At endorsement report the nurse learns that MS. V is in opiate withdrawal. For what objective data should the nurse be alert? a. somnolence, constipation, normal pupils and hypothermia c. visual and tactile hallucinations, agitation and grand mal seizure b. lacrimation, rhinorrhea, dilated pupils and muscle spasms d. tremors, hypertension, constricted pupils and deep sleep 29. A 35 year old male admitted to drinking six beers a day 5 years ago. He now requires 10 to 12 beers a day to achieve the same effect. The nurse assesses this as: a. ineffective coping b. tolerance c. altered mental status d. withdrawal 30. A teen-age girl was admitted with a history of cocaine abuse. Her pupils are dilated and she complains of nausea and feeling cold. She insists that she is not addicted but uses cocaine at parties with peers. a. Ineffective denial related to substance use as evidenced by refusal to admit problem b. Impaired verbal communication related to substance use as evidenced by giving untrue information c. Perceptual alteration related to substance use as evidenced by distortion of reality d. altered growth and development related to substance use as evidenced by age of onset Situation 7: Ethico-legal issues challenge the nurse as a researcher. The following situations apply. 31. During the process of data collection in a survey an incidence of mental illness in the community, the nurses picture was with the family who was the research subject and who were so nice and receptive to questioning. This action: a. must be avoided to protect the nurse from future exploitation b. encroached on the rights of the subjects to privacy and confidentiality c. is acceptable considering that Filipinos are generally friendly d. has no bearing on the rights of the subjects to privacy and confidentiality 32. The nurse observer is confronted of the need to provide counselling to a subject, a woman who had experienced mastectomy. It is best for the nurse to: a. be guided with the research protocol c. refrain from doing anything except to observe b. refer the situation to the attending physician d. counsel the client as necessary 33. In situations where a serious ethical problem occurs when data are falsified or misused in research reports, who carries the principal responsibility for data fabrication? a. institution b. investigator/researcher c. project staff d. encoder of data 34. The nurse researcher commonly encounters a conflict of interest in doing a research when he/she is also the: a. co-researcher b. nurse caregiver c. same sex d. same age-group 35. The research process included exposure of subject to a very stressful situation prior to a structured interview conducted by the researcher. Information must be withheld from participating subjects to ensure validity of the results. The research design must incorporate: a. acknowledgement to the subject that deception was committed somehow b. compensation package for the subject for whatever moral and ethical inconsideration that have been inadvertently committed. c. plans for debriefing at some time during the study, most commonly at its completion d. formal acknowledgement of particiapation at the end of the research. Situation 8: Myrna is a 15 year old female who was admitted to the Adolescent Unit because of impulsiveness, uncontrolled outbursts, profane language and involvement in fights in school and frequent absenteeism. 36. During the assessment, Myrna seems upset and irritable. She asks, Will you tell everything to my parents and write a report to my school? Which of the following is the BEST response of the nurse to Myrna? a. Myrna, I may not write a report to your teacher but I need to discuss with your parents. b. Myrna. It is best for your parents and teacher to know so they can guide you. c. Of course not Myrna. Everything you share with me is confidential. d. Myrna, I will maintain confidentiality on matters that are not a risk to you and others. 37. Which of the following questions would be MOST appropriate to obtain data about Myrnas affect? a. You look upset are you? c. Why do you think you always get into fights? b. are you angry or sad? d. How are you feeling? 38. In which part of the mental status examination would the nurse document Myrnas interpretation of the proverb, A rolling stone gathers no moss.? a. quality of speech b. perceptual-sensory function c. higher brain function d. thought content and process

39. The nurse performed a mental status examination and assessed Myrnas mood. What is the MOST important data to document in Myrnas record? a. congruency between thought processes, affect and mood. c. congruency or incongruency between thought content, affect b. congruency between thought process and mood. and mood. d. congruency or incongruency of delusions and mood changes. 40. The data gathered using the Psychosocial Assessment Tool include all of the following EXCEPT: a. individual and family strengths and coping patterns c. personality type b. baseline information about Myrnas level of functioning d. actual and potential problems Situation 9 From the monthly meeting of nurses assigned at the mental health psychiatric nursing facility, a report on patient assault were on the rise. This necessitated a series of nursing team conferences. 