Formative 3 - Ans Key

DECEMBER NLE FORMATIVE 3
:
PALMER:
1. Career planning is one of personnel function. It is the process or various activities which helps the employees
to identify their strengths, weaknesses, specific goals and jobs they would like to occupy. It helps the
possibility of providing the potential for the employees to grow up with organizational expectations at different
levels. Newly registered nurse Margo is planning to apply for a job. In developing her resume, she should not consider
the following essential elements, except.
a. The goal statement does not necessarily need to be related to the specific position for which she is applying,
provided that it does highlight her skills.
b. Begin sentences with action verbs. Proofreading by someone is not necessary.
c. Make sure that her name appears at the top of your resume and that it is written in a larger font than the rest of
your resume.
d. Include birth date, health status, religious affiliation or social security number.
ANSWER: C
RATIONALE:
ESSENTIAL ELEMENTS OF A GOOD RESUME:
1. Your contact and personal information. Name appears at the top of your resume and that it is written in a larger font
than the rest of your resume. It should also include a way for employers to contact you through phone and/or
email. (CHOICE C)
2. Career objective or goal. Optional; specific; keep it short, no more than three or four lines; explain your career goals,
expertise, and main strengths; tailored to the specific role or position you are seeking to obtain.(CHOICE A)
3. Education and training. Always begin with your most recent education. Include the name of the university or college
you attended along with the degree title. If you have any special certifications, you can include them here.
4. Work Experience. Include the dates of employment along with your job title and the name of the company you worked
for. The most common way to present this information is chronologically, although some situations call for the use of
the functional style where achievements are listed first. Sometimes, a combination of the two styles are used.
5. Additional Information. Any foreign languages; any specialized skills.
6. Other Considerations
Limit the use of personal pronouns such as "I. Begin sentences with action verbs (CHOICE B). Be honest but avoid
writing anything negative in your resume.
Well-Written. No spelling or grammatical mistakes; clear and concise. Have someone proofread your resume
(CHOICE B). Use a simple, easy to read font style, 10-14 point. Use high quality paper.
Proper Length. 1 2 pages. 1 page for entry level candidates and those with 5 years of experience or less. 2 page
resumes - over ten years of experience.
Attractive. Typed and professional in appearance.
Relevant. Include only information having to do with the job you are seeking or your career goals.
Personalized
Appropriate. Information and format must conform to the employer expectations.
Balanced. Include only data that will help you get an interview. Eliminate any information that may not act in your
favor such as age, religious affiliation, etc. Always ask your-self the question, Will this bit of data help get an
interview? If not, do not use it. (CHOICE D)
Reference: https://www.tcc.edu/students/career/resumes/pic_of_you.htm
http://www.washington.edu/doit/Careers/resume_key.html

2. Resume is a document that outlines an applicants skills and experiences at a glance. A resume sells YOU! It
is often the first contact you have with employers. Your resume tells an employer: Who you are; What you
know; What you have done. In developing her resume, Nurse Margo is aware that the cover letter is a formal
accompaniment to the resume, intended to introduce a job candidate. She knows that resume and cover letter are
marketing tools to get the attention of her desired audience. With this in mind, she reads about effective cover letter
writing. She wants to whet her readers appetite, get them interested enough to move on to her resume, and then want
to interview her. She should be guided by all but one of the following information, except.
a. Every cover letter needs to address two areas: why you are writing and what you have to offer.
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b. The body of the cover letter contains only the information on what position you are applying for only.
c. The first paragraph of the letter should include information on why you are writing. In writing a cover letter
you are not interpreting your resume.
d. The final paragraph is a conclusion of your cover letter by thanking the employer for considering you for the
position.

ANSWER: D
RATIONALE:
OPTION A Every cover letter needs to address three areas: why you are writing, what you have to offer, and what happens
next.
OPTION B The body of the cover letter lets the employer know what position you are applying for, why the employer should
select you for an interview, and how will you follow up.
OPTION C The first paragraph of your letter should include information on why you are writing. Mention the position you are
applying for and where you found the job listing. Include the name of a mutual contact, if you have one. Middle Paragraph(s)
should describe what you have to offer the employer. Mention specifically how your qualifications match the job you are applying
for. Remember, you are interpreting your resume, not repeating it.
OPTION D In final paragraph conclude your cover letter by thanking the employer for considering you for the position. Include
information on how you will follow-up.
Reference: http://jobsearch.about.com/od/coverletters/a/aa030401a.htm

3. Leadership is not necessarily tied to a position of authority and that each of us has the potential. Leadership
involves influencing other people to work toward the achievement of the groups goals. Nurse Steve Gru is
newly appointed as the head nurse of their unit. He must be guided by all but one of the following key characteristics of
formal and informal leadership, except.
a. The formal leader cannot act as informal leader at the same time.
b. In formal leadership, decision-making responsibility, influence and authority come with position.
c. Formal leaders cannot benefit from informal leaders ability to challenge the status quo.
d. Informal leadership requires group courage and group risk taking.

ANSWER: B
RATIONALE:
OPTION A - The formal and the informal leader in any group or team may be the same person.
OPTION B - In formal leadership, decision-making responsibility, influence and authority come with position. Informal leaders
create influence and informal authority without the benefit of formal titles.
OPTION C Formal leaders can benefit from informal leaders ability to challenge the status quo.
OPTION D - Informal leadership requires personal courage and risk taking

DIFFERENCE BETWEEN FORMAL AND INFORMAL LEADERSHIP
FORMAL LEADERS INFORMAL LEADERS
Appointed or elected Not appointed or elected

Accountable to those who have formally
elected them for their job.

Authority to direct and control the activities of
subordinates.

Not given any formal authority

Can issue orders and instructions.

Cannot issue orders and instructions, but members voluntarily submit to his
guidance and agree to be influenced by him.

Institutional

Personal
Reference: De Carolis, Gary. Leadership Without Easy Answers, pp. 4, 6.
Griffin, Ricky W. Fundamentals of Management, p.406
Talloo, Thelma J., Business Organization and Management, 2008, p.129

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4. Nurse staffing plans for each unit define the number and mix of nursing personnel in accordance with current
patient care needs. Objectives of nurse staffing are excellent care and high productivity. Nurse Manager Lucy
Weg is faced with making staffing decision to increase productivity. She reviewed the JCAHO standards related to
nurse staffing and finds all but one of the following as not precise benefits of efficient staffing, aside from.
a. It helps in discovering and obtaining competent employees for various jobs.
b. It helps to diminish the quantity and quality of the output by putting the right man on the right job.
c. It reduces the cost of personnel by avoiding wastage of human resources.
d. It improves the job satisfaction of employees.
ANSWER: B
RATIONALE:
EFFICIENT STAFFING PROVIDES THE FOLLOWING BENEFITS:
1. It helps in discovering and obtaining competent employees for various jobs.
2. It helps to IMPROVE the quantity and quality of the output by putting the right man on the right job.
3. It reduces the cost of personnel by avoiding wastage of human resources.
4. It improves the job satisfaction and morale of employees through objective assessment and fair rewarding of their
contributions.
5. It facilitates the growth and diversification of business with the help of talent of employees.
Reference: Murugan, M. Sakthivel, Management Principles and Practices, 2004, p.222.

5. Human resources are the most important asset of an organization. The ability of an organization to achieve its
goals depends upon the quality of its human resources. Hence, staffing is very important managerial function.
Nurse Manager Lucy Weg realizes that no organization can be successful unless it can fill and keep filled the various
positions provided for in the structure with the right kind of people. All but one of the following interrelated activities is
the incorrect arrangement of staffing process:
a. Human resource planning (or) manpower planning, orientation, recruitment, selection, placement, training and
development, remuneration and compensation, promotion, transfer, and performance evaluation.
b. Human resource planning (or) manpower planning, recruitment, selection, placement, orientation, training and
development, remuneration and compensation, performance evaluation, promotion, and transfer.
c. Recruitment, selection, placement, orientation, training and development, remuneration and compensation,
performance evaluation, and human resource planning (or) manpower planning, promotion and transfer.
d. Recruitment, selection, placement, orientation, training and development, remuneration and compensation,
human resource planning (or) manpower planning, and performance evaluation, promotion, and transfer.

ANSWER: B
RATIONALE:
STAFFING PROCESS:
i. Human resource planning (or) manpower planning: involves forecasting and determining the number and kind
of manpower required by the organization in the future.
ii. Recruitment: to identify the sources of required personnel and include them to ply for jobs in the organization.
iii. Selection: process of choosing, selecting and appointing the right candidates for various job positions in the
organization.
iv. Placement: putting the selected candidates on right jobs.
v. Orientation: process of familiarizing newly appointed candidates with their jobs, work groups and the
organization.
vi. Training and development: process of imparting enhanced knowledge on various personnel in the business;
improving job and work knowledge, skills, and attitudes of employees in the form of payment of wages and
salaries and other monetary benefits provided for employees in the organization.
vi.vii. Remuneration and compensation: it is the compensation paid to employees in the form of payment of wages
and salaries and other monetary benefits provided for employees in the organization.
vii.viii. Performance evaluation: is the appraisal and evaluation of various categories of employees in terms of their
behavior and their performance in the work spot.
viii.ix. Promotion: process of moving employees to positions of higher responsibility on the basis of merit or seniority
depends upon the nature of work and situation.
ix.x. Transfer: moving of employees to similar positions in other work units.
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Reference: Murugan, M. Sakthivel, Management Principles and Practices, 2004, pp.223-224

6. Patient Classification System (PCS) is a measurement tool used to articulate the nursing workload for a
specific patient or group of patients over a specific period of time. The measure of nursing workload that is
generated for each patient is called the patient acuity. You are the nurse manager of the medical-surgical unit of
St. Joseph Tertiary Hospital. Mr. Benjie Bratt, one of your patients was admitted due to motor vehicular accident. He is
unconscious; attached to mechanical ventilator, has IV line and BT line, you checked his VS and obtained the following
data: BP= 90/80 mm Hg, PR= 95 bpm, RR= 20 cpm and T= 38 C. Based on the assessment, you conclude that he
needs constant monitoring and categorized under what level of care?
a. Minimal care
b. Moderate care
c. Maximum care
d. Intensive care
ANSWER: D
RATIONALE:
PATIENT CLASSIFICATION SYSTEM:
I. CATEGORY I: Self-Care/Minimal Care
- Patients who are convalescing and who are no longer require intensive, moderate or maximum care.
- Patients who require diagnostics studies, minimal therapy, less frequent observations, and daily care for minor
conditions and who are awaiting elective surgery.
II. CATEGORY II: Moderate Care
- Patients who are moderately ill or are recovering from the immediate effects of a serious illness and/or an
operation.
- Patients require nursing supervision or some assistance related to ambulating and caring for their own hygiene.
III. CATEGORY III: Maximum Care
- Patients who need close attention throughout the shift, that is complete care for patients who require nursing to
initiate, supervise and perform most of their activities or who require frequent and complex medications or
treatments.
IV. CATEGORY IV: Intensive Care
- Acutely ill patients who have a high level of nurse dependency, including those requiring intensive therapy and/or
intensive nursing care and whose unstable condition requires frequent evaluation with adjustment of therapy.
Reference: http://www.scribd.com/doc/40519854/Patient-Classification-System

7. The importance of having a functional knowledge of law in the practice of the nursing profession cannot be
overemphasized. Although the law is becoming complex and a nurse cannot be expected to have a complete
understanding of it, it is significant, however for the nurses to understand legal responsibilities as it applies to
nursing practice. Practice through Special/Temporary Permit may be issued by the Board to the following persons
except:
a. Licensed nurses from foreign countries/states whose services are either for a fee/free if they are intentionally well-
known specialists or outstanding experts in any branch or specialty of nursing.
b. Nurses registered in the Philippines desiring to practice in said foreign state or country.
c. Licensed nurses from foreign country/state on medical mission whose services shall be free in a particular
hospital, center, or clinic.
d. Licensed nurses from foreign countries/states employed by school/colleges of nursing as exchange professors in
a branch or specialty of nursing.

ANSWER: B
RATIONALE:
This can be a qualification for registration by reciprocity. All the other options are considered in issuing a special/temporary
permit.
Reference: Bellosillo, josue N. et.al., fundamentals of Nursing Law, Jurisprudence and Ethics, 2008, p.428.

8. There is a common set of actions a nurse can take to protect himself against ligation. Although each client
encountered presents unique situations that can place the nurse at legal risk, certain general nursing care
activities decrease this risk. A client had been receiving a drug by injection for a few weeks now. As the clinical
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symptoms of the patient change, the attending physician wrote an order on the clients order sheet shifting the method
of administration from injection to oral. When the nurse on the unit came back to duty after a several days off and was
preparing to give medication by injection, the client objected and referred the nurse to the physicians new orders. The
nurse should:
a. Go back to the order sheet and check the order.
b. Talk with the nurse who had taken care of this particular client while he or she had been off duty.
c. Talk with the head nurse about the advisability of using oral rather than injectable medications.
d. Check the order sheet for the changed order then speak with the attending physician concerning the changed
order.

ANSWER: D
RATIONALE:
Although answer A is correct, answer D is the best answer because the nurse would validate the changed order and learn
the physicians rationale for the change. The court found that the nurse who went ahead and gave the medication was negligent.
The court went on to say that the jury could find the nurse negligent by applying ordinary common sense to establish the
applicable standard of care.
CHOICE B and C: are incorrect because talking with nurses is not the direct way to clarify and validate order.

