NURSING PRACTICE V

Situation 1: Nick, a 35-year-old employee was admitted to the

hospital because of behavioral problems at the ofce !e
started to be bossy, claimin" that he is the mana"er on the
unit #n admission he was dia"nosed to be havin" bipolar
disorder, manic phase
1 Nick$s condition is primarily a problem of
% %&ect
' (hou"ht
) *erception
+ )onscience
, % therapeutic environment for Nick is
% -inimal environmental stimuli
' Strict isolation and withholdin" privile"es
) No limitation on his activities
+ .ell lit and basically colored room
3 +urin" sociali/ation Nick was provoked, became
furious, started shoutin" and makin" personal
demands % therapeutic intervention of the nurse is
% (ake him away from the "roup until he
mana"es to have control of himself
' 0estrain him and put him on isolation to
protect other patients
) *revent him from becomin" more furious by
"ivin" an e1tra *0N dose of sedative
+ 0espond with, 2Nick, we don$t favor anyone
3verybody in the ward is on e4ual foolin"5
6 (herapeutic use self is essential in relatin" with
psychiatric patients (his is best demonstrated by the
nurse in
% Sympathi/in" with the miserable feelin"s of
Nick
' Suppressin" her own feelin"s towards Nick
) 3n"a"in" Nick in productive activity
+ 3n"a"in" Nick is introspective activity
5 (he nurse may recommend in introspective thinkin"
% 3asily 7nishes pro8ects "iven to him durin"
occupational therapy
' (akes his medications without remindin"
him
) +emonstrates skills in activities of daily
livin"
+ )omplies with hospital rules and re"ulations
Situation ,: (he nurse considers factors related to safety
e&ectiveness in the plannin" and delivery of nursin" services
9 (he nurse notices that the comatose client starts to
li"hten She is aware that without protection, the
client could fall or be in8ured .hich of the followin"
is the least intervention:
% 0estrain the client to prevent from fallin"
' ;ive ade4uate support when turnin" or
movin"
) <eep the side rails up in bed
+ *rotect the client$s head
= >ollowin" hip replacement after ,6 hours, the client
asks for assistance onto bedpan She is placed in an
orthopedic bed and to facilitate the use of the
bedpan, how should the nurse assist the client:
% *ull on the trape/e to lift the pelvis
e1tendin" both le"s
' ?iftin" the pelvis o& the bed and turn "ently
toward the operative side
) %ssist the client in liftin" the pelvis
+ 3levate the pelvis usin" the trape/e
involvin" the una&ected e1tremity and
unoperated le"
@ 'ert, an elderly client is to be dischar"ed after
sustainin" a sprain from fall while ne"otiatin" the
last step of the stairs (he dau"hter asks the nurse
how to promote safety in the stairways and hallways
in the home (he nurse recommends e1tra li"htin" at
the stairways and su""ests repaintin" the hallways
with
% 0ed and yellow
' 'lue and "reen
) 'lack and white
+ )ream and white
A 3rna, 3, years old, has a problem with the olfactory
nerve (hey live in a thickly populated area and is
concerned for the safety of her 3 youn" children
.hat measure should the nurse recommend for
home safety:
% Bnstall additional li"htin" for visibility
' -ild water heater temperature
) *articipate in 7re prevention trainin"
+ Bnstall a smoke detector device
1C ?ola %ndan", =9 years old, is livin" alone !er
married dau"hter visits her form time to time She
can do activities of daily livin" with limited assistance
and seems to be independent physically .hich of
the followin" measure should be recommended to
reduce sensory deprivation:
% 3ncoura"e ac4uaintances to come to the
house for a chat
' 0edecorate the house and provide a
separate room
) *rovide pictures of family members
+ Bnvite friends to share meals at home
Situation 3: Nurse encounter situations in which they must
make decision based on the determination of what is ri"ht and
wron" *rofessional nursin" actions are both ethical and
moral
11 -rs -iriam, a middle-a"ed obese woman seeks
medical help often for recurrin" lower back pain She
does not lose wei"ht in spite of medical advice
.hich of the followin" 4uestions should the nurse
ask the client:
% 2.hat do you think will happen to you if you
don$t follow medical advice:5
' 2%ren$t you bothered about your condition:5
) 2%re you considerin" other course of
action:5
+ 2Bs it difcult to follow the medical advice:5
1, % =5-year-old frail woman had a cervical disk
disorder )onservative mana"ement did not work and
the client re4uires sur"ery (he client insisted that
she does not want sur"ery but the family and the
sur"eon insisted (he sta& nurse assi"ned to her
decided not to help in the preparation of sur"ery
Dsin" carin" based reasonin", which of the followin"