41. Staff nurses become increasingly controlling initially because: a. they need to assert nurses professional role c. there is lack of trust and fear of future incidents of untoward events b. patients must learn autonomy and self-reliance d. they must not be blamed by their colleagues and administration 42. The staffs reactions to both patient suicide and patient assault reported cognitive, affective and behavioural changes. Which of these reactions include all of the three aspects? a. exaggerated startle response, increased staff control over patients, compulsive behaviour b. self-blame, anger, change in relationships with co-workers c. flashbacks, pre-occupation with the incident and distressing recollection of the event d. fear of another incident, anger at the institution and apprehension of being held liable 43. An increase in burn-out, absenteeism and staff turnover as an aftermath of patient suicide or assault must be primarily recognized as: a. the nursing staff and anciliary staff are in a state of upheaval b. patient suicide and assault must constitute occupational hazards for psychiatric nurses and ancilliary staff c. the nursing staff and ancilliary staff need stress debriefing d. the quality of patient care is compromised 44. As the nurse conducts the nursing audit, she checks completion of patient record with diagnosis of post-traumatic stress disorder. She particularly would look at records documenting: a. grief as a reaction to actual or perceived loss c. effects of incident on significant disruption in clients functioning b. an element of trauma d. painful feelings to threats to self-esteem, trust and perceived loss of control 45. A corrective and preventive measure to mitigate the effects of post-traumatic stress disorder that the nurse prioritize is: a. immediate pharmacologic treatment with anti-anxiety drugs b. conduct progressive relaxation exercise c. utilize family and social support to promote expression of feelings, thoughts and responses arising from the event d. organize emergency preparedness programs for calamities such as fires, earthquakes and floods. Situation 10: The nurse wants to indentify factors conducive to the adjustment of discharged patients on their return to the community. The following questions apply. 46. The nurse examined the variable on readmission rates to psychiatric hospitals. Which of the following are a socio-demographic variables? a. support of friends, spouse, relatives and co-workers c. leisure and church related activities b. frequency of follow-up visits at the mental health clinic and d. gender, age, marital status, employment status compliance with medication 47. Which of the following will yield data through a retrospective self-report questionnaire on social activities? a. hypothetical situations b. recall of subjects c. present experience of subjects d. future plans or subjects 48. Which questionnaire allowed respondents to give free comments regarding relationship with a significant other? a. indirect b. open ended c. closed ended d. direct 49. Sixty percent of the respondents rated friends as personal support systems. If there were120 respondents, how many respondents checked friends as greatest influence on avoiding hospitalization? a. 66 b. 60 c. 70 d. 72 50. Given the list of work opportunities, which is the method of placing preference in an ascending or descending order? a. coding b. Q sort c. rating d. ranking 50. Given a list of work opportunities, which is the method of placing preference in an ascending or descending order? A. Coding B. Q sort C. Rating D. Ranking SITUATION 11- Lorena is a 30 year old single mother who is is dependent on her family for support. Her diagnosis is mild mental retardation with post traumatic disorder with depressive episodes. Her current symptoms include depressed mood with irritability, difficulty tolerating, frustration, difficulty falling asleep, increased appetite and weight gain, hyper vigilance and worry that something terrible will happen to her child. 51. a cognitive assessment to Lorena indicated that according to Piagets theory she was functioning at the concrete operational stage. Which of these behaviors wound the nurse observe on Lorena? A. makes and test hypothesis C. Thinks logically and sees possibilities B. Feels her own reasoning should agree with the reasoning of others. D. Understands only her own viewpoint. 52. Lorena has difficulty tolerating frustration. The goal of the nurse is to assist Lorena to: A. mobilize her resources B. Recognize her needs C. Increase her self-esteem D. cope with anxiety 53. Which of the following historical data MOST probably led to a Post-traumatic stress disorder? A. No gang-relationship with peers C. dropping out of school B. Suicide of her mother D. unstable relationship with ex-fiancee 54. Given her problems of hyper vigilance and worry that something terrible will happen to her child, nursing interventions would be aimed at addressing her needs for: A. self-esteem B. Biological integrity C. Psychological security D. love and belongingness 55. In terms of social support therapy, which of these is MOST appropriate and therapeutic? A. Vocational training with moderate supervision but not beyond second grade academic challenges. B. Individualized relationship with a caregiver C. High structured environment with constant aid and supervision. D. With appropriate supports, live in the community either independently or in supervised settings. SITUATION 12 A 60 year old male client is brought to the hospital due to numbness of the face arm or leg, visual disturbances and severe headache. His admitting diagnosis is cerebrovascular accident (CVA). 56. The nurse must have been assessment skills to appropriately assess the client. Which of the following must be determined by the nurse during assessment? A. Past medical history, current medications and onset and C. Diagnostic test, Vital signs and current medication. progression of symptoms. D. Monitoring of vital signs, Fluids and Medications B. Condition of the client, current medications and diagnostic test. 57. Which of the following is the responsibility of the nurse during the acute phase of the stroke client? A. Management of airway, breathing and cardiopulmonary support. C. Diagnostic test, Medications and fluids. B. Continuous assessment and monitoring of vital signs. D. Monitoring of vital signs, fluids and medications 58. The nurse is planning the nursing care of the client. Without of the following is the goal in the management of stroke client?