ACTIONS TO DECREASE THE RICK OF LIABILITY:
1. Communicate with your clients by keeping them informed and listening to what they say.
2. Acknowledge unfortunate incidents and express concerns about these events without taking the blame, blaming
others, or reacting defensively.
3. Chart and time your observations immediately, while facts are still fresh in your mind.
4. Take appropriate actions to meet the clients nursing needs.
5. Follow the facilitys policies and procedures for administering care and reporting incidents.
6. Acknowledge and document the reason for any omission or deviation from agency policy, procedure or standard.
7. Maintain clinical competency and acknowledge your limitations. If you do not know how to do something, ask for help.
8. Promptly report any concern regarding the quality of care, including the lack of resources with which to provide care, to
a nursing administration representative.
9. Time and document changes in conditions requiring notification of the physician and include the response of the
physician.
10. Delegate client care based on the documented skills of licensed and unlicensed personnel.
Reference: Daniels, Rick, Nursing Fundamentals: Caring and Clinical Decision Making, 2004, p.157

9. Nurses are increasingly engaged in disciplined studies that benefit the profession and its patients, and that
contribute to improvements in the entire health care system. Nursing research is systematic inquiry designed
to develop knowledge about issues of importance to the nursing profession, including nursing practice,
education, administration, and informatics. As part of the conceptual phase, the Alpha group formulated a good
research problem. From what source of research problem did the Alpha group use when their curiosity was aroused by
the topic from feminist movements who raised questions about such topics as gender equity and domestic violence?
a. Theories
b. Clinical experiences
c. Social issues
d. Ideas from external sources

ANSWER: C
RATIONALE: Social Issues are topics sometimes suggested by social or political issues of relevance to the health care
community. Theories from nursing and other related disciplines are another source of research problems. External sources and
direct suggestions can sometimes provide the impetus for a research idea. Clinical experience- the nurses everyday experience
is a rich source of ideas for research topics.
Sources of Research Problem:
E-xperiences
L-iterature
I-ssues
T-heories
E-xternal Sources
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10. Research process has five major phases namely; Conceptual, Design and Planning, Empirical, Analytical, and
Dissemination phase. Fabia et.al group is now working collaboratively in the initial phase of the research process.
Which among the following major steps are included in this phase?
1. Determining the purpose of the study
2. Acknowledging the limitations of the study
3. Conducting a pilot study
4. Formulating and delimiting the problem
5. Formulating the hypothesis
6. Developing protocols
7. Specifying the method to measure the research variables
A. 1,2,4 B. 1,2,4,6 C. 1,2,4,5 D. All of the above

ANSWER: C
RATIONALE:
Phase 1: Conceptual Phase
1. Formulating and delimiting the problem
2. Determining the purpose of the study
3. Reviewing the Related Literature
4. Undertaking fieldwork
5. Defining the framework and developing conceptual definitions
6. Acknowledging the limitations of the study
7. Formulating the hypothesis
Phase 2: Design and Planning Phase
1. Selecting a research design
2. Identifying the population to be studied
3. Designing the sampling plan
4. Specifying the method to measure the research variables
5. Developing methods for safeguarding human/animal subjects
6. Finalizing and reviewing the research plan
Phase 3: Empirical Phase
1. Collecting data
2. Preparing the data for analysis
Phase 4: Analytic Phase
1. Analyzing the data
2. Interpreting the results
Phase 5: Dissemination Phase
1. Communicating the findings
2. Utilizing the findings in practice

FUNDA:

11. Nursing health assessment differs in purpose, framework, and end result from all other types of professional
health care assessment. Assessment is the first and most critical step of the nursing process and accuracy of
assessment data affects all other phases of the nursing process. A student in a cardiac unit is performing
auscultation of a clients heart. Nurse Lucy Weg recognizes that the student is performing pulmonic auscultation
correctly when the stethoscope is placed:
a. Between the apex and the sternum
b. At the fifth intercostal space at the left midclavicular line
c. At the second intercostal space, left of the sternum
d. At the manubrium

ANSWER: C
RATIONALE: The pulmonic area is found in the second intercostal space, left of the sternum.
OPTION B is the correct location of the tricuspid area.
OPTIONS A and D: are not assessment locations for heart auscultation.

12. Nurses should be aware of the factors that can affect a clients body temperature so that they can recognize
normal temperature variations and understand the significance of body temperature measurements that
deviate from normal. Student Nurse Miranda is not incorrect if she states which of the following factors affecting body
temperature:
a. Hard work or strenuous exercise can increase body temperature to as high as 38.3 to 40C (101 to 104F)
measured axillary.
b. The point of highest body temperature is usually reached between 12:00 NN and 2:00 PM.
c. The lowest point is reached during sleep between 8:00 PM and midnight.
d. Childrens temperatures continue to be more variable than those of adults until puberty.
ANSWER: D
RATIONALE:
OPTION A: is incorrect. Hard work or strenuous exercise can increase body temperature to as high as 38.3 to 40C (101 to 104F)
measured rectally and not axillary.
OPTION B: is incorrect. The point of highest body temperature is usually reached between 8:00 PM and midnight.
OPTION C: is incorrect. The lowest point is reached during sleep between 4:00 and 6:00 AM.

Factors affecting Body Temperature:
1. Age. The infant is greatly influenced by the temperature of the environment and must be protected from extreme
changes. Childrens temperatures continue to be more variable than those of adults until puberty. Many older people,
particularly those over 70 years old, are at risk of hypothermia for a variety of reasons, such as inadequate diet, loss of
subcutaneous fat, lack of activity, and reduced thermoregulatory efficiency.
2. Diurnal variations (circadian rhythms). Body temperatures normally change throughout the day, varying as much as
1.0C (1.8F) between the early morning and the late afternoon.
3. Exercise. Hard work or strenuous exercise can increase body temperature to as high as 38.3 to 40C (101 to 104F)
measured rectally
4. Hormones. Women usually experience more hormone fluctuations than men. In women, progesterone secretion at
the time of ovulation raises body temperature by about 0.3 to 0.6C above basal temperature.
5. Stress. Stimulation of the sympathetic nervous system can increase the production of epinephrine and
norepinephrine, thereby increasing metabolic activity and heat production.
6. Environment. Extremes in environmental temperatures can affect a persons temperature regulatory systems.
Reference: Kozier, et.al

13. Body temperature reflects the balance between the heat produced and the heat lost from the body, and is
measured in heat units called degrees. There are two kinds of body temperature: core temperature and
surface temperature. The body continually produces heat as a by-product of metabolism. When the amount of
heat produced by the body equals the amount of heat lost, the person is in heat balance. While reviewing a
chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 40 C. There is
no documented intervention. The nurse should:
a. Check the doctors order for an antipyretic.
b. Ask the client whether she has received any medication for her fever.
c. Call the nurse at home to validate whether the medication was given.
d. Retake the temperature.

ANSWER: D
RATIONALE:
OPTION D: The nurse should retake the clients temperature to determine accuracy because no intervention was done.
OPTIONS A, B, and C depend on the clients present temperature reading before they are implemented.

14. Vital signs, which should be looked at in total, are checked to monitor the functions of the body. The signs
reflect changes in function that otherwise might not be observed. Monitoring a client's vital signs should not
be an automatic or routine procedure; it should be a thoughtful, scientific assessment. Vital signs should be
evaluated with reference to clients' present and prior health status, their usual vital signs results (if known),
and accepted normal standards. The nurse is assessing the pulse of a client. The nurse could interpret the finding
correctly basing on the knowledge that:
a. Young persons have higher pulse than older persons.
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b. Males have higher pulse rates than females after puberty.
c. Digitalis has a positive chronotropic effect.
d. In lying position, pulse rate is higher.

ANSWER: A
RATIONALE:
As age increases, the pulse rate decreases. Young people have higher pulse rates.
OPTION B: After puberty, males have slightly lower pulse than females.
OPTION C: Digitalis has a negative chronotropic effect and positive inotropic effect; it increases the force of contraction.
OPTION D: In lying down, pulse rate is lower.

15. The importance of the accuracy of blood pressure assessments cannot be overemphasized. Many judgments
about a client's health are made based on blood pressure. It is an important indicator of the client's condition
and is used extensively as a basis for nursing interventions. Two possible reasons for blood pressure errors
are hurrying on the part of the nurse and subconscious bias in which a nurse may be influenced by the client's
previous blood pressure measurements or diagnosis and "hear" a value consonant with the practitioner's
expectations. Elsa Katie is obtaining the blood pressure of a client who is obese. To obtain a blood pressure reading,
she should use a cuff that is:
a. 2/3 the diameter of the clients upper arm.
b. the diameter of the clients upper arm.
c. 1/3 the diameter of the clients upper arm.
d. the diameter of the clients upper arm.

ANSWER: A
RATIONALE:
The nurse should use a blood pressure cuff that is 2/3 the diameter of the clients upper arm.
OPTION B and C- if the bladder cuff is too narrow, it will cause a false high reading.
OPTION D- if a bladder cuff is too wide; it will cause a false low reading.

If the bladder is too narrow, the blood pressure reading will be erroneously elevated; if it is too wide, the reading will be
erroneously low. The width should be 40% of the circumference, or 20% wider than the diameter of the midpoint, of the limb on
which it is used. The arm circumference, not the age of the client, should always be used to determinebladder size. The nurse
can determine whether the width of a blood pressure cuff is appropriate: Lay the cuff lengthwise at the midpoint of the upper arm,
and hold the outermost side of the bladder edge laterally on the arm. With the other hand, wrap the width of the cuff around the
arm, and ensure that the width is 40% of the arm circumference. The length of the bladder also affects the accuracy of
measurement. The bladder should be sufficiently long to cover at least two-thirds of the limb's circumference.
Reference: Kozier, et.al., Fundamentals of Nursing, 9
th
edition, p.563.

16. Assessment of the skin involves inspection and palpation. The entire skin surface may be assessed at one
time or as each aspect of the body is assessed. Nurse Elsa Katie is caring to a 65 year-old alcoholic client who was
diagnosed with liver cirrhosis. The client manifests severe weakness, jaundice and pitting edema. As part of her
assessment, the nurse measured the pitting edema of her client as 5mm. The nurse is correct that the corresponding
scale when edema is 5mm in measurement is:
A. 1+ B. 2+ C. 3+ D. 4+
ANSWER: C
RATIONALE:
Scale for Describing Edema
1+ Barely detectable
2+ Indentation of 2-4 mm
3+ Indentation of 5-7 mm
4+ Indentation of more than 7 mm

17. The assessment phase of the nursing process has four major steps: Collection of subjective data, Collection
of objective data, Validation of data, and Documentation of data. Although there are four steps, they tend to
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overlap and you may perform two or three steps concurrently. A 78 year-old clients hematocrit and hemoglobin
are 32.1% and 11.5 g/dl respectively. Based on these results, the most appropriate nursing intervention would be to:
a. Conduct a complete nutritional assessment of the client.
b. Advise the client to have the test repeated in three months.
c. Nothing because these are normal values for this age adult.
d. Understand that mild anemia is a normal response to the aging process.

ANSWER: A
RATIONALE:
OPTION A: nutritional assessment starts the investigation for a cause for the clients anemia.
OPTION B: Treatment should be initiated first and then the test should be repeated to determine the clients response to therapy.
OPTION C: These are not normal values; an intervention is indicated.
OPTION D: Anemia is not a normal response to the aging process.

18. To maintain optimum vision, people need to have their eyes examined regularly throughout life. It is
recommended that people under age 40 have their eyes tested every 3 to 5 years, or more frequently if there is
a family history of diabetes, hypertension, blood dyscrasia, or eye disease (e.g.. glaucoma). After age 40, an
eye examination is recommended every 2 years. Mang Eadji, a 78 year old patient, was admitted due to
hypertension. During assessment, you noticed that he has difficulty distinguishing colors. Which color is often
misinterpreted by elderly clients?
a. Orange
b. Violet
c. Red
d. White

ANSWER: B
RATIONALE:
OPTION B: Elderly clients often expresses loss of color vision as they age. The colors are blue, violet, green.
OPTIONS A, C ,and D: these colors are more easily distinguished.
Reference: Kozier,p.596

19. In a lumbar puncture (LP, or spinal tap), cerebrospinal fluid (CSF) is withdrawn through a needle inserted into
the subarachnoid space of the spinal canal between the third and fourth lumbar vertebrae or between the
fourth and fifth lumbar vertebrae. At this level the needle avoids damaging the spinal cord and major nerve
roots. The client is positioned laterally with the head bent toward the chest, the knees flexed onto the
abdomen, and the back at the edge of the bed or examining table. The physician has ordered a lumbar puncture
on a client suspected of having meningitis. Following the procedure, the nurse should:
a. Place the collection vials on ice.
b. Number the collection vials
c. Rotate the collection vials to prevent settling.
d. Carry the second and third vials to the lab after discarding the first vial.

ANSWER: B
RATIONALE:
OPTION B: The nurse should number the vials and take them to the laboratory for examination of protein, glucose, and cell
count.
OPTION A: The vials are not placed on ice
OPTION C: The vials should not be rotated.
OPTION D: incorrect statement.

20. A reflex is an automatic response of the body to a stimulus. It is not voluntarily learned or conscious. The
deep tendon reflex is activated when a tendon is stimulated (tapped) and its associate muscle contracts.
Franz, a graduating nursing student is eliciting the patellar reflex of his client. He asked the client to sit on the edge of
the examining table so that the legs hang freely and he located the patellar tendon directly below the patella.
Afterwards, he delivered a blow with the percussion hammer directly to the tendon. He observed that his client has no
single
response on it. As a knowledgeable nurse, if no response occurs in eliciting patellar reflex because the client is not
relaxed enough, you ask him to:
a. Touch each finger of one hand to the thumb of the same hand as rapidly as possible.
b. To pat both knees with the palms of both hands and then with the backs of the hands alternatively.
c. To interlock the fingers and pull.
d. To simultaneously stimulate two symmetric areas of the body, such as thighs, knees and hands.

ANSWER: C
RATIONALE:
OPTION A: A test for Fine Motor for the Upper Extremities: Fingers to Thumb (Same Hand). Ask the client to touch each
finger of one hand to the thumb of the same hand as rapidly as possible.
OPTION B:. A test for Fine Motor for the Upper Extremities: Alternating Supination and Pronation of Hands on Knees. Ask
the client to To pat both knees with the palms of both hands and then with the backs of the hands alternatively.
Patellar Reflex Assessment. If no response occurs and you suspect the client is not relaxed, ask the client to interlock the
fingers and pull. This action often enhances relaxation so that a more accurate response is obtained.
OPTION D: Tactile Discrimination: Extinction Phenomenon. Simultaneously stimulate two symmetric areas of the body, such
as thighs, knees and hands.

21. Nursing health assessment differs in purpose, framework, and end result from all other types of professional
health care assessment. Assessment is the first and most critical step of the nursing process and accuracy of
assessment data affects all other phases of the nursing process. There are four types of nursing assessment:
initial comprehensive, ongoing or partial, focused or problem-oriented, and emergency. Mang Eadji is 3-day
post laparotomy. He has an indwelling foley catheter. One morning while going over his chart, you noticed that he was
febrile during the last shift, and the physician ordered for culture and sensitivity. When obtaining a urine specimen for
culture and sensitivity from an indwelling catheter, the nurse should.
a. Empty the bag from the drainage port.
b. Wear sterile gloves
c. Cleanse the entry site prior to inserting the needle.
d. Drain the bag and wait for a fresh urine sample to send from the drainage bag.

