June 2007-NPT 1 - Rationale

ANSWERS WITH RATIONALE
Situation 1- As an RN, you assume responsibility for systematically assessing and planning for the needs of your clients.
You admitted Tony to the ward.
1. CORRECT ANSWER: A
RATIONALE: Establishing rapport is a process of creating goodwill and trust. It can begin with a greeting (“Good
morning Tony”) or a self introduction (“Good morning. I’m Tel, your new nurse”) accompanied by nonverbal
gestures such as a smile, a handshake, and a friendly manner. The nurse must be careful not to overdo this
phase; too much superficial talk can arouse anxiety about what is to follow and may appear insincere.
SOURCE: Kozier. Fundamentals of Nursing. 7th Edition p. 268
RATIONALE: Social data includes the home and neighborhood conditions, family relationships/ friendships, ethnic
affiliation, ethnic affiliation and lifestyle (personal habits, diet, sleep/rest patterns, ADLs, recreation).
Kozier. Fundamentals of Nursing.7th Edition.p. 263
Perception of illness belongs to the health history.
RATIONALE: Kardex provides a concise method of organizing and recording data about a client, making
information readily accessible to all members of the health team. It is a series of flip cards usually kept in portable
file. It is a way to ensure continuity of care from one shift to another and from one day to the next. It is a tool for
Change-of-Shift-report. But endorsement is not simply reciting content of kardex. The health care need of the
client is still the primary basis for endorsement.
B and C- Progress notes or the Nurse’s note (SOAPIE format) is a component of Problem-oriented medical record
(POMR). Data about the client are recorded and arranged according to the source of the information. The record
integrates all data about the problem, gathered by the members of the health team.
SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 158-161
RATIONALE: Involving the client in care planning enhances cooperation. Participation in the determination of
goals and objectives increases commitment, transforming them from stated to real goals. It also motivates the
patient to assume responsibility for his own care.
SOURCE: Kozier. Fundamentals of Nursing.7th Edition.p 299
RATIONALE: Primary nursing is a care delivery model designed to maintain continuity of care across shifts, days
or visits. The RN assumes responsibility for a caseload of clients overtime. The RN selects the clients for his/her
caseload and care for the same clients during their hospitalization or stay in a health care setting.
Team Nursing- this model involves the delivery of nursing care by staff of various educational preparations. An
RN leads the team composed of other RN’s, and assistive personnel. The team members provide direct client
care to group of clients under the direction and coordination of the RN team leader.
Case-management- it is care delivery approach that coordinates and links health care services to clients and their
families. This involves professional nurse assuming responsibility for client care from admission through and
following discharge. Clinicians, either as individuals or as a part of collaborative groups oversee the management
of case-type-based care.
Functional Nursing- this care delivery model involves the division of tasks, with one nurse assuming responsibility
for certain tasks while another nurse assumes responsibility for others. Nurses tend to become highly competent
with the tasks that are repeatedly assigned to them. However, functional nursing is task-focused, not client-
focused. There is absence of holistic view of clients, and there is great probability that care becomes mechanical.
Situation 2 - The professional nurse has a major responsibility for enhancing client’s capacity for self-care.
6. CORRECT ANSWER: B
RATIONALE: Dorothea Orem developed the Self-Care and Self-Care deficit Theory. She defined self care as the
practice of activities that individuals initiate and perform on their own behalf in maintaining life, health and well-
being.
OPTION A: She presented the Adaptation model. She viewed each person as a unified biopsychosocial system in
constant interaction with the changing environment.
OPTION C: She conceptualized the Behavioral system model. According to Johnson, each person as a
behavioral system is composed of seven subsystems namely: ingestive, eliminative, affiliative, aggressive,
dependence, achievement, sexual and role identity behavior.
OPTION D: She conceptualized the Human Caring model
SOURCE: Udan Fundamentals of Nursing 2nd ed.
RATIONALE: Demonstration is often used with explanation, so client can learn through cognitive domain. During
return demonstration it permits the clients to have hands-on experience or to personally do and explain what the
teacher taught. Learning was maximized because clients were actively participating.
OPTION B- Role-playing only permits affective and cognitive learning, the participants still can’t learn the skills.
OPTION C- Lecture discussion- teacher controls content and pace. Learner is passive; therefore retains less
information than when actively participating.
OPTION D- Group dynamics- group members learn from one another, learner can obtain assistance from
supportive group.
SOURCE: Kozier. Fundamentals of Nursing.7th Edition. P. 461
RATIONALE: Primary Health Care (PHC) characterized by partnership and empowerment of the people shall
permeate as the core strategy in the effective provision of essential health services that are community based,
accessible, acceptable, and sustainable, at a cost, which the community and the government can afford. It is a
strategy, which focuses responsibility for health on the individual, his family and the community. It includes the full
participation and active involvement of the community towards the development of self-reliant people, capable of
achieving an acceptable level of health and well-being. It also recognizes the inter-relationship between health
and the overall political, sociocultural and economic development of society.
OPTIONS A, C, and D are the strategies used in meeting the goal of the primary health care.
(Community health nursing services in the department of health Philippines pp. 67-68)
RATIONALE: The modern concept of health refers to optimum level of individuals, families and communities.
There are several factors in the eco-system which affect this level of functioning. These factors are:
Political- politics greatly influence the social climate in which people live. Political jurisdictions have the power and
authority to regulate the environment. Examples are safety, oppression and people empowerment. Increase of
crimes and the lack of safety in streets and and even in the homes are major concerns of society. Oppression
especially of the poor, differential treatment in various classes of society affects health.
Socio-economic influence- families from the lower income groups are the ones mostly served in public health
services and by the community health nurses. This is because, people from the lower income groups tend to have
proportionately greater number of illnesses and health problems than those in the higher income groups.
However, the middle and upper income group has also very pressing health problems such as drug abuse and
lifestyle diseases.
Environment- the menace of pollution has been growing over the years and has greatly affected the health of the
people. The diseases today are largely man-made. Examples f these are communicable diseases due to poor
sanitation, poor garbage collection, smoking, air pollution and utilization of chemicals such as pesticides.
Heredity- understanding genetically influenced diseases is increased through knowledge about the nature of
genetic materials and about the process by which genetic traits are transmitted. New opportunities for preventive
health care are also produced.
SOURCE: Community health nursing services in the department of health Philippines pp. 13-15
10. CORRECT ANSWER: C