A. Improve level of consciousness. C. Immediate rehabilitation B. Restore function and independence. D. Prevent further stroke 59. The recommended plan of care using interdisciplinary services includes the following EXCEPT: A. Performing surgery for rapid evacuation of hematoma. C. Managing general health functions throughout all stages of treatment. B. Preventing recurrent stroke and complications D. Documenting and assessing acute and rehabilitation stages. 60. Several disciplines join on the management of facilitating the recovery of the client following a stroke. Who of the following members of the interdisciplinary team works with the client to retain activities of daily living and practice independence using assistive devices? A. Occupational Therapist B. Health Care Therapist C. Physical Therapist D. Speech Therapist SITUATION 13 Suicide as a major public health problem thought the world, poses a continuing challenge to health professionals. The following questions have implications on the nurses role. 61. Suicide is related life circumstances such as death, illness, family and work related issues. Which of the following interventions would be MOST appropriate in such life circumstances? A. behavior therapy B. mental health education C. crisis counseling and intervention D. Individual and group therapy 62. For the family members of those at risk for suicide and community helpers, which of these training programs would be MOST appropriate? A. How to implement action programs to manage substance abuse and suicidal behavior B. How to develop strategies to reduce the stigma associated with depressive illness C. How to enhance resources in communities for suicide prevention D. How to recognize and respond to people exhibiting signs of suicide 63. Suicide tends to be ignored by society mainly because of: A. apathy B. Ignorance C. Stigma D. Indifference 64. In developing suicide prevention program for adolescents which of the following topics is MOST appropriate for adolescents? A. Peer interpersonal relationships B. Alcohol and drugs C. Coping skills development D. Healthy life style 65. Suicide is a preventable problem and best addressed by: A. education approach in schools and work places C. community health approach of people and institutions B. medical approach by psychiatrists D. mental health approach by professionals in clinical settings SITUATION 14 Nurses partner with others in delivering health care services to clients. Collaboration requires the nurse to use effective interpersonal skills, maximize coordination of members a involved in giving care services and as necessary provide continuity of care. 66. The nurse is caring for client diagnosed with rheumatoid arthritis. She coordinated with the physician and understood that the laboratory test to be done is: A. alkaline phosphatase B .c-reactive protein C. erythrocyte sedimention rate D. antinuclear antibody test 67. The physician ordered low purine to a client with gout. The nurse made a special dietary consultation to fit the clients background. Which of the following food should be nurse advice the clients to eliminate in the diet? A. Fish and Pork B. Fruits and vegetables C. Beef and chicken D. Organ meats, wine and mussels 68. The physician ordered an axillary crutch to Mr. Elmer who is treated with fracture of the femur. The nurse collaborated with the physical therapist on safety measure in the use of crutch. The following are safety measures EXPECT: A. support body weight from the axillae C. inspect routinely crutch rubber tips B. Use crutches that are measured for him D. identify the danger of pressure in the axillae when learning on the crutches 69. Mr. Nino is scheduled for magnetic resonance imaging (MRI) because of recurring back pain. The nurse made an arrangement with the diagnostic center for the procedure. In preparation for the procedure. It is essential for the nurse to ask which of the following? A. Do you have fear of open spaces? C. Do you get tired easily? B. do you have any allergy? D. Do you have any mental in you body? 70. The management of client diagnosed with Parkinsons disease is collaborative effort among nurses physician, physical therapist and the client himself or herself. What is the primary goal set for the client? A. To reduce muscle irritability C. To strengthen muscle tissues B. To increase muscle endurance D. To maintain joint flexibility SITUATION 15 Communication is the fundamental element of nurse client relationship. It is a mechanism for demonstrating compassion and caring. The nurse must be able to communicate clearly and accurately in order for the clients needs to be met. The following situations apply. 71. Nurse is working a client with moderate hearing impairment. Which of the following nursing approaches should the nurse follow to promote communication? A. Invite the client in a room for privacy C. Speak louder B. Use visible expression D. Quietly slip from behind the client and speak softly. 