ANSWER: C
RATIONALE: Disinfecting the insertion site removes or destroys any microorganisms on the surface of the catheter, thereby
avoiding contamination of the needle and the entrance of microorganisms into the catheter.
OPTION D: if the urine is obtained from the drainage bag it is unsterile since the bag contains microorganisms.
OPTION A: the drainage bag port can only be used to obtain a non-sterile specimen; therefore, a nurse cannot obtain a urine
culture and sensitivity from this port.
OPTION B: sterile gloves are unnecessary when obtaining culture and sensitivity; since the nurse does not disrupt the closed
system except with a sterile needle.

22. Pharmacological pain treatment involves administering medication that relieves the patient of pain. There are
four categories of pain medication: nonnarcotic analgesics, nonsterioidal anti-inflammatory drugs (NSAIDs),
narcotic analgesics, and salicylates. Mrs. Agnes, 35 years old, status 1 day post appendectomy, expressed her
concern about surgical incision pain which may hinder her activities. Nalbuphine HCl (Nubain) has been ordered for
postoperative pain. After administering this medication, which side/adverse reactions may the nurse expect to occur?
Select all that apply.
i. Ureteral spasm vi. Constipation
ii. Depression vii. Increased urine output
iii. Dysphoria viii. Dry skin
iv. Hallucination ix. Increased fecal fat and flatulence
v. Pseudomembranous colitis x. malabsorption syndrome

a. iii, vii, viii c. i, ii, iv, vi
b. v, ix, x d. i, ii, iv, ix

ANSWER: C
spacing: single
RATIONALE:
ADVERSE REACTIONS TO NALBUPHINE:
CNS: confusion, depression, dizziness, euphoria, fatigue, hallucinations, headache, nervousness, restlessness,
seizures, syncope, tiredness, weakness.
CV; hypertension, hypotension, tachycardia.
EENT: blurred vision, diplopia, dry mouth
GI: abdominal cramps, anorexia, constipation, nausea, vomiting.
GU: decreased urine output, ureteral spasm
RESP: dyspnea, pulmonary edema, respiratory depression, wheezing
SKIN: diaphoresis, flushing, pruritus, rash, sensation of warmth, urticuria.
OTHER: injection-site burning, pain, redness, swelling and warmth.
OPTION B-they are all adverse effects of neomycin sulfate.

Reference: Jones and Barlett, 2012 Nurses Drug Handbook, 11
th
edition, p.739, 755

23. Pain is sensed when a nerve ending is stimulated sending an impulse along the neural pathway to the brain
that interprets the impulse as pain. Pain is assessed in a patient by asking the patient to describe the intensity
of the pain on a pain scalethe higher the value, the more severe the pain. Besides intensity, pain is assessed
according to onset, duration, frequency, what started the pain (precipitating cause), and what relieves the
pain. An 84 year old client with an end-stage dementia is admitted to the orthopedic unit after undergoing internal
fixation on the right hip. How should the nurse manage the clients postoperative pain?
a. Administer oral opioids as needed.
b. Provide patient-controlled analgesia
c. Administer pain medication through a transdermal patch.
d. Administer analgesic around the clock.

ANSWER: D
RATIONALE:
OPTION D- because assessing pain medication needs a client with end-stage dementia is difficult, analgesics should be
administered around the clock.
OPTION A-clients at this stage of dementia typically cant request oral pain medications when needed.
OPTION B-they are also unable to use patient-controlled analgesia devices.
OPTION C-transdermal patches are used to manage chronic pain; not postoperative pain.

24. Indirect auscultation is the use of a stethoscope, which transmits the sounds to the nurse's ears. A
stethoscope is used primarily to listen to sounds from within the body, such as bowel sounds or valve sounds
of the heart and blood pressure. When assessing the bowel sounds, Nurse Lucy Weg incorrectly uses the
stethoscope when she does which of the following, except.
a. Use the flat disk diaphragm shortly after eating.
b. Use the bell of the stethoscope long after eating.
c. Place diaphragm of the stethoscope in each of the four quadrants of the abdomen over aorta, renal arteries, iliac
arteries, and femoral arteries.
d. Listen for active bowel soundsirregular gurgling noises occurring about every 1 to 2 seconds.

ANSWER: C
RATIONALE:
OPTION A-Shortly after or long after eating, bowel sounds may normally increase. They are loudest when a meal is long
overdue. Four to 7 hours after a meal, bowel sounds may be heard continuously over the ileocecal valve area while the digestive
contents from the small intestine empty through the valve into the large intestine.
OPTION B-bell of the stethoscope is used for relatively low-pitched sounds.
OPTION C- Correct statement. Auscultatory sites: aorta, renal arteries, iliac arteries, and femoral arteries.
OPTION D- Listen for active bowel soundsirregular gurgling noises occurring about every 5 to 20 seconds. The duration of a
single sound may range from less than a second to more than several seconds.

Reference: Kozier, et.al., Fundamentals of Nursing, 9
th
edition, p. 642.

25. Assessing is the systematic and continuous collection, organization, validation, and documentation of data
(information). In effect, assessing is a continuous process carried out during all phases of the nursing
process. The nurse has just received a report from the previous shift. Which of the following clients should the nurse
visit first?
a. A 50-year-old COPD client with a PCO2 of 50
b. A 24-year-old admitted after an MVA complaining of shortness of breath
c. A client with cancer requesting pain medication
d. A 1-day post-operative cholecystectomy with a temperature of 100F

ANSWER: B
RATIONALE:
OPTION B: The nurse should prioritize these clients and decide to see the client with the shortness of breath because this could
be a possible alteration in breathing.
OPTION A: The client in has an abnormal PCO2 (normal 3545), but this would be expected in a client with COPD. OPTION C:
The clients condition can be corrected by pain medication that someone else could administer.
OPTION D is incorrect because a temperature elevation of this level would not be a reason for great concern in a client after
gallbladder surgery.

26. Pulmonary tuberculosis (TB) is a contagious bacterial infection that involves the lungs. It may spread to other
organs. Pulmonary tuberculosis (TB) is caused by the bacteria Mycobacterium tuberculosis (M. tuberculosis).
You can get TB by breathing in air droplets from a cough or sneeze of an infected person. The resulting lung
infection is called primary TB. The following signs and symptoms of pulmonary tuberculosis (PTB) is precise,
except?
a. Cough of two weeks or more, fever, significant weight loss.
b. Fever, red-orange urine, paresthesia
c. Muscle weakness and ulcers that do not heal
d. Sudden and abrupt onset of fever, nosebleeding, joint pain.

ANSWER: A
RATIONALE:
OPTION B-fever is one the signs/symptoms of PTB but red-orange urine and paresthesia are side/adverse effects of drugs for
PTB
OPTION C-signs/symptoms of leprosy
OPTION D- signs/symptoms of dengue.

27. Patient-centered approach to TB control is a fundamental principle of TB control as recommended by the Stop
TB Strategy. Prevention of TB includes interventions to reduce transmission, and to reduce the risk of TB
disease in infected persons. Some of the interventions results in specific activities of TB control programmes:
contact tracing, detection of sources, infection control, preventive therapy, BCG vaccinations, and treatment
of HIV-infected persons with ARV. Student Nurse Fabia and his group is conducting case finding for pulmonary
tuberculosis, which of the following patients are not allowed to have DSSM?
a. A symptomatic patient without x-ray.
b. A symptomatic patient suspected with extra-pulmonary TB
c. A patient with measles.
d. A patient with massive spitting of blood that originated in the lungs and bronchial tubes.

ANSWER: D
RATIONALE:
The only contraindication for sputum collection is massive hemoptysis. All symptoms identified shall be made to undergo smear
examination for diagnosis prior to initiation of treatment, REGARDLESS of whether they have available x-ray results (OPTION
A), whether they are suspected of having EPTB (OPTION B), or whether they have measles (OPTION C).

28. The detection of TB cases requires that affected individuals are aware of their symptoms, have access to
health facilities and are evaluated by health workers (doctors, nurses, medical assistants, clinical officers)
Formatted: Font: 10 pt, Not Italic
who recognize the symptoms of TB. The nurse is administering the purified protein derivative (PPD) test to a
homeless client. Which of the following statement concerning PPD testing is true?
a. A positive reaction indicates that the client has active TB.
b. A positive reaction indicates that the client has been exposed to the disease.
c. A negative reaction always excludes the diagnosis of TB.
d. The PPD can be read within 24 hours after the injection.

ANSWER: B
RATIONALE:
A positive reaction means that the client has been exposed to TB; it isnt conclusive of the presence of active disease. A positive
reaction consists of palpable swelling and induration of 10mm and above for normal
5mm and above for immunocompromised ______________. It can be read 48 to 72 hours after the injection. In clients with
positive reactions, further studies are usually done to rule out active disease. In immunosuppressed client, a negative reaction
doesnt exclude the presence of active disease.

29. Tuberculosis (TB) is considered as the worlds deadliest disease and remains as a major public health
program in the Philippines. All patients undergoing treatment shall be supervised (DOT). No patient shall
initiate treatment unless the patient sand DOTS facility staffs have agreed upon a case holding mechanism for
treatment compliance. Mr. Barrigan was diagnosed with active tuberculosis, category 1. He is now under the DOTS
program. Which of the following side effects of the TB drugs require discontinuation and immediate referral?
a. Orange/red urine
b. Arthralgia due to hyperuricemia
c. Burning sensation in the feet
d. NOTA

ANSWER: D
RATIONALE:
Only major side effects of the drugs require discontinuation and referral.
OPTION A-orange/red urine (due to rifampicin) only needs reassurance to patient that is normal.
OPTION B-arthralgia due to hyperurecemia (due to pyrazinamide) can be corrected by giving aspirin or NSAID.
OPTION C-burning sensation in the feet due to peripheral neuropathy can be treated by giving vitamin B6.

30. Cases of TB in children are reported and identified in two instances: The patient sought consultation, was
screened and was found to have signs and symptoms of TB; and the patient was reported to have been
exposed to an adult TB patient. Aling Agnes asks Student Nurse Jilian, When can my child be suspected of having
TB and be conisered as a TB symptomatic?Devorah gave a correct answer if she said which of the following, except.
i. Cough/wheezing of 2 weeks or more
ii. Unexplained fever of 2 weeks or more
iii. Loss of appetite/loss of weight/failure to gain weight/weight faltering
iv. Failure to respond to 2 weeks of appropriate antibiotic therapy for lower respiratory tract infection.
v. Failure to regain previous state of health 2 weeks after a viral infection or exanthema (measles)
vi. Positive tuberculin test
vii. Abnormal chest radiograph suggestive of TB
viii. Laboratory findings suggestive or indicative of TB.

a. All except iv and v
b. All except iii, iv, viii
c. All except vi, vii, viii
d. AOTA

ANSWER: C
RATIONALE:
TB SYMPTOMATIC IN CHILDREN (any three of the following signs/symptoms:
1. Cough/wheezing of 2 weeks or more
2. Unexplained fever of 2 weeks or more
3. Loss of appetite/loss of weight/failure to gain weight/weight faltering
Formatted: Font: 10 pt, Font color: Red
Formatted: Font: 10 pt, Font color: Auto
4. Failure to respond to 2 weeks of appropriate antibiotic therapy for lower respiratory tract infection.
5. Failure to regain previous state of health 2 weeks after a viral infection or exanthema (measles)

DIAGNOSED OR CONFIRMED OF HAVING TB IN CHILDREN (any three of the following:
1. Positive history of exposure to an adult/adolescent TB case.
2. Presence of signs/symptoms suggestive of TB.
3. Positive tuberculin test.
4. Abnormal chest radiograph suggestive of TB
5. Laboratory findings suggestive or indicative of TB (histological, cytological, biochemical, immunological, and/or
molecular). However, bacteriological demonstration of TB bacilli in the smear/culture makes a diagnosis of TB in
children.

Reference: Public Health Nursing in the Philippines, 2007, 10
th
edition, pp.247-248

31. Statistics refers to a systematic approach of obtaining, organizing and analyzing numerical facts so that
conclusion may be drawn from them. Vital statistics refers to the systematic study of vital events such as
births, illnesses, marriages, divorce, separation and deaths. We say that a Filipino has attained longevity when he
is able to reach the average lifespan of Filipinos. What other statistic may be used to determine attainment of
longevity?
a. Age-specific mortality rate
b. Proportionate mortality rate
c. Swaroops index
d. Case fatality rate

ANSWER: C
RATIONALE:
Swaroops index is the percentage of the deaths aged 50 years or older. Its inverse represents the percentage of
untimely deaths (those who died younger than 50 years).