8ustify the refusal nurse in the preparation of
sur"ery:
% 2B empathi/e with the client because of her
a"e and her fear of not survivin" sur"ery5
' 2B stron"ly feel that sur"ery will cause her
more su&erin" and probably will not survive
and the family may even fell "uilty later5
) 2B feel that my responsibility with the client
is protectin" her ri"hts and meetin" her
needs5
+ 2B support the client since she has the ri"ht
to decide on her medical treatment and
mana"ement5
13 % community health nurse in her home visits
encountered a 5@-year-old woman who was
depressed and tearful She was hospitali/ed before
with "laucoma She knows that she could be o help
to the client by stayin" and talkin" to her lon"er for
another hour !owever, she has still two client visitsE
one of them is Nelson who is in plaster cast of the le"
and needs a "reat deal of teachin" and the other a
9C-year-old female, hemiple"ic needin" assistance in
performin" activities of daily livin" .hich of the
followin" is the appropriate action of the nurse:
% .ei"h the facts carefully in order to divide
her time 8ustly amon" her clients
' (ell the client she will come back after
attendin" to the other clients
) %sk one of the family members to attend to
the client
+ Stay with the client to prevent further
depression
16 -rs -arsha, a 6C-year-old professional was con7ned
after su&erin" mild stroke She has been critical of
the care she received which she re"arded as not of
hi"h 4uality (he followin" actions of the nurse are
appropriate in addressin" the complains, e1cept:
% *rovide client with knowled"e of what
constitutes "ood care
' *rovide client with the list of her ri"hts
) %sk the client what her e1pectations are
+ ;ive a list of evaluation criteria and ask the
client to respond
15 (he nurse demonstrates ethics of care when she
plays the role of a
% (eacher
' )are provider
) ;uidance counselor
+ )lient advocate
Situation6: >ollowin" are situations that are a concern for
records mana"ement of nurses
19 % delusional patient said, 2B have no head, no
stomach5 (he nurse would record this in which part
of the mental status assessment:
% )ontent of thou"ht
' 3motional state
) )haracteristics of talk
+ Sensorium or orientation
1= >or proper orientation and accountability of all
entries to the client$s chart, it is important for the
nurse to inspect that
% %ll notes must have si"nature and title of
the person makin" the entry
' (he sta& must not abbreviate S#%*
) (he nurse implements the use of problem-
oriented pro"ress notes
+ )lient$s problems in the medical record
must bear the date of entry and numbers of
client$s problem
1@ .hich of the followin" statements about *rocess
recordin" is not true:
% Bt provides data from which nurses can
assess their own behavior in interactions
with clients
' Bt is a tool for assessin" nurse-client
interactions
) Bt is an important means of communication
between nurses or nursin" students and
their clinical supervisorsFinstructors about
their peer relationship
+ Bt ac4uaints the studentsFnurse with
rudimentary applied research skills
1A +ata: )lient is pacin", cryin", wavin" his hands,
yellin" at another sta& and other patients Bn the
problem-oriented pro"ress notes, these data would
be noted under
% %ssessment
' Sub8ective
) #b8ective
+ *lan
,C Bn order for the process recordin" to be an e&ective
learnin" tool for nurses, data should be
% Dnedited and comprehensive
' Salient points that are summari/ed
) 'rief and simple but focused on essentials
+ 3dited and comprehensive
Situation 5: in today$s health care environment, nurses are
increasin"ly accepted as essential members of the
interdisciplinary health care team
,1 (he nurse is workin" in a tertiary hospital for almost
a year Bn order to e&ectively participate and lead a
health care team, she must have which of the
followin" traits:
% )ourteous and respectful to the health team
and members
' )ommitted in the e1ercise of duties and
responsibilities to clients and co-workers
) <nowled"e of the most e&ective and reliable
evidence-based approach to care
+ ;ood interpersonal relationship with clients
and families and the health team
,, % sta& nurse consulted a more e1perienced nurse
and other health care providers whether a""ressive
ambulation e1pedites the patient$s recovery or it
re4uires too much ener"y .hile this approach is
e1tremely common, she is likely to obtain clinical
answers that are
% Scienti7c
' 3vidence-based
) (radition-based
+ 0outine
,3 %n e1perienced nurse is new in the work settin"
;iven this situation, what should the nurse do to
conform to the institution$s e1pectations:
% *ursue post-"raduate course to enhance
skills and competence
' *articipate in the in-service education
pro"ram o&ered by the institution
) %ttend seminars, conference and national
conventions related to the nursin"
profession
+ ?earn new values, skills, attitude and social
rules
,6 Bma"e makers provide the "reatest number of visual
ima"es of nurses at work such as an"els of mercy,
love interest particularly to the physicians, nau"hty
nurse, handmaiden to the physician and others
)han"in" nurse$s ima"e in the public eye will not be
easy .hich of the followin" strate"ies isFare needed
to chan"e nursin" ima"e in the mind of ima"e
makers:
1 0estriction of the term 2nurse5 to mean licensed
0N
, Bnvolvement in the political processes that shape
their profession
3 Bncreased e&ort to publicly praise and value
nursin"
6 3mphasi/es the contribution of nursin" to
patients, particularly on their desired health
% 1, ,, 3 and 6
' 1, 3, and 6
) 3 only
+ 1 only
,5 Nurses naturally work to e&ect policy in the work
place .hich of the followin" actions can nurses take
to increase their inGuence in policy settin":
1 (o be a member of a nursin" or"ani/ation
, .rite lobbyin" letters
3 *articipate in coalitions of or"ani/ations
6 ;et to know their elected ofcials
% 1, ,, 3, and 6
' 1, 3, and 6
) 3 only
+ 1 only
Situation 9: ?eonardo is a survivor or a tra"ic accident wherein
his wife and child drowned when their boat sank due to
stormy weather .ithin the ne1t 9 months form the accident,
he was observed to be detachin" himself form others, unable
to sleep and concentrate and fre4uently would 8ust be 4uiet
and stare
,9 !e tells you, 2Bt is my fault .hat kind of husband
and father am i:5 !e is e1pressin"
% +epersonali/ation
' ;uilt
) Bnappropriate a&ect
+ )o"nitive disturbance
,= (he nurse can best intervene by mobili/in" the
client$s relatives, friends, and people to provide
% Spiritual support
' Social support
) -aterial support
+ -edical support
,@ % therapeutic attitude the nurse can convey to the
client while he talks about his loss is
% Sympathy
' *assivity
) %cceptance
+ #ptimism
,A (he nurse encoura"es the client to communicate and
sociali/e because internali/ed hostility can lead to
% +epression
' %mok
) Herbal assaultiveness
+ *hysical assaultiveness
3C (he patient is havin" a

% *ost traumatic stress disorder
' *sychotic breakdown
) +evelopment crisis
+ *ersonality dysfunction
Situation =: Bncreasin" problems of substance abuse continue
to challen"e the competencies of professional nurses
31 (he )omprehensive +an"erous +ru"s %ct I0% A195J
challen"es the nurse in his role as aFan
% %dvocate
' )ounselor
) (herapist
+ !ealth educator
3, (he nurse is conductin" parent education classes
%ware of the scope of nursin" practice, the nurse
reco"ni/es the necessity to network with other
a"encies to discuss this area
% )ommunication skills appropriate for
di&erent a"es
' )onstructive discipline
) Normal and deviant child and adolescent
behavior and development
+ ?e"al implications of ille"al dru" use
33 .hich of these characteristics has the least potential
success of treatment of dru" dependency:
% %n addict who has reached bottom pit level
of self-dis"ust and who wants help
' %n individual who became dependent on a
dru" before or durin" the teen years
) Bndividuals who have access to support form
intact family "roups
+ % person who has be"an takin" dru" of
choice for recreational or e1perimental
reasons
36 (he best model of dru" abuse prevention supports
% *ro"rams focusin" on means of dealin" with
problems and frustration of adolescents
' -andatory basic education transformation
of society
) %n inte"rated pro"ram re4uirin"
development of both intellectual and
e&ective health
+ (he medical treatment of dru" abuse
utili/in" less addictive dru"s
35 % client says, 2B am not a substance user B take dru"s
only when B am under stress5 .hat defense
mechanism is this client employin":
% 0epression
' Substitution
) )ompensation
+ +enial
Situation @: )onsumers of health care re4uire improvement in
health care Nurses must deliver activities and behaviors and
to do the ri"ht thin"s well and continue to strive to do better
to meet and satisfy the diverse needs of clients
39 Nurse 3thel observes the client with "laucoma while
he instills his eye drops (he client looks up the
ceilin" and instills the correct number of drops at the
middle of the eyeball (he techni4ue used by the
client in the instillation of the medication is
% )orrect as this spreads the medication over
the eyeball
' %imed to protect the eyeball from in8ury
) %llowed so that the client is less likely to
blink
+ Bncorrect because it may dama"e the
cornea