RATIONALE: Socio-economic influence- families from the lower income groups are the ones mostly served in
public health services and by the community health nurses. This is because, people from the lower income groups
tend to have proportionately greater number of illnesses and health problems than those in the higher income
groups. However, the middle and upper income group has also very pressing health problems such as drug
abuse and lifestyle diseases.
Community health nursing services in the department of health Philippines p. 15
Situation 3- Mental health covers the psychosocial concerns of daily living covering the different stages of life. Efforts to
train manpower have been done by the government through the National Mental health Programs.
11. CORRECT ANSWER: D

RATIONALE: A bill of rights consists of statements of civil liberties and rights that a government may not take
away from the people who live under the government's authority. A bill of rights sets legal limits on the power of
government to prevent public officials from denying liberties and rights to individuals, which they possess on the
basis of their humanity. http://www.answers.com/topic/bill-of-rights?cat=biz-fin
OPTION A: Constitution of the Philippines - Fundamental and entrenched rules governing the conduct of a nation,
and establishing its concept, character, and structure. It is usually a short document, general in nature and
embodying the aspirations and values of its writers and subjects.
http://www.businessdictionary.com/definition/constitution.html
OPTION B: A penal code can be defined as that portion of a state's laws that deal with defining the elements of
particular crimes and specifying the punishment for each crime http://en.wikipedia.org/wiki/Penal_code
OPTION C: Laws of the land - Aggregate of all custom, statute, usage, and other types of laws of a country
applicable to everyone (including the government) within the jurisdiction of its courts. See also legal system.
http://www.businessdictionary.com/definition/law-of-the-land.html

RATIONALE: The undefined burden of mental problems refers to the economic and social burden for families,
communities and countries. Although obviously substantial, this burden has not been efficiently measured. This is
because of the lack of quantitative data and difficulties in measuring and evaluating.
The hidden burden refers to the burden associated with stigma and violations of human rights and freedoms.
Again, this burden is difficult to quantify. This is a major problem throughout the world, as many cases remain
concealed and unreported.
(http://www.who.int/mediacentre/factsheets/fs218/en/)
According to literatures, there are no future and defined burden.