Swaroops index is a sensitive indicator of the standards of health care. Developed countries have higher Swaroops
index than the less developed countries. For example, a swaroops index of 80% means that only 20% of the population are
dying before the age of 50 years old, good indication of the health/ longevity of the population.

th
edition,
http://dc395.4shared.com/doc/g6kaUWZj/preview.html

32. Epidemiology is the study of the distribution and determinants of health-related states or events (including
disease), and the application of this study to the control of diseases and other health problems. Various
methods can be used to carry out epidemiological investigations: surveillance and descriptive studies can be
used to study distribution; analytical studies are used to study determinants. Mr. Reyantino, the community
health nurse of Bgy. Sinakupan, works collaboratively with his group to conduct an epidemiological study. Their
arrangement of steps is not precise if they do which of the following, except?
i. Relate the characteristics of the group in the community.
ii. Correlate all data obtained.
iii. Establish the presence of epidemic.
iv. Establish time and space relationship of the disease.

a. ii, iii, iv, i
b. ii, i, iii, iv
c. iii, iv, i, ii
d. iv, i, ii, iv

ANSWER: C
RATIONALE:
STEPS IN EPIDEMIOLOGIC INVESTIGATION
1. Establish fact of presence of epidemic.
Formatted: Indent: First line: 0.5", Line
spacing: single
2. Establish time and space of relationship of the disease.
3. Relations to characteristics of the group of community.
4. Correlation of all data obtained.

th
edition,

33. The definition of epidemiology emphasizes that epidemiologist are concerned not only with deaths, illness
and disability, but also with more positive health states and with the means to improve health. Student Nurse
Dana Edith was asked by her Clinical Instructor regarding the uses of epidemiology. She gave an incorrect answer to
the query if she did not answer which of the following.
i. Estimate the risk of disease, accidents, defects, and the chances of avoiding them.
ii. Search for causes of health and disease by comparing the experience of groups that are clearly defined by
their composition, inheritance, experience, behavior and environment.
iii. Complete the clinical picture of acute diseases and describe their natural history.
iv. Identify syndromes by describing the distribution and association of clinical phenomena in the population.
v. Study the history of the health population and the rise and fall of health programs.
vi. Diagnose the health of the community and the condition of people.
vii. Directed towards action on the determinants or cause of health.
viii. To provide a clinic-level data base which can assess for further services.
ix. The Indices of the health and illness status of a community.
x. Serves as basis for planning, implementing, monitoring and evaluating community health nursing programs
and services.

a. All except iii, v, vii, viii, ix, x
b. All except vii, viii, ix, x
c. I, ii, iii, ix, x
d. AOTA

ANSWER: A
RATIONALE:
CHOICE iii Epidemiology is used to complete the clinical picture of CHRONIC disease, not the acute one.
CHOICE V to study the history of the health population and the rise and fall of diseases and changes in their character
CHOICE Vii principle of health promotion
CHOICE ix and x uses of vital statistics

th
edition,

34. The National Epidemic Sentinel Surveillance System (NESSS) is a hospital based information system that
monitors the occurrence of infectious diseases with outbreak potential. It also serves as a supplemental
information system of the DOH. An outbreak of cholera has been reported in one of the barangay in the municipality
of Los Angeles. The Epidemiologic and Surveillance Team decided to investigate an outbreak. One nurse of the team
incorrectly arranged the following steps, except.
i. Developing hypothesis
ii. Evaluate hypothesis
iii. Refine hypothesis and execute additional studies
iv. Verify diagnosis
v. Define and identify cases
vi. Prepare for fieldwork
vii. Perform descriptive epidemiology
viii. Establish the existence of an outbreak
ix. Implement control and preventive measures
x. Communicate findings
xi. Follow-up recommendations

a. I, II, III, IV, V, VI, VII, VIII, IX, X, XI
b. I, II, III, VIII, VI, VII, IV, V, IX, X, XI
c. VI, VIII, IV, V, VII, I, II, III, IX, X, XI
d. VI, IV, VIII, V, VII, I, II, III, IX, X, XI

ANSWER: C
RATIONALE:
STEPS IN OUTBREAK INVESTIGATION:

1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify diagnosis
4. Define and identify cases
5. Perform descriptive epidemiology
6. Developing hypothesis
7. Evaluate hypothesis by
- Comparing with establish facts
- Use analytical epidemiology (case control studies; retrospective control studies)
8. Refine hypothesis and execute additional studies because:
- Unrevealing analytic studies poor hypothesis
- May need more specific exposure histories
- May need more specific control group.
9. Implement control and prevention measures
- Prevent additional cases
- Prevent outbreak in the future
10. Communicate findings
- Writing and disseminating full report
- Meetings and discussions
- Local and mass media
11. Follow-up recommendations

th
edition, pp.72-74

35. Because health providers, health agencies and the public have responsibility on disease prevention and
control, they should be included among those who receive feedback of surveillance information. All of the
following are functions of Nurse Vande in epidemiology except:
a. Laboratory diagnosis
b. Surveillance of disease occurrence
c. Refer cases to hospital if necessary
d. Isolate cases of communicable disease

ANSWER: A
RATIONALE:
SPECIFIC ROLE DURING EPIDEMIOLOGICAL INVESTIGATIONS:
1. Maintains surveillance of the occurrence of notifiable disease (OPTION B).
2. Coordinates with other members of the team during the disease outbreak.
3. Participates in case findings and COLLECTION OF LABORATORY SPECIMEN only (not laboratory diagnosis
OPTION A).
4. Isolates cases of communicable disease (OPTION D).
5. Renders nursing care, teaches, and supervises nursing care.
6. Performs and teach household members method, concurrent and terminal disinfection.
7. Gives health teaching to prevent further spreads of disease to individual and families.
8. Follow up cases and contacts.
9. Organizes, coordinates, and conducts community health education campaign/ meetings.
10. Refer cases when necessary (OPTION C).
11. Coordinates with other concern agencies.
12. Accomplishes and keeps records and reports and submits to proper office/ agency.
th
edition, p. 75.

36. Public health surveillance is an on-going systematic collection, analysis, interpretation and dissemination of
health data. Surveillance system is often considered information loops or cycles involving health care
providers, public health agencies and the public. Given the following data, which among them indicates the state of
health of a community and the success or failure of health work?
a. Crude Birth Rate
b. General Fertility rate
c. Morbidity and mortality rates
d. Swaroops index

ANSWER: C
RATIONALE:
Statistics of disease (morbidity) and death (mortality) indicate the state of health of a community and the success of
failure of health work.

Morbidity data are often helpful in clarifying the reasons for particular trends in mortality. Changes in death rates could
be due to changes in morbidity rates or in case fatality. For example, the recent decline in cardiovascular disease mortality rates
in many developed countries could be due to a fall in either incidence (suggesting improvements in primary prevention) or in
case fatality (suggesting improvements in treatments).

Policy-makers face the challenge of responding to current disease prevention and control priorities, while being
responsible for predicting future priorities. Such decisions should be based on summary measures that quantify the amount of
disease at the population level. These measures need to combine deaths and time spent in ill-health in an internally consistent
way, using a common unit of measurement.

Such summary measures serve as a common currency for reporting the burden of disease in populations. They
provide a way of monitoring and evaluating population health, so that prevention and control actions can be taken rapidly when
necessary.

Morbidity and mortality data are used in the development and planning of public health programs to promote health,
prevent and control disease, and develop treatments.

th
edition, p. 75.
Bonita, Robert, et.al., Basic Epidemiology, 2006, 2
nd
edition, pp. 30, 32-33
Porche, Demetrius James, Public and Community Health Nursing Practice: A population-based approach, 2004, p.3771

37. Statistics refers to a systematic approach of obtaining, organizing and analyzing numerical facts so that
conclusion may be drawn from them. Vital statistics refers to the systematic study of vital events such as
births, illnesses, marriages, divorce, separation and deaths. In a certain barangay, there was a sudden
leptospirosis outbreak. The following data are gathered by the public health nurse:

I. Total number of live births: 70,000
II. Total number of deaths (all causes): 450
III. Total number of deaths (under 28 days of age): 130
IV. Total number of fetal deaths: 95
V. Total number of deaths (from leptospirosis): 18
VI. Total number of cases (of leptospirosis): 105

The nurse wants to determine the index of the killing power of leptospirosis in the barangay. She is correct when she
calculates:

A. 120/100,000 population
B. 18/100 cases
C. 17.14/100 cases
D. 75/1000 deaths
Formatted: Justified, Indent: First line: 0.5"
Formatted: Font: 10 pt, Not Bold
Formatted: Font: 10 pt, Superscript
single

ANSWER: C
RATIONALE:
CASE FATALITY RATIO the index of killing power of a disease.

(

) x 100

- 18/105 x 100 = 17.14/100 cases

SITUATION (38-44): The rural health nurses of Barangay Mexico want to know the health and illness status of the
community for the year 2013. They have gathered the following data to help them in their research.
Total Population: 10, 569
Total Deaths: 986
Total Live Births: 2, 406
Total Maternal Deaths: 65
Total Infant Deaths: 48
Total Fetal Deaths: 19
Total Neonatal Deaths: 19
Total deaths due to Dengue: 12
Total Deaths from CVD: 96
People with pneumonia 78
People exposed with pneumonia 246

38. Statistics on population and the characteristics such as age and sex distribution are obtained from the
National Statistic Office (NSO). Births and deaths are registered in the office of the Local Civil Registrar of the
municipality or city. In cities, births and deaths are registered at the City Health Department. The RHU nurses
are computing for the rate of natural growth or increase of a population. Based on the given data above, they will come
up with:
a. Crude Birth Rate of 12.648 per 100 population
b. Crude Birth Rate of 227.65 per 1,000 population
c. General Fertility Rate of 126.48 per 1,000 population
d. General Fertility Rate of 12.648 per 100 population

ANSWER: B
RATIONALE:
Crude Birth Rate is a measure of one characteristic of the natural growth or increase of a population.
CBR=

CBR=

General Fertility Rate=

Reference: Maglaya, 4
th
ed, p. 176

39. Vital statistics derived from civil registration are the only nationally representative source of information on
mortality by cause of death. The timely recording of deaths by cause can provide early insights into the trends
in disease prevalence, thus helping to design prevention strategies. The RHU nurses proceed to computing for
the crude death rate. They are aware that among which of the given data above would NOT be considered relevant in
computing for the CDR?
a. Total population
b. Total number of deaths
c. Total live births
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d. Midyear population

ANSWER:
RATIONALE:
Crude Death Rate is a measure of one mortality from all causes which may result in a decrease of population.
CDR=

th
ed, p. 176

40. Vital statistics are an essential input for the planning of human development. Knowledge of the size and
characteristics of a countrys population on a timely basis is a prerequisite to socioeconomic planning. One of
the nurses is curious about the increase in the population for the year 2013. She opts to compute for the rate of natural
increase for the year 2013 and comes up with:
a. 33. 76
b. 133. 76
c. 13. 76
d. 1, 376

ANSWER: B
RATIONALE:
Rate of natural increase is the difference between the Crude Birth Rate and Crude Death Rate occurring in a population in a
specified period of time.
Rate of Natural Increase= ( ) ( )
CBR=

CBR=

CDR=

CDR=

Rate of Natural Increase:
th
ed, p. 173

41. Rate shows the relationship between a vital event and those persons exposed to the occurrence of said event,
within a given area and during a specified unit of time. What is the cause specific death rate from cardiovascular
disease of Brgy. Mexico?
a. 90.8/100 population
b. 908/1,000 population
c. 9.08/1,000 population
d. 9.08/100 population

ANSWER: C
RATIONALE:
CSDR = no. of deaths from specific cause registered in a given year/ total population x 1,000
CSDR = 96/10,569 = 0.0090831678 x 1,000 = 9. 08
th
edition, p.77

42. What is the attack rate of pneumonia?
a. 31/ 1000 population
b. 31/ 100 population
c. 32/ 100 population
d. 0. 317/ 100 population

ANSWER: C
RATIONALE:
Attack Rate = No. of persons acquiring a disease/ no. of registered deaths x 100
AR = 78/ 246 = 0.317 or 0.32 x 100 = 31. 7 or 32
th
edition, p.78

43. When the civil registration data on births, deaths and marriages are adequate, they provide a wealth of
information for analyzing the different facets of population dynamics and their correlates. Eadji, one of the RHU
nurses, would like to have an idea about the general health condition of the community. As a member of the team, you
CORRECTLY advise Eadji that a good index of finding that out would be through which of the following vital statistics?
a. 0 percent of pregnancy wastage
b. Infant mortality rate of 19. 95 per 1000 live births
c. Low specific mortality rate
d. Low Proportionate Mortality Rate

ANSWER: B
RATIONALE:
Infant mortality rate measures the risk of dying during the 1
st
year of life. It is a good index of the general health condition of a
community since it reflects the changes in the environment and medical condition of a community.
Option A- refers to fetal death rate.
Option C- describes more accurately the risk of exposure of certain classes or groups to particular disease.
Option D- shows the numerical relationship between deaths from all causes and the total number of deaths from all
causes in all ages taken together.
Reference: Reyala, 2007, p. 76

44. The RHU nurses are aware that one statistical indicator serves as an index of prenatal care and obstetrical
management of the newborn. They do not need further teaching if they compute the risk of dying in the 1
st
month of
life and come up with:
a. Fetal death rate of 78. 97 per 100 live births
b. Fetal death rate of 7. 897 per 1000 live births
c. Neonatal death rate of 78. 97 per 100 live births
d. Neonatal death rate of 7. 897 per 1000 live births

ANSWER: D
RATIONALE:
Neonatal death rate measures the risk of dying in the 1
st
month of life. It serves as an index of prenatal care and obstetrical
management of the newborn.
NDR=
( )

NDR:

Reference: Reyala, 2007, p. 77

45. The public health nurse is responsible for presenting the municipal health statistics using graphs and tables. To
compare the frequency of the leading causes of mortality in the municipality, which graph will you prepare?
a. Line
b. Bar
c. Pie
d. Scatter diagram

ANSWER: B
RATIONALE:
OPTION B: A bar graph is used to present comparison of values, or percentages of a particular observation like causes of illness
and deaths.
OPTION A: shows peaks, valleys, and seasonal trends. Also used to show the trends of birth and death rates over a period of
time.
OPTION C: a pie graph for population composition or distribution.
OPTION D: scatter diagram for correlation of two variables.
th
edition, p.79.

46. Pregnancy is a normal life event that involves considerable physical and psychological adjustments for the
mother. Traditionally, signs and symptoms of pregnancy have been grouped into the following categories:
presumptive, probable, and positive. A nursing instructor asks a nursing student who is preparing to assist with the
assessment of a pregnant client to describe the process of quickening. Which of the following statement if made by the
student indicates an understanding of this term?
a. It is the irregular, painless contractions that occur throughout pregnancy.
b. It is the soft blowing sound that can be heard when the uterus is auscultated.
c. It is the fetal movement that is felt by the client.
d. It is the thinning of the lower uterine segment.

ANSWER: C
RATIONALE:
OPTION C: Quickening is fetal movement and may occur as early as the fourteenth to sixteenth week of gestation; the expectant
mother first notices subtle fetal movements that gradually increase in intensity.
OPTION B: A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and this is known
as uterine souffl. This sound is due to the blood circulation to the placenta and corresponds to the maternal pulse.
OPTION A: Braxton Hicks contractions are irregular painless contractions that may occur throughout pregnancy.
OPTION D: a thinning of the lower uterine segment occurs about the sixth week of pregnancy and is called Hegars sign.

47. Most women who come to a healthcare facility for a diagnosis of pregnancy have already guessed that they
are pregnant based on a multitude of subjective signs. Most have already used a home pregnancy test to
confirm the pregnancy for themselves. Pregnancy is officially diagnosed on the basis of the symptoms
reported by the woman and the signs elicited by a health care provider. Upon assessment of a 22-year old
teacher, you determine that she has been experiencing so much fatigue and increased frequency on urination. Her
pregnancy tested positive, Chadwicks and Hegars signs are present, and ballottement, quickening, and uterine souffl
has also been noted. Which of the following would least indicate that this client is pregnant?
a. Quickening and uterine souffl
b. Hegars sign and Chadwicks sign
c. Fatigue and polyuria
d. Ballottement and positive Pregnancy Test

ANSWER: C
RATIONALE:
The pregnant womans signs and symptoms are grouped into 3. Presumptive which are subjective signs felt by the mother,
probable, which are objective signs felt by the examiner, and positive signs which are true signs of pregnancy. Among the three,
presumptive signs are least indicative of pregnancy.
OPTION C - are presumptive signs, considered at the least indicative of pregnancy because they can easily indicate other
condition.
OPTIONS A- quickening is presumptive while uterine souffl is probable
OPTIONS B, AND D are Probable signs

48. Every system of a womans body changes during pregnancy to accommodate the needs of the growing fetus,
and with startling rapidity. The physical changes of pregnancy can be uncomfortable, although every woman
reacts uniquely. A worried pregnant client comes into the prenatal clinic and tells you her concern about the presence
of darkened area on her face, on her cheeks, and across her nose. You plan to include in your health teaching that this
is known as melasma, and that:
a. Avoiding exposure from the sunlight may keep the pigmentation from getting any darker.
b. She should see her dermatologist immediately. This might lead to cancer if left untreated.
c. This is in irreversible result of hormonal changes due to pregnancy.
d. Applying bleaching cream at least thrice a day will help.