3= (he client had cataract sur"ery Shortly after, he
complains of nausea .hich of the followin" course
of action should be "iven priority by the nurse:
% %dminister the prescribed antiemetic
' ;ive ice chips to relieve nausea
) %ssure the client that this is e1pected
followin" sur"ery
+ 0eport the complaint to the attendin"
physician
3@ (he members of the nursin" team were discussin"
about the activity of the client treated with detached
retina durin" the nursin" rounds .hich of the
followin" statements serves as "uide for the client
durin" the rehabilitation phase: (he client
% -ay resu8me his activity with moderation
the day after the treatment
' -ay indul"e in normal activities after the
treatment
) -ust be restricted in bed for 1 week
+ -ay resume "radually her usual activities
within 5-9 weeks
3A +urin" the nursin" conference, Nurse 3lla shares with
the team the concerns of the wife of a client with
-eniere$s disease She is concerned about the
chan"e in the husband$s social activities (o assist
the wife in ad8ustin" to the present situation, the
team should
% *lan the course of action with the husband
' )reate an atmosphere of sense of belon"in"
for the couple
) %ssist the wife to accept the condition of the
husband
+ 31plain to the wife that her husband is
e1periencin" social isolation related to
attacks of verti"o
6C (he sta& nurse performs ear irri"ation on a client for
removal of cerumen .hat relevant information
should the nurse share withy the client at the start of
the procedure:
% 31perience a feelin" of fullness, warmth and
occasional discomfort when the Guids comes
in contact with the tympanic membrane
' %ny medication needs to be withheld after
the procedure and the physician must be
noti7ed
) 3ar irri"ation re4uires cooperation from the
client to facilitate the introduction of the
solution
+ %ssume lyin" position on the a&ected side
after the procedure to facilitate draina"e
Situation A: %ntonia, the mother of two children was cookin"
dinner and wonderin" why her husband was so late (hen she
received a telephone call from the police notifyin" that her
husband had 8ust been pulled from the river .itnesses say
her husband 8umped from a brid"e in the locality
61 %ntonia, to"ether with her children, walked a 1C-
block way to the funeral home to meet the medical
e1aminer to identify the body of her husband
.ithout a tear, she became focused on attendin" to
her children and simply si"ned the necessary
paperwork She is in state of
% Bnte"ration
' 0ecovery
) Shock
+ 0eality
6, Bn the followin" weeks after the death of her
husband, %ntonia stru""led not only with 7nances
but with confusion and ra"e in response to her
husband$s actions and abandonment (he nursin"
dia"nosis is
% Spiritual distress
' *owerlessness
) +isturbed self-esteem
+ Social isolation
63 Dnable to handle her emotions, %ntonia hurls an"ry
and e1plosive outburst toward those who are helpful
to her (his behavior is an e1ample of
% Sublimation
' +isplacement
) 0eaction formation
+ Bntro8ection
66 !ostility is distinct form of an"er in that the former is
% )ompatible with love
' ;rowth-promotin"
) +estructive
+ 3"o-syntonic
65 +urin" nurse-patient interactions with %ntonia, when
she actively works out her ra"e which of the
followin" is not therapeutic:
% %sk %ntonia to describe what is the hardest
part of the death for the family
' %ssure that death of husband is not her fault
) %n encoura"ement toward normalcy must
be communicated
+ (he nurse should be non-reactive
Situation 1C: (o produce a bene7cial e&ect on eye
medications, the nurse should make sure that the amount of
medication reaches the ocular site of action in sufcient
concentration
69 (he nurse in the 33N( unit is preparin" the 9:CC am
medication She is fully aware that topical
administration of ocular medication results in how
many percent rate of absorption:
% ,1K to ,5K
' 19K to ,CK
) 1C5 to 19K
+ 1K to =K
6= (he nurse is preparin" ocular medications for topical
route administration (he most common ocular
medication is administered throu"h instilled eye
drops and applied ointments .hat is the advanta"e
of ointment application from installation of eye
drops:
% Self-administration, ease of absorption, and
decreases risk of contamination
' 31tended retention time and provides a
hi"her concentration
) 3asy to administer with reduced adverse
reaction
+ *romotes efciency, safety and distribution
of solution evenly
6@ (he nurse is to administer an eye ointment to a
patient .hich of the followin" "uides the nurse in
the administration of the ointment:
% %dminister durin" naptime or bedtime
' Bnform the relative of the action of the dru"