72. Lola Marta has closed angle glaucoma. She asks the nurse. If her condition is hereditary. The MOST appropriate response of the nurse should be: A. There is a strong hereditary factor in glaucoma. Annual intraocular measurements is required for children age 40 years and above B. if you have children over 40 years old they should be evaluated for intraocular measurement. C. There is no relationship between the occurrence of glaucoma and heredity. D. Family member all ages should have annual intraocular measurement. 73. Aling mameng, an elderly client is having ophthaimologic assessment by the nurse. She tells the nurse that she has difficulty focusing on near objects and lessened field of peripheral vision. The BEST response of the nurse is: A. I will refer you to opthaimologist. B. What made you say that? C. There is no relationship between the occurrence of glaucoma and heredity. D. Family member all ages should have annual intraocular measurement. 74. Nurse Bette is caring for Mr. Dan who has eye patches on both eyes following eye surgery . To avoid starting the client, which of the following interventions should the nurse do when entering the room during treatment and medication? A. Proceed to the beside and speak louder. C. Knock at the door and introduce yourself. B. Quietly enter the room and greet the client. D. Announce presence, state name clearly before entering the room. 75. Mr. Wency, 67 years old has a detached retina. He asks Nurse Rosalie what may have contributed to the development of his detached retina. The nurses MOST appropriate reply is: A. Those with oranial terrors are predisposed to retinal detachment. B. The most predisposing factor in the development of retinal tear is nearsightedness. C. Sinusitis predisposes a person to retinal detachment.

D. Presons with hypertension are prone to develop retinal tear. SITUATION 16 Stabilizing and immobilizing of fractured on injured body parts are important components in restoring and preserving body functions. The following are situations where concept and principles of care apply. 76. A long leg plaster cast is applied to a client. Which of the following measures must be observed by the nurse after the cast is applied? A. Document procedures and teachings as well as familys understanding of instruction. B. Check the cast if completely dry by palpating with the finger tips. C. Assess and document color, pulses movement of the casted legs. D. Support drying cast on a pillow but does not cover. 77. A client is in skeletal traction. The nurse understands that this procedure involves pulling force: A. Using more than one force to support the injured extremity. c. Directly through the clients skin. B. Directly through pins inserted into the bone. d. Physically on the extremity affected. 78. In caring for clients with traction, an important consideration is to maintain the pulling force and direction. The nurse should ensure that: A. Assessment of the affected part is monitored regularly. c. Complications be reported to the physician immediately B. Weight should hang freely and do not touch the floor. d. Care of the area with traction is observed. 79. Which of the following types of traction uses more than one force of pull to raise and support the injured extremity off the bed and ensure mobility while maintaining bone position? A. Balance suspension traction C. Skeletal traction B. External fixator device D. Bucks traction 80. A client with cervical spinal cord injury is treated with a Halo Traction for cervical stabilization. The nurse should understand that this type of treatment is indicated for a client who: A. May achieve walking with braces. c. Needs excellent bed mobility B. Does not require surgery and allows for early ambulation d. Needs adaptive device to propel wheelchair. SITUATION 17 A child seizure disorder is brought to the hospital following another attack. 81. Which of the following interventions should be initially performed by the nurse on admission? A. Discuss seizures events with the mother. C. Obtain seizure history. B. Observe for apnea and cyanosis. D. Loosen any tight clothing. 82. The nurse expected outcome for the child is to remain free from physical injury. This can be accomplished when the nurse performs which of the following? A. Review medication protocol. C. Keep side rail up. B. Listen to parent concern and reassure as needed. D. Stay with the child. 83. The child had seizure attack. After the nurse secure a safe position for the child, which of the following should be her focus of documentation? A. Gathering data that precipitated the seizure attack. c. Describing the preceding circumstances and the seizure itself. B. Making emergency equipment inventory available d. Prepare a report on the event of situation. 84. The child felt tired and sore and could not remember anything after awakening from the deep sleep following the attack. Which of the following should be the appropriate nursing measures? A. Recognize the tension of the child c. Provide ongoing emotional and informational support. B. Reassure the child regarding the episode. d. Attempt to remove false idea regarding epilepsy. 