ANSWER: A
RATIONALE:
Formatted: Font: Arial Narrow
Melasma or chloasma is a tan or dark skin discoloration. It is known as the mask of pregnancy. Melasma is thought to be the
stimulation of melanocytes or pigment-producing cells by the female sex hormones estrogen and progesterone to produce
more melanin pigments when the skin is exposed to sun. Advise the woman to stay out of the sun as much as possible and wear
a sunscreen of at least SPF 15 (sunlight can also intensify hyperpigmentation). A hat and long sleeves are a good idea if youre
fair-skinned. Bleaching cream can be applied postpartum but not during pregnancy because it may harm the baby..

49. Assessing fetal growth throughout pregnancy, by such means as fundal height and fetal heart rate, is
important because these predictable signs of fetal development provides guides for determining the well-
being of fetuses. From the following statements, select the one that accurately describe the development of a fetus at
gestational week 36?
a. The fetus is approximately 42 to 48 cm in length.
b. Eyelids begin to fuse.
c. Fetal heart rate begins to beat.
d. The fetal skin is transparent.

ANSWER: A
RATIONALE:
OPTION A: at gestational week 36, the fetus weighs 2, 500 g and is approximately 42 to 48 cm in length. The skin is pink and
body is rounded. Lanugo is disappearing, and the L/S ratio is greater than 2:1.
OPTION B: gestational week 8.
OPTION C: gestational week 5
OPTION D: week 16

50. Teratogenic Maternal Infections can involve either sexually transmitted or systemic infections. These
organisms cross the placenta can be viral, bacterial, or protozoan. Most infections important to a healthy
pregnancy outcome cause relatively mild, flulike symptoms in a woman but can have much more serious
effects on a fetus or newborn. A prenatal clinic nurse is providing instructions to a group of pregnant clients
regarding measures to prevent toxoplasmosis. Which statement if made by one of the client indicates a need for further
teaching?
a. I should cook meat thoroughly.
b. I should drink unpasteurized milk only.
c. I should avoid contact with materials that are possibly contaminated with cat feces.
d. I should avoid touching mucous membranes of my mouth or eyes when while handling raw meat.

ANSWER: B
RATIONALE:
All pregnant clients should be advised to do the following to prevent the development of toxoplasmosis:
1. Clients should be instructed to cook meats thoroughly, particularly pork, beef, and lamb.
2. Avoid touching mucous membranes of the mouth or eyes while handling raw meat.
3. Thoroughly wash all kitchen surfaces that come in contact with uncooked meat.
4. Wash the hands thoroughly after handling raw meat.
5. Avoid uncooked eggs and unpasteurized milk.
6. Wash fruits and vegetables before consumption.
7. Avoid contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sand boxes, or
garden soil.

51. Adolescent in pregnancy is not a new phenomenon. Adolescence is a vulnerable time for pregnancy because
the developmental tasks of pregnancy are superimposed on those of adolescence. The developmental tasks
of the average adolescent are fourfold: to establish a sense of worth or a value of system, to emancipate from
parents, to adjust to a new body image, and to choose a vocation. A nurse in the prenatal clinic taking a nutritional
history from a 16-year old pregnant adolescent. Which of the following statement if made by the adolescent would alert
the nurse to a potential psychosocial problem?
a. I only want to gain 10 lbs because I want to have a small, petite baby.
b. I will continue drinking my afternoon milkshake.
c. I dont like dairy products.
d. Im not used to eating so much food, but I will try.

ANSWER: A
RATIONALE:
OPTION A: Only option that suggests a possible psychosocial problem. Pregnant adolescents are at higher risk for
complications. Peer pressure is an important influence on nutritional status. Adolescents often are concerned about their body
image. If weight is a major focus for adolescent, the adolescent is more likely to restrict calories to avoid weight gain.
OPTIONS B, C, AND D: relates to physiological issues.

52. As early as the 12
th
day of pregnancy, maternal blood begins to collect in the intervillous spaces of the uterine
endometrium surrounding the chorionic villi. By the third week, oxygen and other nutrients such as glucose,
amino acids, fatty acids, minerals, vitamins, and water, osmose from the maternal blood through the cell
layers of the chorionic villi into the villi capillaries. A nursing student is assigned to a client in labor. A nursing
instructor asks the student to describe fetal circulation specifically ductus venosus. The nursing instructor determines
that the student understands fetal circulation if the student states that ductus venosus:
a. Connects the pulmonary artery to the aorta.
b. Is an opening between the right and left atria.
c. Connects the umbilical vein to the inferior vena cava.
d. Connects the umbilical artery to the inferior vena cava.

ANSWER: C
RATIONALE:
OPTION C: the ductus venosus connects the umbilical vein to the inferior vena cava.
OPTION B: foramen ovale
OPTION A: ductus arteriosus.

53. Labor is the series of events by which uterine contractions and abdominal pressure expel a fetus and placenta
from a womans body. Regular contractions cause progressive dilatation and create sufficient muscular force
to allow a baby to be pushed from the birth canal. Assessment of a woman in labor must be done quickly yet
thoroughly. The characteristics of uterine contraction can help determine if the client is experiencing preliminary signs
of labor or if she is already experiencing true labor. Mrs. Lopez inquires about the difference of true from false labor,
and your response is:
a. False contractions are felt first abdominally while true contractions are felt first in the lower back.
b. True contractions sweep to the abdomen and groin while false contractions radiate to the lower back.
c. False contractions are regular and do not achieve cervical dilatation while true contractions begin irregularly but
become regular and they achieve cervical dilatation.
d. True contractions are relieved by ambulation while false contractions continue despite the level of activity.

ANSWER: A
RATIONALE:
Signs of true labor:
Begin irregularly but become regular and predictable.
Felt first in lower back and sweeps around the abdomen in a wave
Continue no matter what the womans level of activity.
Increase in duration, frequency, and intensity.
Achieve cervical dilatation.
Signs of false labor:
Begin and remain irregular
Felt first abdominally and remain confined to the abdomen and groin.
Do not increase in duration, frequency or intensity.
Do not achieve cervical dilatation.
Often disappear with ambulation and sleep.
Reference: Simpson, Kathleen Rice, et.al. Perinatal Nursing, 2008, p.303

54. During the active phase of labor, cervical dilatation occurs more rapidly, increasing from 4 to 7 cm.
Contractions grow stronger, lasting 40 to 60 seconds, and occur approximately every 3 to 5 minutes. This
phase lasts approximately 3 hours in a nullipara and 2 hours in a multipara. A nurse is caring for a client in active
labor. Which of the following nursing interventions would be the best method to prevent fetal heart rate decelerations?
a. Increase the rate of oxytocin (Pitocin) infusion.
b. Encourage an upright or side-lying maternal position.
c. Monitor the fetal heart rate every 30 minutes.
d. Prepare the client for a cesarean delivery.

ANSWER: B
RATIONALE:
Side-lying and upright position such as walking, standing, and squatting can improve venous return and encourage effective
uterine activity.
OPTION A: the nurse should discontinue an oxytocin infusion in the presence of fetal heart rate decelerations, thereby reducing
uterine activity and increasing uteroplacental perfusion.
OPTION C: monitoring fetal heart rate every 30 minutes will not prevent fetal heart rate decelerations.
OPTION D: many nursing actions are available to prevent fetal heart rate decelerations, without necessitating surgical
intervention.

55. Amniotomy is the artificial rupturing of membranes. Rupturing membranes if they do not rupture
spontaneously allows a fetal head to contact the cervix more directly and, although not well proved to do so,
may increase the efficiency of contractions and speed the pace of labor. For this, a womans cervix must be
dilated at least 3 cm. A nurse assists health care provider to perform an amniotomy on a client in labor. What is the
priority nursing action after this procedure?
a. Assess the fetal heart rate.
b. Change the pads under the client.
c. Check the clients temperature.
d. Check the clients respiratory.

ANSWER: A
RATIONALE:
Following amniotomy or when the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate for
at least 1 minute to detect changes associated with prolapsed or compression of the umbilical cord. The quantity, color, and odor
of the amniotic fluid are also noted. The clients temperature should be assessed every 2 to 4 hours, and the nurse also would
check the clients vital signs. The pad under the client should be checked regularly to promote comfort and reduce the moist
environment that favors bacterial growth, but this is not the priority.

56. Attachment and trust are the key developmental issues of infancy and the infant-career dyad is pivotal. The
physical examination of a young infant (less than 5 months of age) is relatively straightforward and can
usually proceed in a cephalocaudal manner. The examination of older infants will require flexibility in the
examination sequence. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his
mothers lap. Which should the nurse do first?
a. Check the Babinski reflex
b. Listen to the heart and lung sounds
c. Palpate the abdomen
d. Check tympanic membranes

ANSWER: B
RATIONALE:
OPTION B: The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If
the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the childs ear first, the child will begin to cry and it will be
difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect

57. Optimum maternal health and positive developmental outcomes for babies depend on practitioners who can
provide consistency in standards of care on the basis of current best evidence, and on those who are
competent and professionally accountable within their role. The nurse is caring for a client admitted to labor and
delivery. The nurse is aware that the infant is in distress if she notes:
a. Contractions every three minutes
b. Absent variability
c. Fetal heart tone accelerations with movement
d. Fetal heart tone 120130bpm

ANSWER: B
RATIONALE:
OPTION B: Absent variability is not normal and could indicate a neurological problem.
OPTIONS A, C, and D are normal findings.

58. During toddlerhood the child begins to seek autonomy, explores the world, learns how things work, begins to
tolerate limitations, express desires, and develops relationships. However, this toddlers excitement and
frustration make this period challenging. Before administering eardrops to a toddler, the nurse should recognize
that it is essential to consider which of the following?
a. The age of the child.
b. The childs weight.
c. The developmental level of the child.
d. The IQ of the child.

ANSWER: A
RATIONALE:
OPTION A: Before instilling the eardrops, the nurse should consider the age of the child because the ear should be pulled down
and back to best deliver the drops in the ear canal.
OPTIONS B, C, and D are not considerations when instilling eardrops in a small child.

59. Toilet training is one of the biggest tasks the toddler must achieve. There are many theories concerning, and
understanding the procedure thus becomes one of the biggest tasks of this period for parents. Most first -time
parents ask when to start, when the training should be completed, and how to go about it. The mother of a 1-
year-old wants to know when she should begin toilet training her child. The nurses response is based on the
knowledge that sufficient sphincter control for toilet training is present by:
a. 1215 months of age
b. 1824 months of age
c. 2630 months of age
d. 3236 months of age
ANSWER: B
RATIONALE:
OPTION B: Children ages 1824 months normally have sufficient sphincter control necessary for toilet training.
OPTION A is incorrect because the child is not developmentally capable of toilet training.
OPTIONS C and D are incorrect choices because toilet training should already be established.

Toilet training is an individualized task for each child. It should begin and completed according to a childs ability to accomplish
it, not according to a set schedule. Before children can begin to be toilet trained, they must have reached three important
developmental levels, one physiologic and the other two cognitive:
1. They must have control of rectal and urethral sphincters.
- Because physiologic development is cephalocaudal, the rectal and urethral sphincters are not mature enough for
control in most children until at least the end of the first year, when tracts of the spinal cord are myelinated to the
anal level. A good way for a parent to know that a childs development has reached this point is to wait until the
child can walk well independently.
2. They must have a cognitive understanding of what it means to hold urine and stools until thay release them at a certain
place and time.
- The markers of readiness are subtle, but as a rule children are ready for toilet training not only when they can
understand what their parents want them to do but also when they begin to be uncomfortable in wet diapers. They
demonstrate this by pulling or tugging at soiled diapers; they may bring a parent a clean diaper after they have
soiled so that they can be changed.
spacing: single
3. They must have a desire to delay immediate gratification for a more socially accepted action.

Reference: Pillitteri, Adele, Maternal and Child Health Nursing, 2003, vol.2, pp. 842-843

60. The developmental milestones of the toddler years are less numerous but no less dramatic than those of the
infant year, because this is a period of slow and steady, not sudden growth. Toddler development is
influenced to some extent by the amount of social contact and the number of opportunities children have to
explore and experience new degrees of independence. Which play activity is best suited to the gross motor skills of
the toddler?
a. Coloring book and crayons
b. Ball
c. Building cubes
d. Swing set

ANSWER: B
RATIONALE:
OPTION B: The toddler has gross motor skills suited to playing with a ball, which can be kicked forward or thrown overhand.
OPTIONS A and C: incorrect because they require fine motor skills.
OPTION D: incorrect because the toddler lacks gross motor skills for play on the swing set.

61. The preschool period traditionally includes ages 3, 4, and 5 years. Although physical growth slows
considerably during this period, personality and cognitive growth are substantial. This is also an important
period of growth for parents. Parents report that their daughter, age 4, resists going to bed at night. After instruction
by the nurse, which statement by the parents indicates effective teaching?
a. Well let her fall asleep in our room, then move her to her own room.
b. Well lock her in her room if she gets up more than once.
c. Well play running games with her before bedtime to tire her out, and then shell fall asleep easily.
d. Well read her a story and let her play quietly in her bed until she falls asleep.

ANSWER: D
RATIONALE:
OPTION D: spending time with the parents and playing quietly are positive bedtime routines that provide security and prepare a
child for sleep. Children in this age group may refuse to go to sleep because of fear of the dark. Night waking from nightmares or
night terrors reaches its peak. So , they may also need a night light.
OPTION A: the child should sleep in her own bed.
OPTION B: locking the door is frightening and may cause insecurity.
OPTION C: active play before bedtime stimulates the child and increases the time needed to settle down for sleep.

Reference: Pillitteri, Adele, Maternal and Child Health Nursing, 2003, vol.2, p. 860.