) 31plain the procedure to the patient
+ )heck medical conditions that would
contraindicate the use of the dru"
6A )ommon ocular medications include topical
anesthetic Bn the application of topical anesthetics,
the nurse must instruct the patient which of the
followin" measures:
% *lace the 7n"ers on the sides of the nose to
prevent medication from drainin"
' *lace the patient in supine position with the
head sli"htly hypere1tended
) )lose both eyesE "ently move eyes
+ 0efrain from rubbin" the eyes to prevent
corneal dama"e
5C (he nurse is assessin" a patient receivin" mydriatic
eye drops (he patient is sweatin", complainin" of
blurred vi@sion and drowsiness (hese manifestations
are indicative of
% >ear and an1iety
' #verdose of the medication
) %ller"ic reaction
+ Systemic anticholiner"ic e&ect
Situation 11: -any clients in a psychiatric unit receive anti-
psychotic medications, also referred to as neuroleptics
51 )lients may be shifted form typical to atypical
antiposychotic medications because of its minimal
e1trapyramidal side e&ects % common
e1trapyramidal symptom that is very unpleasant and
intolerable to clients is called akathisia (his is
% Dpward rollin" of the eyes
' Bnability to sit or stand
) *ill rollin" movement of the hands
+ Sti&enin" of the client$s neck
5, !ealth instructions about !aloperidol I!aldolJ have
been "iven to ?ester while in the hospital and before
his dischar"e (he client correctly understands the
health teachin"s of the nurse when he says, 2B will
% Bmmediately report any episodes of diarrhea
or vomitin" to my doctor5
' +rink about , liters of Guid daily and e1pect
to urinate fre4uently5
) .ear lon" sleeve clothin" and sun block
when B "o out5
+ %void pi//a, any food with cheese and
processed meat5
53 .hile "ivin" )hlorproma/ine I(hora/ineJ to a client,
the nurse remembers that she should stop "ivin" the
medication when she observes the side e&ect
% ShuLin" "ait
' Mellow sclera
) >ine tremors
+ >acial "rimacin"
56 %nother client in the ward is "iven (hora/ine (his
medication has several side e&ects .hich side e&ect
should cause the nurse to be most concerned:
% Dncomfortable sunburns
' Sore throat, fever, decreased .')
) (remors, inability to stand still
+ ?ow blood pressure upon "ettin" up from
bed
55 )lients on antipsychotic medications usually receive
antiparkinson dru"s to reduce *arkinson-like side
e&ects .hat medication would the nurse e1pect the
client to receive:
% )o"entin I'en/tropineJ
' Nardil I*henel/ineJ
) >luphena/ine I*roli1inJ
+ >luo1etine I*ro/acJ
Situation 1,: (he followin" 4uestions refer to nurses$ e&orts to
inte"rate in mental health community work
59 (he most important role of the nurse as a member of
the team is to
% <eep a ,6-hour watch for the client
' -eet the needs for the physical well-bein"
of patients
) )arry out medical orders
+ )oordinate the psychosocial care and
mana"ement of clients
5= %ctivity therapy is a treatment that utili/es which of
the followin":
% *sychotherapy
' 'ehavioral therapy
) Somatic therapy
+ -ilieu therapy
5@ .hich of these nursin" sections belon" to the
secondary level of preventive intervention:
% *rovidin" mental health education to
members of the community
' *rovidin" mental health consultation to
health care providers
) *rovidin" emer"ency psychiatric services
+ 'ein" politically active in relation to mental
health issues
5A .hen the nurse identi7es a client who has attempt to
commit suicide the nurse should
% 0efer the matter to the police
' 0efer the client to the psychiatrist
) )all a priest
+ )ounsel the client
9C (he community health nurse was invited by the
principal of an elementary school and was asked to
"ive a talk to parents %n appropriate topic would be
% (he le"al aspects of dru" abuse
' +iscipline of children at home and school
) -arital crises
+ (he problems of out of school youth
Situation 13: (he nurse assi"ned in the neurolo"y unit is
takin" care of a patient with medical dia"nosis of increased
intracranial pressure
91 %n intracranial pressure monitor is in place and the
patient is becomin" lethar"ic (he nurse noted the
intracranial pressure is hi"h .hich of the followin"
should be the immediate action of the nurse:
% (urn the patient to his left side with the back
supported with pillows
' 3levate the le"s at 15 de"rees with a pillow
under the head
) 3levate the head of the bed to 3C de"rees
+ 0aise the head of the bed to AC de"rees and
the head supported with pillows
9, (he nurse is monitorin" the intracranial pressure of
the patient .hich of the followin" nursin"
assessment would identify the earliest indication of
increasin" intracranial pressure:
% .idenin" pulse pressure