85. The child is on anticonvulsive therapy. The physician orders Phenobarbital 4mg/kg/day parenterally for 7 to 10 days. Which of the following measures MUST be observed by the nurse when administering the partial does of Phenobarbital thru the IV infusion? A. Instruct the parents to report the health care provider if the child develops severe dizziness. B. Injected partial dose into tubing and assess response of the client before continuing C. Assess vital signs closely during IV administration. D. Warn the parents that the drug will make child drowsy. SITUATION 18 The nurse volunteered to register in a Disaster Preparedness Program. After undergoing a review of basic nursing knowledge and skills she indicated she/he is now ready to be On Call. The following questions apply. 86. The crisis intervention model that the nurse utilizes in emergency situation is the best flitted in which prespective? A. Socio- Cultural b. Medical C. Spiritual D. Biological 87. Soledad lost her 3 school aged children in a fire that razed an overly crowded depressed are. Crisis intervention focus on the following EXCEPT: A. Immediate social integration c. The here and now B. The event in perspective of Soledads life d. Past psychological history of Soledad 88. The nurse expects to be called to do crisis intervention for affected clients in these situation EXCEPT: A. Catastrophic events like fire and floods c. Civil riot B. Chronic phase of mental illness d. Terrorist attacks 89. The onset of crisis is triggered by a: A. Long standing deep seated interpersonal issues. C. History of disturbed family relationship B. Sudden Precipitating event D. Childhood conflicts 90. The nurse must refer to a psychiatrist a client who: A. Verbalizes helplessness of hopelessness C. Is unable to problem-solve B. Intermittently lies and seems confused D. Has suicidal tendency SITUATION 19 As a follow-up of patients who have been discharged, the nurse conducts small group meetings to allow them to share their thoughts and feelings regarding going back to their communities. 91. Which of the following would BEST demonstrative effecting copy of clients to live in the community? A. Avoidance of interpersonal conflicts. C. Active involvement in their care. B. Availability of strong support system. D. Strict compliance with medical regime 92. Martha, 40 year old, expressed feelings of isolation. Of the following behaviors, which is the BEST coping behavior? A. Goes to church everyday to attend Mass? c. Regularly reads a book, The Art Living B. Helps around the house and do errands outside the home d. Engages in computer word games like Scrabble 93. Julia, married, 45 years old woman reports difficulties in dealing with family stressors and conflicts. The nurse recognizes the patients need for: A. Social support on a daily basis C. Continued nurse-patient relationship B. Intensive marital therapy D. Work therapy 94. Tony, middle aged man expressed, I heard voices and things yesterday while shopping at SM mall. I was real nervous. Which of the following is a behavior strategy that is helpful in coping with hallucination? A. Increase his psychotropic medication c. Retreat to a less stimulating environment. B. Talk about those voices with his family. d. Examine which of his thoughts is irrational. 95. Psychosocial rehabilitation is BEST achieved through: A. Full community support C. Provision of adequate housing facilities B. Balance of control versus caring behaviors D. Compliance with home medications SITUATION 20 The nurse is admitting a client with complaints of paroxysmal whirling vertigo, aural fullness and fluctuating hearing loss. She reported that these feeling last for days. She is diagnosed with Menieres disease. 96. When assessing a client with Menieres disease, the nurse expects the client to experience: A. Headache B. Nystagmus C. Postural Hypotension D. Ring of the ears 97. The nurse plans to reduce the risk of injury of the clients tendency to lose balance. Which of the following should the nurse do while the client is in bed? a. Assess clients hearing acuity.

b. Darken the room and encourage the client to move in bed slowly c. Encourage client to perform balance exercises d. Encourage client to talk about feelings and personal perception of danger 98. The nurses focus of care on clients with hearing and balance problem is: A. Diet and medication C. Prevention and control of infection B. Activity and rest D. Safety and promotion of independence 99. The client continues to have the disabling effect of vertigo. A labyrinthectomy can be performed to treat Menieres disease. This procedure results in: A. Accumulation of cerumen C. Loss of sense of smell B. Permanent irreversible deafness D. Persistent earache 100. The physician modifies the diet of the client. Which of the following is the appropriate diet for the client? A. Low Fat B. High carbohydrate C. Low protein D. Low sodium