62. Like the toddler period, the preschool years are not a time of fast growth, so the child is not likely to have a
ravenous appetite. The mother of a 4-year old child tells the nurse that her child is a very poor eater. What is the
nurses best recommendation for helping her increase her childs nutritional intake?
a. Offer small servings of food and allow the child to feed herself.
b. Use specially designed dishes for children for example, a plate with the childs favorite cartoon character.
c. Only serve the childs favorite foods.
d. Allow the child to eat at a small table and chair by herself.

ANSWER: A
RATIONALE:
OPTION A: Offering small servings of food is still a good idea, so the child is not overwhelmed and is allowed the successful
feeling of cleaning a plate and asking for more. Allowing the child to feed herself is important because the child stage of
development is the initiative.
OPTION B: special dishes would enhance the primary recommendation which is option A.
OPTION C: its important to offer new foods and choices, not just serve her favorite foods.
OPTION D: using a small table and chair would also enhance the primary recommendation
Reference: Pillitteri, Adele, Maternal and Child Health Nursing, 2003, vol.2, p.859.

63. Always assess children as individuals to understand the particular developmental needs of each child bases
on what developmental status he or she has achieved, not on what stage you think he or she should have
reached. The school aged period is usually the first time that children begin to make truly independent
judgments. If the school-age child is not given the opportunity to engage in tasks and activities he can carry through to
completion, he is likely to develop feelings of:
a. Guilt
b. Shame
c. Stagnation
d. Inferiority

ANSWER: D
RATIONALE:
OPTION D: According to Erikson, the school-age child needs the opportunity to be involved in tasks that he can complete so that
he can develop a sense of industry. If he is not given these opportunities, he is likely to develop feelings of inferiority.
OPTION A: not associated with the psychosocial development of the school-age child.
OPTION B: Toddler (autonomy vs. shame and doubt)
OPTION C: Middle adulthood (generativity vs. stagnation)
Reference: Pillitteri, Adele, Maternal and Child Health Nursing, 2003, p.785

64. Parents of school-age children often mention behavioral issues or conflicts during yearly health visits. Some
parents feel they are losing contact with their children during these years. This can cause them to misinterpret
a normal change in behavior, especially if they are not prepared for what to expect from their child. A mother
tells the nurse that her daughter has become quite a collector, filling her room with Beanie babies, dolls, and stuffed
animals. The nurse recognizes that the child is developing:
a. Object permanence
b. Post-conventional thinking
c. Concrete operational thinking
d. Pre-operational thinking

ANSWER: C
RATIONALE:
OPTION C: As the school-age child develops concrete operational thinking, he/she learns several new concepts; one of these is
the concept of Class Inclusion.
Class Inclusion is the ability to understand that objects can belong to more than one classification. The school-age
child can categorize items in many ways (e.g., stones and shell can be differentiated by shapes, sizes, and textures).
The ability to classify objects leads to the collecting activities of the school-age period; they become more selective and
discriminating in their collections.
OPTION A: refers to the cognitive development of the infant;
OPTION B: refers to moral, not cognitive, development;
OPTION D: refers to the cognitive development of the toddler and preschool child.
Reference: Pillitteri, Adele, Maternal and Child Health Nursing, 2003, pp.884-885.

65. Adolescents invariably feel a sense of pressure throughout this period. They want to work but are too young
for a full-time job. They are mature in some respects but still young in others. Adolescents develop values
through talking to peers. They also need an attentive adult ear, someone who will listen to their fears, hopes,
dreams, and the pressure they feel to be somebody, the pressure of wanting to do something and yet not
knowing what or how. To establish a good interview relationship with an adolescent, which of the following strategies
is most appropriate?
a. Asking questions unrelated to the situation.
b. Writing down everything the teen says.
c. Asking open-ended questions.
d. Discussing the nurse own thoughts and feelings.

ANSWER: C
RATIONALE:
OPTION C: open-ended questions allow the teen to share information and feelings.
OPTION A: asking personal questions unrelated to the situation jeopardizes the trust that must be established because the
adolescent may feel as though he is being probed with unnecessary questions.
OPTION D: discussing the nurses thoughts and feelings may bias the assessment and is inappropriate when interviewing the
client.

66. Hashimotos disease is an autoimmune thyroiditis characterized by high levels of antimicrosomal antibodies;
most common cause of hypothyroidism in the United States; also known as chronic lymphocytic thyroiditis or
autoimmune thyroiditis. Its common in women older than age. Mrs. Dana Ger, a 53 year old patient, has been
diagnosed with Hashimotos disease, an autoimmune disorder. Mrs. Dana Ger most probably exhibited which signs
and symptoms that lead to the diagnosis of Hashimotos disease?
a. Weight loss, increased appetite, and hyperdefecation
b. Weight loss, increased urination, and increased thirst
c. Weight gain, decreased appetite, and constipation
d. Weight gain, increased urination, and purplish red striae

ANSWER: C
RATIONALE:
Hypothyroidism results from suboptimal levels of thyroid hormone. Thyroid deficiency can affect all body functions and can range
from mild, subclinical forms to myxedema, an advanced form. The most common cause of hypothyroidism in adults is
autoimmune thyroiditis (Hashimotos disease), in which the immune system attacks the thyroid gland.Since the main purpose of
thyroid hormone is to run the bodys metabolism, it is understand that people with this condition will have symptoms associated
with a slow metabolism.
Signs and symptoms:
Early: Nonspecific, extreme fatigues, hair loss, brittle nails, dry skin, numbness and tingling of the fingers, husky voice,
menstrual disturbances (menorrhagia or amenorrhea)
Severe: subnormal temperature and pulse rate, weight gain, decreased appetite, constipation, lethargy, coarse hair,
expressionless and masklike face, cold intolerance, enlarged tongue; elevated cholesterol level, atherosclerosis.
Advanced: personality and cognitive changes characteristic of dementia; inadequate ventilation and sleep apnea; pleural
effusion, pericardial effusion, and respiratory muscle weakness; abnormally sensitive to sedatives, opioids, and anesthetic
agents.
OPTION A hyperthyroidism
OPTION B uncontrolled DM
OPTION D hypercortisolism

Reference: Brunner and Suddarth, Medical Surgical Nursing, p.1227

67. The primary objective in the management of hypothyroidism is to restore a normal metabolic state by
replacing the missing hormone. Synthetic levothyroxine (Synthroid or Levothroid) is the preferred preparation
for treating hypothyroidism and suppressing nontoxic goiters. The dosage for hormone replacement is based
on the patients serum TSH concentration. Mrs. Nasim Pe develops flu-like symptoms and forgets to take her
thyroid replacement medicine. Skipping her medication will put her at risk for which life-threatening complication?
a. Exopthalmos
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema

ANSWER: C
RATIONALE:
Myxedema coma or severe hyperthyroidism, is a life threatening condition that may develop if thyroid replacement medication
isnt taken. Myxedema coma describes the most extreme, severe stage of hypothyroidism, in which the patient is hypothermic
and unconscious.
OPTION A is seen with hyperthyroidism
OPTION B life threatening also, but it is caused by hyperthyroidism
OPTION D or peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isnt life threatening.

68. The term myxedema refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial
tissues. Although myxedema occurs in long-standing hypothyroidism, the term is used appropriately only to
describe the extreme symptoms of severe hypothyroidism. Mrs. Nasim Pe is admitted to the hospital with
myxedema coma. The most critical nursing intervention for the patient at this time is:
a. Administering an oral dose of levothyroxine (Synthroid).
b. Warming the patient with a warm blanket.
c. Measuring and recording intake and output accurately.
d. Maintaining a patent airway.

ANSWER: D
RATIONALE:
OPTION D: because respirations are depressed in myxedema coma, resulting in alveolar hypoventilation, and progressive C02
retention, maintaining a patent airway is the most critical nursing intervention. Ventilator support is usually needed.
OPTION B: although myxedema coma is associated with severe hypothermia, a warming blanket shouldnt be used.
Application of external heat (eg, heating pads) is avoided because it increases oxygen requirements and may lead to vascular
collapse and shock.
OPTION A: thyroid replacement will be administered I.V. until consciousness is restored.
OPTION C: although intake and output is important, it isnt critical at this time.
Reference: Brunner and Suddarth, Medical Surgical Nursing, p.1228.

Situation: Shannon, is a 25 year old factory worker recently diagnosed with Graves disease. She comes back to the
hospital for follow-up check-up.

69. Which of the following data from Shannon confirmed her diagnosis?

i. Decreased serum lipids
ii. Decreased peristalsis
iii. Increased serum lipids
iv. Constipation
v. Emotional instability
vi. Diarrhea
vii. Reduced fertility
viii. Impaired short term memory
ix. Increased peristalsis
x. Enhanced fertility

a. i, vi, viii, ix, and x
b. iii, vi, vii, viii, and ix
c. iii, v, vi, vii, and ix
d. i, v, vi, vii, and ix

ANSWER: D
RATIONALE:
Graves disease is the most prevalent etiology of hyperthyroidism.It is a diffuse hyperfunctioning of the thyroid gland with
autoimmune etiology. Points i, v, vi, vii, and ix are all manifestations of hyperthyroidism while the rest are that of hypothyroidism.

Reference: Black 2009, p. 1022

70. Treatment of hyperthyroidism is directed toward reducing thyroid hyperactivity to relieve symptoms and
remove the cause of important complications. Treatment depends on the cause of the hyperthyroidism and
may require a combination of therapeutic approaches. While assessing her medication history, she tells you that
she is currently taking Propylthiouracil. You know that this medication helps your client by:

a. Counteracting symptoms of tachycardia, tremors and anxiety
b. Trapping thyroid hormones in the thyroid gland
c. Inhibiting synthesis of thyroid hormone
d. Blocking conversion of T4 to T3

ANSWER: D
RATIONALE:
Propylthiouracil blocks thyroid synthesis (conversion of T4 to T3, and since T3 is more potent than T4, this also reduces the
activity of thyroid hormones.
OPTION A is the action of beta blockers
OPTION B is for Strong Solution of Potassium Iodide (SSKI) or Lugols solution.
OPTION C is for methimazole (Tapazole).


71. Surgery to remove thyroid tissue was once the primary method of treating hyperthyroidism; today, surgery is
reserved for special circumstancesfor example, in pregnant women allergic to antithyroid medications,
patients with large goiters, or patients unable to take antithyroid agents. Surgery for treatment of
hyperthyroidism is performed soon after the thyroid function has returned to normal (4 to 6 weeks). Shannon is
on her 4
th
day on the hospital and has undergone Thyroidectomy 2 days ago. Her physician emphasized to you to
watch out and be vigilant in observing for signs of thyroid storm. Which of the following vital signs assessment would
you give the most priority?
a. Blood pressure
b. Respiratory rate
c. Cardiac rate
d. Temperature

ANSWER: D
RATIONALE:
Manifestations of thyroid storm can develop very quickly. These manifestations are caused by sudden increase in metabolic rate.
Hyperthermia is the earliest sign of thyroid storm.
Reference: ULG p. 336

Situation: Mrs. Ava Ares, a 35 year old patient, complains of weight gain, facial hair, absent menstruation, frequent bruising, and
acne. The doctors diagnosis is Cushings syndrome.

72. Cushings syndrome results from excessive, rather than deficient, adrenocortical activity. The syndrome may
result from excessive administration of corticosteroids or ACTH or from hyperplasia of the adrenal cortex. Mrs.
Ava Ares will undergo a transsphenoidal hypophysectomy to remove the pituitary tumor. Preoperatively, the nurse
should assess the patient for potential complications by:
a. Testing for ketones in her urine.
b. Testing her urine for specific gravity
c. Checking her temperature every 4 hours.
d. Performing capillary glucose testing every 4 hours.

ANSWER: D
RATIONALE:
OPTION D: the nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin
resistance, placing the patient at risk for hyperglycemia.
OPTION A: urine ketone testing isnt indicated because she does secrete insulin and therefore isnt at risk for ketosis.
OPTION B: urine specific gravity isnt indicated because, although fluid balance may be compromised, it usually isnt
dangerously imbalanced.
OPTION C: temperature regulation may be affected by excess cortisol; it doesnt accurately indicate infection.

Situation: Mr. Nefario, age 52, was admitted to the hospital with acute adrenal insufficiency. He has a history of Addisons
disease for which he has been taking hydrocortisone. Over the past week, he has had flulike symptoms accompanied by nausea
and vomiting. When he awoke this morning, her wife noticed that he was confused and extremely weak, so she brought him to
the hospital for evaluation.

73. Addisons disease, or adrenocortical insufficiency, results when adrenal cortex function is inadequate to meet
the patients need for cortical hormones. Autoimmune or idiopathic atrophy of the adrenal glands is
responsible for 80% of cases. Other causes include surgical removal of both adrenal glands or infection of the
adrenal glands. Mr. Nefarios blood pressure is 90/58 mmHg, his heart rate is 116 bpm, and his temperature is 101 F
(38.3 C).The nurse should expect to start an IV infusion of:
a. Insulin
b. Hydrocortisone
c. Potassium
d. Hypotonic saline

ANSWER: B
RATIONALE:
OPTION B: emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone, followed
with 5% dextrose in normal saline.
OPTION A: insulin isnt indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia.
OPTION C: Potassium isnt indicated because those patients are usually hyperkalemic.
OPTION D: he needs normal saline, not hypotonic saline.

74. The patient at risk is monitored for signs and symptoms indicative of addisonian crisis. These symptoms are
often the manifestations of shock: hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme
weakness. The patient with addisonian crisis is at risk for circulatory collapse and shock; therefore, physical
and psychological stressors must be avoided. The patient in Addisonian crisis is unable to respond to stress.
Before discharge, the nurse should instruct Mr. Nefario and his family that during stress itll be necessary to:
a. Administer cortisone I.M.
b. Drink 8 oz (237 ml) of fluids.
c. Perform capillary blood glucose monitoring four times daily.
d. Continue to take his usual dose of hydrocortisone.

ANSWER: A
RATIONALE:
OPTION A: patients with addisons disease and their family members should know how to administer I.M. hydrocortisone during
periods of stress.
OPTION B: Its important to keep well hydrated during stress, but the critical component of discharge planning in this situation is
to know how and when to administer hydrocortisone I.M.
OPTION C: Capillary blood glucose monitoring isnt indicated in this situation because the patient does not have diabetes
mellitus and cortisol replacement doesnt cause insulin resistance.
OPTION D: usual dose is not enough during period of stress.