' )han"e in level of consciousness
) )yanosis and hypotension
+ Bncreased body temperature
93 (he nurse completed a nursin" assessment .hich of
the followin" data concludes that the patient is
showin" si"ns of increased intracranial pressure:
% +ecrease in pulse pressure, increased in
heart rate, irre"ular breathin" pattern
' +ilatation of the pupil, decreased blood
pressure, and increased level of
consciousness
) Bncrease in heart rate and respiratory rate,
and decreased level of consciousness
+ Slowin" of the heart rate, increase in pulse
pressure, and irre"ular breathin" pattern
96 Bn preparin" the plan of care, the nurse should
prioriti/e which of the followin" nursin" and medical
measures:
% !i"h back rest to prevent Halsalva$s
maneuver and promote venous draina"e
' (urnin" every , hours with lo"rollin"
movement to maintain proper position
) 3levatin" the head of the bed and keepin"
the head in proper ali"nment
+ *roper positionin" and fre4uent chan"e in
position
95 (he nurse plan of care includes preventin"
environmental stimuli that may stimulate an increase
in intracranial pressure .hich of the followin"
measures should the nurse include in the nursin"
care plan:
1 <eepin" li"hts on low settin"
, <eepin" noise at a minimum
3 *rovidin" a calm and restful environment
6 !avin" a coolin" blanket available
% 1, ,, 3, and 6
' 1, ,, and 3
) 1 and ,
+ ,, 3, and 6
Situation 16: the stress of hospitali/ation can lead to
difculties between nurses and patients >ollowin" are
situations that nurses presented durin" a monthly nursin"
circle
99 Neil asked the nurse to have an 2out on pass5
privile"e for the weekend but his re4uest was not
"ranted by the nurse !e remarked, 2B thou"ht you
really liked me5 % therapeutic response of the nurse
would be
% 2B understand, you feel bad but of course, B
like you5
' Say as a matter-of-fact, 2Mour behavior did
not meet the criteria for out-on-pass
privile"e
) B"nore Neil$s remark
+ 'e transparent and e1press disapproval
openly, 2Mou upset me with your remark5
9= (he dynamics of behavior underlyin" manipulative
behavior e1plains that it is a behavior of
% % sense of security and control
' 31hibitin" uncooperative and hostile
behavior
) 0educin" patient$s an1iety
+ Sensin" fear of other people
9@ Hictoria, an elderly client ideali/es some nurses as
2terri7c5, 2the best5, or 2so understandin"5, but
refers to others as 2mean5, 2incompetent5, or
2indi&erent5 (his behavior can be understood by the
sta& as
% %voidin" takin" responsibility for her own
behavior and underlyin" feelin"s
' %n understandable behavior of an elderly
that must not be taken seriously
) %n invitation to have a social and intimate
relationship with the nurse
+ Bmmature and childish behavior
9A % patient with delirium touches the nurse
appropriately (he therapeutic response of the nurse
would be
% %sk for the patient$s name and if whether he
is aware where he is
' 0emove the patient$s hand while sayin"
calmly, 2B$m the nurse and this is a
hospital5
) Say nothin" and 8ust "o on with the usual
nursin" interventions
+ Say her name,5B$m )athy, B$m your nurse5
=C (he sta& nurses have di&erin" emotional reactions to
the use of limit settin" Some sta& view it as
unprofessionally punitive and uncarin" (he most
appropriate approach to address this nursin" concern
is throu"h
% )ounselin" with the nursin" supervisor
' Nursin" conference
) Seminar-workshop
+ 'rainstormin" session
Situation15: -rs Samson is an @5-year-old woman who was
hospitali/ed due to urinary tract infection and dehydration
She has %l/heimer$s disease, osteoporosis and a tendency to
wander She has an BH in her left forearm which was difcult to
establish )oncerned that -rs Samson mi"ht pull her BH out
and wander o& the Goor, the sta& is considerin" the possibility
of usin" restraint on her
=1 (he sta& is considerin" the possibility of usin"
restraint on -rs Samson, however, she repeatedly
declares that she does not want to be restrained (he
sta& is faced with an ethical dilemma of autonomy
versus
% 'ene7cence
' >airness
) Heracity
+ Nustice
=, .ith a history of osteoporosis and a tendency to
wander, which of the followin" should be a priority:
% 0e4uest for a sitter
' .heelchair privile"e
) *revention of fall
+ *rovision of a bedside commode
=3 .hich of the followin" would be least appreciated by
-rs Samson:
% *layin" a table board "ame
' Sin"in" to or with her
) ;oin" throu"h family picture album
+ ?istenin" to old familiar music
=6 (he nurse aims at hi"hest level of self care .hich of
the followin" will the nurse minimi/e:
% *rovidin" mouth swabs
' !and and body lotion
) Dsin" clothin" with buttons and /ippers