RATIONALE: Involuntary hospitalization is a legal procedure used to compel an individual to receive inpatient
treatment for a mental health disorder against his or her will. The legal justifications vary somewhat from state to
state, but are generally based on a determination that a person is imminently dangerous to self or others; is
gravely disabled; or clearly needs immediate care and treatment. Involuntary hospitalization is synonymous with
involuntary commitment or involuntary treatment, and is an extremely controversial course of action. It is generally
a last resort used in dealing with a person who is so ill that he/she is unable to use proper judgment or insight in
deciding to refuse treatment. http://www.minddisorders.com/Flu-Inv/Involuntary-hospitalization.html

RATIONALE: Confidential information may also be revealed as provided for by law in Article IV, Section 4(1) o the
New Constitution, which states that “the privacy of communication and correspondence shall be inviolable except
upon lawful order of the court or when public safety and order require otherwise.”
Confidential information may be revealed only when:
▪ the patient himself/herself permits such revelation as in the case of claim for hospitalization, insurance benefits,
among others;
▪ the case is medico-legal which have to be reported to the local police or NBI or constabulary;
▪ the patient is ill of communicable disease and public safety may be jeopardized; and
▪ given to members of the health team if information is relevant to his care.
SOURCE: Venzon. Professional Nursing in the Philippines.10th ed. p. 106

RATIONALE: Options A,B, and D are all responsibilities of the nurse in mental health promotion. Option C is a
responsibility of the nurse during the rehabilitation phase. Please refer to Community health nursing services in
the department of health Philippines pp. 197-198 for a complete list of the responsibilities of the nurse in the
Mental Health Program of the DOH
Situation 4- A research was conducted on “The Effects of the Nurse Expressive Role in the Reduction of Anxiety in
Patients who will undergo NGT insertion.”

RATIONALE: If researchers have concerns about their study plan, they may undertake a pilot study, which is a
small-scale version or trail run of the major study.
Pretest- the trial administration of a newly developed instrument (ex. questionnaire) to identify flaws or assess
time requirements.
Proposal- a document specifying what the researcher proposes to study.
Test-retest reliability- assessment of the stability of an instrument by correlating the scores obtained on repeated
administrations.
SOURCE: Polit, D. Nursing Research Principles and Methods. 7th ed. pp. 51, 728, 734

Rationale: Independent variable- the variable that is believed to cause or influence the dependent variable; in
experimental research, the manipulated (treatment) variable. (Polit, D. Nursing Research Principles and Methods.
7th ed. p. 720)
In the above research, expressive role of the nurse is the independent variable.
Patient who will undergo NGT insertion is the subject of the study.
Reduction of patient’s anxiety is the dependent variable.

Rationale: The dependent variable is also known as the measured variable, the responding variable, the
explained variable, or the outcome variable. (http://en.wikipedia.org/wiki/Dependent_and_independent_variables)
Therefore, the variable that can be measured is the reduction of anxiety.
Patients who will undergo NGT insertion is the subject of the study.
The Nurse expressive role is the independent variable.

Rationale: Independent variable- the variable that is believed to cause or influence the dependent variable; in
experimental research, the manipulated (treatment) variable. (Polit, D. Nursing Research Principles and Methods.
7th ed. p. 720)
The expressive role of the nurse is the variable that can be manipulated (independent variable).
Patient who will undergo NGT insertion is the subject of the study.
Reduction of patient’s anxiety is the dependent variable.

Rationale: Results from experimental studies are primarily concerned with whether or not a treatment works.
Experimental or “true” designs are the gold standard for research because these studies attempt to establish
causal relationships between two or more factors. Experimental study seeks to produce definitive conclusions and
measurable results. A well-designed experimental study allows the researchers to answer a research question
with a high degree of certainty because their conclusions are backed up by concrete data.
B- Quasi-experimental research projects seek to compare two groups of individuals who are thought to have
similar characteristics.
C- Descriptive studies are conducted to address the question of why something occurs.
D- Exploratory research is a study that explores the dimensions of a phenomenon or that develops or refines
hypotheses about relationships between phenomena.
SOURCE:http://www.air.org/publications/documents/Becoming%20an%20Educated%20Consumer%20of
%20Research.pdf
Situation 5 - Communication between patient-nurse and nurse-health team is very important