Situation: Steeve Kugan, an unrestrained driver, was admitted to the hospital after a motor vehicle accident. His head hit the
windshield, and hes very sleepy. His serum sodium level is 132 mEq/L, his serum osmolality is 270 mOsm/L, and his urine
specific gravity is 1.007. Hes being observed for Syndrome of Inappropriate Antidiuretic Hormone (SIADH).

75. The syndrome of inappropriate antidiuretic hormone (SIADH) secretion includes excessive growth hormone
(ADH) secretion from the pituitary gland even in the face of subnormal serum osmolality. Which would alert the
nurse that Mr. Steeve Kugans hyponatremia is worsening?
a. Chvosteks sign
b. Vomiting and abdominal cramps.
c. Diaphoresis and tremors.
d. Hyporeflexia and paresthesia.

ANSWER: B
RATIONALE:
OPTION B: vomiting and abdominal cramps indicate that the patients hyponatremia is worsening, and therefore, his SIADH is
worsening. Head trauma is a common cause of SIADH. Other possible causes are pulmonary conditions, meningitis,
subarachnoid hemorrhage, AIDS, delirium tremens, or a variety of conditions.
OPTION A: chvosteks sign, facial muscle contraction when the facial nerve in front of the ear is tapped, indicates hypocalcemia.
OPTION C: diaphoresis and tremors may indicate hypoglycemia.
OPTION D: hyporeflexia and paresthesia are seen in hypokalemia.

76. The primary function of the thyroid hormone is to control the cellular metabolic activity. T4, a relatively weak
hormone, maintains body metabolism in a steady state. T3 is about five times as potent as T4 and has a more
rapid metabolic action. Mr. Steeve Kugan is thirsty and frequently asks the nurse for water. The most appropriate
response would be to:
a. Keep adequate water at his bedside.
b. Give him extra fluids with his medications.
c. Explain that his fluid intake must be restricted to 27 to 34 oz (800 to 1,000 ml)/day.
d. Prepare and I.V. infusion of hypotonic saline.

ANSWER: C
RATIONALE:
Along with meticulous intake and output, fluid restriction is an important nursing intervention in SIADH to prevent further dilutional
hyponatremia. Patients with this disorder cannot excrete dilute urine. They retain fluids and develop a sodium deficiency known
as dilutional hyponatremia Ice chips may be offered for severe thirst. A hypotonic saline solution would cause further fluid
retention. If I.V. fluids are given because of severe hyponatremia, hypertonic (3% to 5%) saline is used.

SITUATION: Kristen Haal, age 40 was admitted to the hospital to have a pituitary tumor removed. After surgery, she developed
diabetes insipidus, a common complication of this surgery.

77. Diabetes insipidus is a disorder of the posterior lobe of the pituitary gland characterized by a deficiency of
antidiuretic hormone (ADH), or vasopressin. It may be secondary to head trauma, brain tumor, or surgical
ablation or irradiation of the pituitary gland. It may also occur with infections of the central nervous system
(meningitis, encephalitis, tuberculosis) or tumors (eg, metastatic disease, lymphoma of the breast or lung).
Another cause of diabetes insipidus is failure of the renal tubules to respond to ADH. The nurse should expect
to administer which drug to treat Mrs. Kristen Haals diabetes insipidus:
a. Furosemide (Lasix)
b. Vasopressin (Pitressin)
c. Regular Insulin (Humulin R)
d. Dextrose 10% in water

ANSWER: B
RATIONALE:
Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect
hormone replacement therapy with synthetic vasopressin. The diuretic furosemide is contraindicated because the patient
experiences polyuria in this disorder. Insulin and dextrose 10% are used to treat diabetes mellitus and its complication not
diabetes insipidus.

78. Without the action of ADH on the distal nephron of the kidney, an enormous daily output of very dilute, water-
like urine with a specific gravity of 1.001 to 1.005 occurs. The urine contains no abnormal substances such as
glucose and albumin. Because of the intense thirst, the patient tends to drink 2 to 20 liters of fluid daily and
craves cold water. Which outcome indicates that treatment for Mrs. Kristen Haals diabetes insipidus has been
effective?
a. Fluid intake of less than 2,500 ml in 24 hours.
b. Urine output of more than 200 ml/hour.
c. Blood pressure of 90/70 mm Hg.
d. Pulse rate of 116 bpm.

ANSWER: A
RATIONALE:
Diabetes insipidus is characterized by polyuria (up to 8 L/day), constant thirst, and an usually high intake of fluids. Treatment with
the appropriate drug should decrease urine output and oral fluid intake. A urine output of 200 ml/hour indicates continuing
polyuria. A blood pressure of 90/70 mm Hg and a pulse rate of 116 bpm are signs for compensation for continued fluid deficit,
suggesting that treatment hasnt been effective.

79. The objectives of therapy are (1) to replace ADH (which is usually a long-term therapeutic program), (2) to
ensure adequate fluid replacement, and (3) to identify and correct the underlying intracranial pathology.
Nephrogenic causes require different management approaches. A nursing diagnosis of Risk for fluid volume
excess related to aggressive fluid resuscitation is appropriate for Mrs. Kristen Haals because she requires water
replacement. When the nurse evaluates her response to water replacement, which signs and symptoms would indicate
water intoxication?
a. Confusion and seizures
b. Sunken eyeballs and spasticity
c. Flaccidity and thirst.
d. Tetany and increased blood urea nitrogen levels.

ANSWER: A
RATIONALE:
Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will
also occur. Sunken eyeballs thirst, and increased blood urea nitrogen levels indicates fluid volume deficit. Spasticity, flaccidity
and tetany are unrelated to water intoxication.

SITUATION: Mr. Ken Jong has had history of renal insufficiency. Hes renal function has worsened and hes admitted to the
hospital for treatment of chronic renal failure.

80. Renal failure results when the kidneys cannot remove the bodys metabolic wastes or perform their regulatory
functions. The substances normally eliminated in the urine accumulate in the body fluids as a result of
impaired renal excretion, leading to a disruption in endocrine and metabolic functions as well as fluid,
electrolyte, and acidbase disturbances. In chronic renal failure, symptoms may not become apparent until later
stages of the disease because:
a. Liver hormones mask the symptoms.
b. The kidneys have great functional reserve.
c. Other body systems take over some of the kidneys functions.
d. The adrenal glands compensate for the kidneys decreased function.

ANSWER: B
RATIONALE:
OPTION B: because of the great functional reserve of the kidneys, chronic renal failure develops more slowly than acute renal
failure and signs and symptoms dont appear until later stages of the disease.
OPTION A: liver hormones dont mask symptoms of renal failure.
OPTIONS C AND D: other body systems dont compensate for the kidneys decreased function.

81. Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the bodys
ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (retention
of urea and other nitrogenous wastes in the blood). Mr. Ken Jongs serum calcium level is low. Low serum calcium
levels in renal failure may be caused by:
a. Decreased amounts of parathyroid hormone.
b. Decreased activation of vitamin D
c. Demineralization of bone
d. Decreased levels of phosphorus.

ANSWER: B
RATIONALE:
OPTION B: decreased activation of vitamin D reduces GI absorption of calcium.
OPTION C: although demineralization of bone can occur with renal failure, the condition is due to repeated episodes of
hypocalcemia.
OPTION D: patient with renal failure have elevated phosphate levels with correspondingly low calcium levels.

82. Cardiovascular disease is the predominant cause of death in patients with ESRD. In chronic hemodialysis
patients, approximately 45% of overall mortality is attributable to cardiac disease, and about 20% of these
cardiac deaths are due to acute myocardial infarction (USRDS, 2001). Mr. Ken Jong is ready for discharge. The
nurse should reinforce which dietary instruction?
a. Be sure to eat meat at every meal.
b. Monitor your fruit intake and eat plenty of bananas.
c. Restrict your salt intake.
d. Drink plenty of fluids.

ANSWER: C
RATIONALE:
In a patient with chronic renal failure, unrestricted intake of sodium, protein, potassium and fluid may lead to a dangerous
accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the patient must limit
his intake of sodium, meat (high in protein), bananas (high in potassium), and fluids (because the kidneys cant secrete adequate
urine).

SITUATION: Benjamin Brand, a 40-year old homemaker, is admitted with signs and symptoms of urinary tract infection.

83. Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both
kidneys. Upper UTIs are associated with the antibody coating of the bacteria in the urine. (This occurs in
the renal medulla; when the bacteria are excreted in the urine, the immunofluorescent test can detect the
antibody coating.) Benjamin Brands doctors diagnosis is acute pyelonephritis. Which clinical manifestations
should the nurse expect?
a. Lower abdominal pain, dysuria and urinary frequency.
b. Pyuria, hematuria, and groin pain
c. Flank pain, urinary frequency, and an elevated white blood cell count.
d. Urinary frequency and cast in the urine.

ANSWER: C
RATIONALE:
OPTION A: are associated with cystitis.
OPTIONS B AND D: pyuria, hematuria, and casts in the urine are common with glomerulonephritis.

84. Patients with acute uncomplicated pyelonephritis are usually treated as outpatients if they are not
dehydrated, not experiencing nausea or vomiting, and not showing signs or symptoms of sepsis. In
addition, they must be responsible and reliable to ensure that all medications are taken as prescribed. The
doctor orders co-trimoxazole (Bactrim) and phenazopyridine hydrochloride (Pyridium) for Benjamin Brand. All but
one of the following are the therapeutic effects of these combination of drugs, except:
a. Pain relief and decreased WBC count.
b. Equal fluid intake an output.
c. Polyuria with a reddish stain
d. Increased complaints of bladder spasm after 20 minutes.

ANSWER: A
RATIONALE:
OPTION A: This combinations therapeutic effect includes pain relief and a decreased WBC count; phenazopyridine is an
analgesic, and co-trimoxazole is an antibiotic.
NOTE: For outpatients, a 2-week course of antibiotics is recommended because renal parenchymal disease is more difficult to
eradicate than mucosal bladder infections. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6
weeks if evidence of a relapse is seen. A follow-up urine culture is done 2 weeks after completion of antibiotic therapy to
document clearing of the infection.
OPTION B: The drugs dont affect fluid intake and output; however, because co-trimoxazole is a sulfa preparation, the patients
fluid intake should be increased to prevent crystallization in the urine.
OPTION C: Phenazopyridine causes a reddish stain in the urine, but this effect has no therapeutic value.
OPTION D: The patients complains of bladder spasm should decrease, not increase, after administration of phenazopyridine.

85. When renal function is so severely impaired that pharmacologic agents cannot act efficiently, other
modalities are considered to remove sodium and fluid from the body. Hemodialysis or peritoneal dialysis
may be used to remove nitrogenous wastes and control potassium and acidbase balance, and to remove
sodium and fluid. Because of difficulties with hemodialysis, Benjamin Brand is admitted to the hospital for
insertion of a Tenckhoff catheter and continuous ambulatory peritoneal dialysis. All but one of the following
nursing diagnoses is considered as the most important while he undergoes continuous ambulatory peritoneal
dialysis, except:
a. Altered urinary elimination
b. Activity intolerance
c. Toileting self-care deficit
d. Risk for infection.

ANSWER: D
RATIONALE:
OPTION D: Because the peritoneal dialysis catheter and regular exchanges of the dialysis bag give bacteria a direct portal of
entry into the body, the patient is at risk for infection. If the patient develops peritoneal infections, continuous ambulatory
peritoneal dialysis may no longer be effective in clearing the bodys waste products.
OPTIONS A, B, AND C: may be pertinent but dont take precedence over option D.

86. Psychiatric nursing is an interpersonal process that promotes and maintains patient behavior that contributes
to integrated functioning. The patient may be an individual, family, group, organization, or community. In
psychiatric nursing, which is considered as the most important tool the nurse brings to a helping relationship?
a. Oneself and a desire to help
b. Advanced communication skills
c. Knowledge of psychopathology
d. Years of experience in milieu management

ANSWER: A
RATIONALE:
OPTION A: the nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic
communication; this is the unique aspect of the helping relationship.
OPTIONS B, C, AND D: this supports the psychotherapeutic management model, but it is not the most important tool used by
the nurse in a therapeutic relationship.

87. The contemporary practice of psychiatric nursing occurs within a social and environmental context. Thus, the
nurse-patient relationship has evolved into a nurse-patient partnership that expands the dimensions of the
professional psychiatric nursing role. An erroneous statement of important goals in the development of a
therapeutic in-patient milieu is all but one of the following:
a. Providing a businesslike atmosphere where clients can work on individual goals.
b. Providing a group forum in which clients decide on unit rules, regulations, and policies.
c. Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own
actions.
d. Discouraging expressions of anger because they can be disruptive to other clients.

ANSWER: C
RATIONALE:
A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior.
The concept of milieu therapy, originally developed by Sullivan, involved clients interactions with one another; i.e., practicing
interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-
to-day problems
BASIC LEVEL OF FUNCTIONS IN MILIEU THERAPY: Maintain therapeutic environment
Teach skills
Encourage communication between clients and others
Promote growth through role-modeling
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing, pp.20, 63

88. Milieu therapy was one of the primary modes of treatment in the acute hospital setting. Management of the
milieu or environment is still a primary role for the nurse in terms of providing safety and protection for all
clients and promoting social interaction. When planning the therapeutic milieu, all but one of the following is the
most important factor in selecting group activities except:
a. Match them to the clients preferences.
b. Consistency with clients skills
c. Achieving clients therapeutic goals
d. Build the skills of group participation

ANSWER: C
RATIONALE:
Option C is the most important factor in selecting group activities. Activity groups are used to enhance therapeutic milieu and to
enhance the psychological and emotional well-being of psychiatric patients, e.g., to minimize withdrawal and regression, to
develop self-care skills, expression of positive and negative feelings and the greater acceptance of oneself, etc.
Reference: Stuart, Gail W. and Michele T. Laraia, Principles and Practice of Psychiatric Nursing, 8
th
edition, p.679

89. As intimacy increases, the need for distance decreases. Knapp (1980) identified five types of touch:
Functional-professional touch, Functional-professional touch, Friendship-warmth touch, Love-intimacy touch,
Sexual-arousal touch. Touching a client can be comforting and supportive when it is welcome and permitted.
The nurse should observe the client for cues that show if touch is desired or indicated. Handshaking is the
preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch
practice is that:
a. Some clients misconstrue hugs as an invitation to sexual advances.
b. Handshaking keeps the gesture on a professional level.
c. Refusal to touch a client denotes lack of concern.
d. Inappropriate touch often results in charges of assault and battery.