+ ?abelin" clothin" items
=5 -rs Samson has a dietary privile"e of food
preferences .hich 4uestion is most e&ective to
communicate with her:
% 2.hich way would you want your e"" done:
Scrambled: Sunny side up: .ith ve"etable
mi1: #r boiled:5
' 2+o you want fried e"" or boiled e"":5
) 2!ow would you want to have your e""
done:5
+ 2.hat is your favorite e"" recipe:5
Situation 19: Nurse <im en"a"ed clients in a "roup e1ercise
for medication education Students are paired with clients to
play a "ame and e1chan"e knowled"e about medications and
disorders *articipants play with a "ame board and color-
coded "ame cards which bear 4uestions on 7ve cate"ories of
psychotropic medications ;ame 4uestions include the 7ve
cate"ori/ed namely: antipsychotic medications,
antidepressants, mood stabili/ers, anti an1iety medications,
and medications for dru" abuse
=9 %n openin" comment about the purpose of the "roup
encoura"ed clients to "ather around the table and
select small toy cars to move playfully around the
racetrack "ame board (he aim of this a&ective
learnin" approach is for the clients to
% -eet diverse learnin" needs
' Satisfy client$s level of functionin"
) Share common feelin"s about medications
+ -a1imi/e the likelihood of compliance
== #ne ob8ective of this "roup e1perience is for the
clients to describe the impact of these medications
on their symptoms and to day activities Bmmediate
discussion and interaction about daily life utili/es the
principle of
% 0einforcement
' 3fciency
) %ppropriateness
+ >le1ibility
=@ .hich of the followin" client behaviors demonstrates
that interpersonal learnin" occurred:
% #ne client advised another client that he
should "et a 2pill bo15 so he would
remember to take medications
' )lients shared a sense of 2we-ness5
) )lients said they were 2all in the same boat5
+ #ne client said, 2B feel that way5
=A #ne client shared her very infre4uent e1periences
with alcohol, which she knew to repeat this5 (his
e1perience included which of these therapeutic
factors:
% %ltruism
' Dniversality
) Bmpairin" information
+ ;roup cohesiveness
@C .hich of the followin" least contributes to creatin" a
therapeutic learnin" environment:
% !etero"eneous composition of participants
' Dse of alternative teachin" strate"ies that
7t the needs of the "roup
) +evelopment of pre-determined, absolute
"roup "oals
+ >le1ibility in accommodatin" the number of
players
Situation 1=: % team of researchers is conductin" a study on
the e&ect of hi"h dose corticosteroids in improvin" the motor
and sensory outcomes of patients with spinal cord in8uries
within 9 weeks if administered within @ hours after in8ury (he
study covers a three-month period
@1 #n the basis of the nature of the investi"ation, which
one of the desi"ns listed below would allow the
researchers to have the most con7dence that the
corticosteroid is e&ective in improvin" the motor and
sensory outcomes of patients with spinal cord in8ury:
% Ouasi or semi-e1perimental desi"n
' Non-e1perimental desi"n
) 31perimental desi"n
+ 0etrospective-prospective study desi"n
@, .hich of the followin" is present in conductin" the
above study:
% 31perimental "roup
' Hariables
) Sub8ects
+ )ontrol "roup
@3 (he tar"et participants of the intended study are
homo"enous in the variables bein" measured Bn
determinin" the sample si/e the researchers should
include how many participants in this study:
% 1C
' 3C
) 3C
+ 5CC
@6 Bn the above study, the researchers manipulate the
variable under study .hich of the followin" variables
is sufcient for the e&ect to occur:
% )lients with spinal cord in8ury
' Bn8ection of corticosteroids within @ hours
after in8ury
) 0esearch methodolo"y
+ -otor and sensory outcomes of patients
with spinal cord in8uries
@5 (he manipulated variable to the e1perimental "roup
is the
% Bmproved recovery and lessened
hospitali/ation period
' Ouestionnaire in "atherin" pertinent data
) Bmproved motor and sensory outcomes
+ Bn8ection of corticosteroids within @ hours
after in8ury
Situation 1A: Nor"e, 1A-year-old second year colle"e student, is
seekin" assistance in copin" with school related stressors and
sleep disturbances +urin" the initial evaluation of the
psychiatric nurse, he reports he is ashamed and embarrassed
by a mistake he made in his class oral report and feels like his
classmates are "oin" to look down on him !e reports that he
failed a practical e1am a year a"o %lthou"h he has made up
for this, he cannot "et this out of his mind
@9 .hen the nurse asked Nor"e about his physical
e1perience, which of these assessment data are
appropriate:
% 2B do not know what to do5
' 2B am tense, nervous and e1hausted all the
time5