Rationale: The second component of the communication process is the message itself – what is actually said or
written, the body language that accompanies the words, and how the message is transmitted.
Feedback- the response, it is the message that the receiver returns to the sender.
Channel- the medium used to convey the message. It is important for the channel to be appropriate for the
message and it should help make the intent of the message clearer.
Kozier. Fundamentals of Nursing.7th Edition.p. 422

Rationale: Listening is the most important skill to learn and develop fully in order to collect complete and valid data
from your client. To listen effectively, you need to maintain good eye contact, smile or display an open,
appropriate facial expression, maintain an open body position (open arms and hands and lean forward). Avoid
preconceived ideas or biases about your client. To listen effectively, you must keep an open mind. Avoid crossing
your arms, sitting back, tilting your head away from the client, thinking about other things, or looking blank or
inattentive. Becoming an effective listener takes concentration and practice.
Effective verbal communication is essential to a client interview. The goal of the interview process is to elicit as
much data about the client’s health status as possible. Several types of questions and techniques to use during
the interview are discussed in the following sections.
Nonverbal communication is as important as verbal communication. Your appearance, demeanor, posture, facial
expressions, and attitude strongly influence how the client perceives the questions you ask. Never overlook this
type of communication or take it for granted.
(http://connection.lww.com/Products/weber3e/documents/PDF/ch03.pdf)
Stereotyped communication is not used in a nurse-client and nurse- health team communication because it is
non-therapeutic.

Rationale: The characteristics of an effective nurse-client relationship are as follows:
an intellectual and emotional bond between the nurse and the patient and is focused on the patient
respects the client as an individual- his ability to participate in his care, ethnic and cultural factors, family
relationships and values
respects client’s confidentiality
focuses on the client’s well-being
based on mutual trust, respect and acceptance
Source: Mastering Fundamentals of Nursing by Quiambao-Udan. P. 157

Rationale: For effective communication, the nurse uses active listening and creates an environment in which the
client feels comfortable expressing feelings. An authoritarian approach is directive and not permissive and will not
create an environment for verbal exchange from the client. Reacting only to the facts are examples of inactive
listening. Reacting enthusiastically is not the most effective strategy.
Silvestri, L. A. Saunders Q&A review for the NCLEX-RN Exam. 3rd Edition. p. 775

Rationale: Nonverbal communication often tells others more about what a person is feeling than what is actually
said, because nonverbal behavior is controlled less consciously than verbal behavior. (Kozier. Fundamentals of
Nursing.7th Edition.p. 424)
Empathy is good because it is an expression of understanding of the feelings of the client but the nurse should not
be in control of the situation.
The nurse should acknowledge both the positive and the negative comments made the clients.
Situation 6 - In clinical nursing research, the subjects are generally clients or patients.

Rationale: Random sampling involves a selection process in which each element in the population has an equal,
independent chance of being selected.
Polit, D. Nursing Research Principles and Methods. 7th ed. p. 295
A - Multistage sampling is best used with populations that are organized into groups, like national and local
political boundaries; large organizations that are divided into departments; classrooms within a school system.
http://www.llc.rpi.edu/web/ResearchMethodsForCommunicationScience/ch06.pdf
B- Anonymity of subjects is preserved in all types of sampling, not only in random sampling.
C – refers to cluster sampling, example, in the first stage 10 states in the US were selected using a complex
stratification procedure. In the second stage, RNs were selected from each state.

Rationale: Convenience sampling entails using the most conveniently available people as study participants. A
faculty member who distributes questionnaires to nursing students in a class is using convenience sample. The
nurse who conducts an observational study of women delivering twins at the local hospital is also relying on a
convenience sample. The problem with convenience sampling is that available subjects might be atypical of the
population of interest with regard to critical variables.
A- Purposive sampling is based on the belief that researchers’ knowledge about the population can be used
to hand-pick sample members. Researchers might decide purposely to select subjects who are judged to
be typical of the population or particularly knowledgeable about the issues under study.]
B- refers to simple random sampling
C- refers to systematic sampling. It involves selection of every kth case from a list or group.
SOURCE: Polit, D. Nursing Research Principles and Methods. 7th ed. pp. 292- 299
Rationale: Prospective participants who are fully informed about the nature of the research and its potential risks
and benefits are in position to make rational decisions about participating in the study. Informed consent means
that the participants have adequate information regarding the research, are capable of comprehending the
information, and have the power of free choice, enabling them to consent to or decline participation voluntarily.
Polit, D. Nursing Research Principles and Methods. 7th ed. p. 151
Options B, C, and D are considered if the subjects agreed to participate in the study.