ANSWER: A
RATIONALE:
Although touch can be comforting and therapeutic, it is an invasion of intimate and personal space. Some clients with mental
illness have difficulty understanding the concept of personal boundaries or knowing when touch is or is not appropriate.
Consequently most psychiatric inpatient, outpatient, and ambulatory care units have policies against clients touching one another
or staff. Unless they need to get close to a client to perform some nursing care, staff members should serve as role models and
refrain from invading clients personal and intimate space. When a staff member is going to touch a client while performing
nursing care, he or she must verbally prepare the client before starting the procedure. A client with paranoia may interpret being
touched as a threat and may attempt to protect himself or herself by striking the staff person. Some clients may confuse physical
care with intimacy and sexual interest, which can erode the therapeutic relationship.
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing, pp.111, 121.

90. The nurse must provide structure in the therapeutic relationship, identify acceptable and expected behaviors,
and be consistent in those expectations. The nurse must minimize attempts by these clients to manipulate and
to control the relationship. The N\nurse could evaluate that the staffs approach to setting limits for a tough, irritated
client was not ineffective if the client:
a. Apologizes for disrupting the units routine when something is needed.
b. Able to understand the reason why frequent calls to the staff were made.
c. Discuss concerns regarding the emotional condition that required hospitalizations.
d. Does not ask nursing staff for assistance.

ANSWER: C
RATIONALE:
This would document that the client feels comfortable enough to discuss the problems that have motivated the behavior. It is
essential that the nurse not view limits as a way of controlling the patient. Rather limit setting must occur in the context of the
patient and nurse working together toward the process of change.
Limit-setting is an effective technique that involves three steps:
1. Stating the behavioral limit (describing the unacceptable behavior)
2. Identifying the consequences if the limit is exceeded
3. Identifying the expected or desired behavior
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing, p.392.

91. Peplau developed the concept of the therapeutic nursepatient relationship, which includes four phases:
orientation, identification, exploitation, and resolution. During these phases, the client accomplishes certain
tasks and the relationship changes that help the healing process (Peplau, 1952). For most nurses, the most
crucial part of the nurse client relationship is:
a. Remaining therapeutic and professional at all times.
b. Being able to understand and accept the clients behavior.
c. Developing an awareness of self and the professional role in the relationship.
d. Accepting responsibility in identifying and evaluating the real needs of the client.

ANSWER: C
RATIONALE:
OPTION C: the nurses major tool in psychiatric nursing is the therapeutic use of self. Psychiatric nurses must learn to be aware
of their own feelings and how they affect the situation.
NOTE: Before he or she can begin to understand clients, the nurse must first know himself or herself. Selfawareness is the
process of developing an understanding of ones own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices,
strengths, and limitations and how these qualities affect others. Self-awareness allows the nurse to observe, pay attention to,
and understand the subtle responses and reactions of clients when interacting with them.
OPTIONS A AND B: this may be true, but awareness of self still seems the most difficult.
OPTION D: this implies that the nurse is working alone in planning care for the client.

92. The ability to establish therapeutic relationships with clients is one of the most important skills a nurse can
develop. Although important in all nursing specialties, the therapeutic relationship is especially crucial to the
success of interventions with clients requiring psychiatric care, because the therapeutic relationship and the
communication within it serve as the underpinning for treatment and success. The nurse is aware that in the
working phase of the nurse-client relationship, clients will not most likely do all but one of the following:
a. Often focus the conversation on the nurse.
b. Accepts limits and initiate topics for discussion.
c. Commonly exhibits testing behaviors such as flirtation and lateness.
d. May repress emotionally charged material to avoid shocking the nurse.

ANSWER: B
RATIONALE:
OPTION B: this is a correct description of the working phase of the relationship; trust has been established and a relationship
has been developed based on mutual respect.
Note: The working phase of the nurseclient relationship is usually divided into two subphases. During
problem identification, the client identifies the issues or concerns causing problems. During exploitation,
the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self-image;
this encourages behavior change and develops independence. The trust established between nurse and client at this point
allows them to examine the problems and to work on them within the security of the relationship.
The client must believe that the nurse will not turn away or be upset when the client reveals experiences, issues, behaviors, and
problems.

OPTIONS A, C, AND D: this would occur during the orientation phase before trust is established.

93. The termination phase, also known as the resolution phase, is the final stage in the nurseclient relationship.
It begins when the problems are resolved, and it ends when the relationship is ended. Its inappropriate for the
nurse to initially discuss terminating the nurse-client relationship with the client during all but one of the following
phases?
a. Working phase when the client brings it up.
b. Orientation phase when a contract is established.
c. Working phase when the client shows some progress.
d. Termination phase when discharge plans are being made.

ANSWER: B
RATIONALE:
OPTION B: when the nurse and the client agree to work together, a contract should be established; the length of the relationship
should be discussed in terms of its ultimate termination.
OPTION A: the client may discuss termination during the working phase; however, the subject should initially be discussed
during the orientation phase.
OPTIONS C AND D: termination and discharge plans may be discussed more thoroughly during this phase, but the subject
should initially be discussed during the orientation phase.

94. Anxiety disorders comprise a group of conditions that share a key feature of excessive anxiety with ensuing
behavioral, emotional, cognitive and physiologic responses. Mr. Steve Car is for an open heart surgery. During
the preoperative health teachings about deep breathing and coughing, the nurse notices that the patient is agitated and
nervous about the upcoming surgery. The patients attention seems to wander off as the nurse is talking. When the
nurse calls the attention of the patient, he looks toward the nurse and answers. The nurse is correct when she
documents Mr. Cars level of anxiety as:
a. severe
b. mild
c. panic
d. moderate

ANSWER: D
RATIONALE:
OPTION D: In moderate anxiety, there is the disturbing feeling that something is definitely wrong. The patient becomes nervous
and agitated. The patient becomes selectively and has difficulty concentrating independently but can still be redirected to the
topic. Perceptual field is narrowed to immediate task. In this case, the nurse must stop to ensure that the patient is still taking in
the information correctly. If the patient is inattentive, the nurse may need to redirect the patient back to the topic.
OPTION B: Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases
and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself. Mild anxiety often
motivates people to make changes or to engage in goaldirected activity. For example, it helps students to focus on studying for
an examination.
OPTION A: A person with severe anxiety has trouble thinking and reasoning. Muscles tighten and vital signs increase. The
person paces; is restless, irritable, and angry; or uses other similar emotionalpsychomotor means to release tension; defensive
responses ensue, and cognitive skills decrease significantly.
OPTION C: In panic, the emotional-psychomotor realm predominates with accompanying fight, flight, or freeze responses.
Adrenalin surge greatly increases vital signs. Pupils enlarge to let in more light, and the only cognitive process focuses on the
persons defense.
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing, p278.

95. Nurses will encounter anxious clients and families in a wide variety of situations such as prior to surgery and
in emergency departments, intensive care units, offices, and clinics. First and foremost, the nurse must
assess the persons anxiety level because that will determine what interventions are likely to be effective. Mrs.
Kate Fish is for craniotomy. This is to do a biopsy to diagnose a tumor in her brain if it is benign or cancerous. The
nurse notices that she cannot sit still and is in severe anxiety. Which among the following nursing interventions is most
helpful in addressing the patients need?
a. allow the patient to process her anxiety and come back if the patient has calmed down and can understand
directions
b. take the patient for a walk at the hallway while talking to her
c. redirect the patients attention back to the topic
d. ask the patient to verbalize what she is feeling

ANSWER: B
RATIONALE:
If the person cannot sit still anymore because of severe anxierty, walking with him while talking can be effective in lowering the
anxiety to moderate or mild level. During severe anxiety, the patients perceptual field is reduced to one. The patient cannot be
redirected back to the topic because the patient will not respond. The patient with severe anxiety would not be able to verbalize
feelings because he would have trouble thinking and reasoning. Primitive survival skills take over, and cognitive skills
significantly decrease. The nurse at this time should stay with the patient because anxiety is likely to worsen when the patient is
left alone.
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing, p278.

96. Antianxiety drugs are among the most widely prescribed medications today. A wide variety of drugs from
different classifications have been used in the treatment of anxiety and insomnia. Benzodiazepines have
proved to be the most effective in relieving anxiety and are the drugs most frequently prescribed. A newly-
diagnosed patient is prescribed with chlordiazepoxide (Librium) for his anxiety. Which of the following health education
statements should be excluded by the nurse?
a. Move slowly when sitting up or standing.
b. If there are signs of early bruising or bleeding, inform the doctor immediately.
c. This drug is only for short-term use. After the prescribed period, you must immediately discontinue drug use.
d. Avoid taking the medication with alcohol or antihistamines.

ANSWER: C
RATIONALE:
Benzodiazepines can produce drug dependence, and an abrupt discontinuation of the drug could produce a withdrawal
syndrome which is potentially lethal. Discontinuing chlordiazepoxide (Librium) requires gradual tapering of dose. Sedation and
dizziness are side effects of the drug, and orthostatic hypotension could worsen these and predisposes the patient to falls.
Thrombocytopenia is a common adverse reaction which must be immediately reported. Benzodiazepines also potentiate the
sedative effect of alcohol and antihistamines, so they must not be taken at the same time.
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing ; Nursing Spectrum Drug Handbook, 2010

97. Treatment for anxiety disorders usually involves medication and therapy. This combination produces better
results than either one alone (Gorman, 2000). For people with anxiety disorders, it is important to emphasize
that the goal is effective management of stress and anxiety not the total elimination of anxiety. Nurse Lucy Weg
asks the patient a series of questions which are What is the worst thing thath could happen?, Is that likely to
happen?, Could you survive that? and What would you do if that happens?. This technique is called:
a. positive reframing
b. decatastrophizing
c. assertiveness training
d. thought stopping

ANSWER: B
RATIONALE:
OPTION B: Decatastrophizing is strategy used in cognitive therapy whereby clients are helped to realize that their fears are
exaggerated by being asked to consider what would actually happen if their worst fears were realized. It is when the individual
prepares a plan to deal with the "worst-case scenario" so he or she will be less afraid of a bad situation if it occurs.
OPTION A: Positive reframing means turning negative messages into positive messages. The therapist teaches the person to
create positive messages for use during panic episodes. For example, instead of thinking, My heart is pounding. I think Im
going to die! the client thinks, I can stand this. This is just anxiety. It will go away. The client can write down these messages
and keep them readily accessible such as in an address book, calendar, or wallet.
OPTION C: Assertiveness training helps the person take more control over life situations. Techniques help the person negotiate
interpersonal situations and foster self-assurance. They involve using I statements to identify feelings and to communicate
concerns or needs to others. Examples include I feel angry when you turn your back while Im talking, I want to have 5 minutes
of your time for an uninterrupted conversation about something important, and I would like to have about 30 minutes in the
evening to relax without interruption.
OPTION D: Thought-stopping is a technique to alter the process of negative or selfcritical thought patterns such as Im dumb,
Im stupid, I cant do anything right. When the thoughts begin, the client may actually say, Stop! in a loud voice to stop the
negative thoughts. Later, more subtle means such as forming a visual image of a stop sign will be a cue to interrupt the negative
thoughts. The client then learns to replace recurrent, negative thoughts of worthlessness with more positive thinking.
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing, p.278, 401.

98. Serial desensitization is used to treat phobias, which is the opposite of flooding or rapid desensitization. Nurse
Georgia Kuk evaluates a patient with dog phobia who has undergone serial desensitization. Which of the following
client behaviors would indicate that the treatment for the patients phobia was successful?
a. the patient recounts how her fear of dogs began and stating that it is both unreasonable and excessive
b. the patient visits dog cages in the pet shelter for 10 minutes 3 times a week
c. the patient can pet the neighbors dog without undue anxiety
d. the patient states that the fear of dogs is greatly diminished

ANSWER: C
RATIONALE: Success in phobic desensitization is shown when the patient is able to do what the average person can do without
undue anxiety. Clients with phobias routinely believe that their fears are unreasonable even before treatment begins.
OPTIONS B and D are both steps in the overall desensitization process, but they are not the end result.
OPTION C: end result.
Reference: Gauwitz, 2007; Videbeck, Sheila L., Psychiatric Mental Health Nursing, 2008

99. Obsessive-compulsive disorder (OCD) involves recurrent thoughts or impulses that are inappropriate and
causes a significant distress. Repetitive behaviors or mental acts are ritualistically performed to reduce
anxiety. Nurse Dirge is caring for a patient with OCD. During a group discussion, the patient takes off her clothes
and puts them back on over and over. This has caused commotion in the group. Which of the following should be the
priority consideration?
a. the nurse should interrupt the ritual every time it is observed
b. the nurse should ask the patient what the rationale is for performing the ritual
c. a less disruptive ritual should be substituted
d. accompany the patient to her room to finish her ritual

ANSWER: D
RATIONALE: Protecting the patients dignity and privacy should be the priority concern. As her ritual is causing a significant
disruption in the group discussion, she should be removed from the group and escorted to her room so that she can privately
finish her ritual. The ritual should not be interrupted as this could cause the patients anxiety to escalate. Substitution of a less
disruptive ritual would not help relieve anxiety. Questioning the client about her ritual would also not help relieve the anxiety and
would only put the patient in a defensive position.
Reference: Gauwitz, 2007

100. Antianxiety drugs, or anxiolytic drugs, are used to treat anxiety and anxiety disorders, insomnia, OCD,
depression, post-traumatic stress disorder, and alcohol withdrawal. Antianxiety drugs are among the most
widely prescribed medications today. Mrs. Eva Bell is now ready for discharge. Student nurse Mira is assigned to
give discharge instructions about medication. She will not include which of the following as amiss with regards to
Diazepam therapy?
a. Clients need to know that antianxiety agents are aimed at treating the underlying problems that cause the anxiety.
b. One drink of alcohol a day is allowable.
c. Clients should be aware of increased response time, faster reflexes, and possible sedative effects of these drugs
when attempting activities such as driving or going to work.
d. Withdrawal of the drug can be fatal.

ANSWER: D
RATIONALE:
OPTION D: Benzodiazepine withdrawal can be fatal: once the client has started a course of therapy, he or she should never
discontinue benzodiazepines abruptly or without the supervision of the physician.
OPTION A: Clients need to know that antianxiety agents are aimed at relieving symptoms such as anxiety or insomnia but do not
treat the underlying problems that cause the anxiety.
OPTION B: Benzodiazepines strongly potentiate the effects of alcohol: one drink may have the effect of three drinks. Therefore
clients should not drink alcohol while taking benzodiazepines.
OPTION C: Clients should be aware of decreased response time, slower reflexes, and possible sedative effects of these drugs
when attempting activities such as driving or going to work.
Reference: Videbeck, Sheila L., Psychiatric Mental Health Nursing,p.47.

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