) 2B feel helpless and depressed5
+ 2B am worried and thinkin" a lot5
@= Nor"e admits that he says 2always been wound up5
8ust like his father and that he has ne"ative thou"hts
of himself !e is havin" a problem of
% Bnferiority
' Sta"nation
) -istrust
+ 0ole confusion
@@ (he nurse teaches a non-pharmacolo"ic ways to
induce sleep .hich of these would she caution Nor"e
to avoid:
% .arm milk
' )lassical music
) )o&ee after dinner
+ % warm bath
@A .hich of these describes the characteristic of free
Goatin" an1iety:
% Bt is not conditioned by a speci7c tri""er
' Bt creates panic
) (here is an easily reco"ni/able stressor that
provokes an1iety
+ Bt results in selective attentionFinattention
AC % "enerali/ed an1iety disorder is distin"uished by
% 31perience of an1iety after e1posure to a
life-threatenin" event
' *resence of e1cessive an1iety for a period of
9 months or more
) Brrational thou"hts and actions
+ >ear of losin" control thus avoid crowds
Situation1A: (he nurse works in an institution that shelters
street children She encounters varies family histories and
presentin" behavior patterns of these clients
A1 %t ni"ht when the children are bein" prepared to "o
to sleep, the nurse hears from a fri"htened child,
2%yaw ko matulo" ma"-isaP -ay multoP IB don$t want
to sleep alone (here$s a "hostPJ (he nurse conveys
acceptance with which of these responses:
% 2;usto mon" i-kwento kun" ano pa an"
naiisip at nararmdaman mo5 I.ould you like
to tell me more about your thou"hts and
feelin"s:5
' 2(ala"a: %non" itsura n" multo:5 I20eally:
!ow does the "host look like:5J
) 2Nakaktakot n"a an" pakiramdam na
"anyan5 I2(hat must really be scary5
+ 2!uwa" kan" matakot 'abantayan kita5
I2+on$t be afraid B$ll keep watch over you5J
A, -ost street children come from broken families (he
nurse is most therapeutic in meetin" their needs by
bein" a
% %ctivity therapist
' -other surro"ate
) )hild therapist
+ (eacher
A3 .ith ade4uate rest, food, cleanliness, shelter,
warmth and safety, the child
% +evelops a sense of competence
' %c4uires a sense of personal power
) +evelops a separate identity
+ ?earns to trust in self and in others
A6 *reventive interventions for children at risk are best
achieved throu"h
% >amily therapy for the dysfunctional families
' Non-"overnment or"ani/ations and other
workers payin" attention to victims in
conGict ridden communities
) Support and carin" to children durin" family
crisis situation
+ *lay and activity therapies for children
A5 Hina was a fre4uent witness to domestic violence
!er father would always come home drunk and beat
up Hina$s mother %s an e&ect of this e1perience she
had ni"htmares, speechless for weeks, inability to
sleep, tension and palpitations lastin" for more than
a month Hina is e1periencin" an1iety due to
% %d8ustment in "rowin" up
' >ear of phobic proportion
) %n identi7able traumatic stress
+ Bma"ined loss of parental love
Situation ,C: -rs )orte/a, 95 years old, has an acute attack
of pain, soreness and swellin" on both knees She is
dia"nosed with rheumatoid arthritis
A9 Nurse Nerissa is assessin" the client .hich of the
followin" is most likely to be assessed:
% 3arly mornin" sti&ness
' Nodules alon" the knees
) Noint deformities
+ ?imited motions of 8oints
A= (he client is in the acute phase of rheumatoid
arthritis Bn addition to the prescribed medication, the
physician orders application of heat and cold to
mana"e arthritis pain .hich of the followin"
statements indicate that the client lacks
understandin" in the application of heat and cold:
% 2)old application is applied for ,C minutes,
then ,C minutes o&5
' 2!ot water pad should be covered with
Gannel to prevent burns5
) 2!eat and cold can be applied as needed5
+ 2!eat producin" liniments can be used while
applyin" heat or cold5
A@ Nurse Nerissa is helpin" the client who is
immobili/ed by pain towards self-reliance and
independence (he nurse should approach the
problem with which of the followin":
% Set a speci7c "oal
' Set a positive attitude toward an eventful
outcome
) Need for a member of the family durin" the
pain episode
+ 0eco"ni/e that little can be accomplished
AA (he nurse should know that a client with rheumatoid
arthritis will most often have pain and limited
movements of the 8oints
% 0esultin" from non-adherence to prescribed
diet
' %fter assistive e1ercise
) 'ecause of inactivity upon awakenin" in the
mornin"
+ +urin" cold weather
1CC (o prevent deformities, the nurse includes inn the
nursin" care plan
% -assa"in" the 8oint with oil liniment
' Bmplementation of strictly prescribed diet
) *erformin" isometric e1ercises twice a day
+ %lternate rest periods with active e1ercises