Rationale: Demographic variables include age, sex, race, and ethnicity. Social data includes educational history,
economic status, and social status.
Kozier. Fundamentals of Nursing. 7th Edition. pp. 180, 263
Informal consent is not an example of a socio-demographic variable, not even a part of a study. In a study,
informed consent is utilized, not informal consent.

Rationale: Researchers are sometimes able to study the outcomes of “natural experiment” in which a group
exposed to natural or other phenomena that have important health consequences are compared with a
nonexposed group. Such natural experiments are nonexperimental because the researcher does not intervene
but simply observes the outcome of an external event or circumstance.
Observational research- studies in which data are collected by observing and recording behaviors or activities
relating to phenomenon of interest.
Quantitative research is the investigation of phenomena that lend themselves to precise measurement and
quantification, often involving a rigorous and controlled design.
Positivist paradigm is the traditional paradigm iunderlying the scientific approach, which assumes that there is
fixed, orderly reality that can be objectively studied; often associated with quantitative research.
Polit, D. Nursing Research Principles and Methods. 7th ed. pp. 191, 726-729
Situation 7- Record management is another responsibility of the nurse

Rationale: Recordings need to be brief as well as complete to save time in communication. The client’s name and
the word client are omitted.
Kozier. Fundamentals of Nursing.7th Edition. p 341

Rationale: Use only commonly accepted abbreviations, symbols and terms that are specified by the agency. Many
abbreviations are used universally. The nurse should know and use only the approved list of abbreviations at the
facility to avoid putting a client at potential risk.
Option A – The client’s name and identifying information should be stamped or written on each page of the clinical
record. Before making any entry, check that it is the correct chart. Recordings need to be brief as well as
complete to save time in communication. The client’s name and the word client are omitted.
Option B – Be timely. A late entry is better than no entry, however the longer the period of time between actual
care and charting, the greater the suspicion.
Option C – all entries must be legible and easy to read to prevent interpretation errors. Document the date and
time of each recording. This is essential not only for legal reasons but also for client safety. Each recording on the
nursing notes is signed by the nurse making it. The signature includes the name and the title.
Kozier. Fundamentals of Nursing.7th Edition.pp 341-344

Rationale: NPO- nil per os (nothing by mouth)
OD- oculus dextre (right eye)
PRN- pro re nata (as needed)

Rationale: Members of the health care team, the speech therapist and physical therapist, who are directly
involved in the treatment of the patient are allowed to have free access on the client’s record. The client is also
allowed to have access on the chart with the supervision of the nurse or any of the members of the health team.

Rationale: Technically, there's no formal definition for a “Code”, but doctors often use the term as slang for a
cardiopulmonary arrest happening to a patient in a hospital or clinic, requiring a team of providers (sometimes
called a “code team”) to rush to the specific location and begin immediate resuscitative efforts.
(http://www.medicinenet.com/script/main/art.asp?articlekey=57667)
DNR means Do Not Resuscitate. This is a specific order not to revive a patient artificially if they succumb to
illness. If a patient is given a DNR order, they are not resuscitated if they are near death and no code blue is
called. http://www.medicinenet.com/script/main/art.asp?articlekey=54842&page=2
Situation 8 - You consider Nurse Crys, chief nurse of your hospital a traditional and bureaucratic leader

Rationale: Characteristics of bureaucratic management:
♥ clear division of labor
♥ well-defined hierarchy of authority in which superiors are separated from subordinates; on the basis of this
hierarchy, remuneration for work is dispensed, authority is recognized, privileges are allotted, and promotions are
awarded.
♥ bureaucrats are not free to act in any way they please. Bureaucratic rules provide systematic control of
superiors over subordinates, thus limiting the opportunities for arbitrary behavior and personal favoritism.
♥ a system of procedures for dealing with work situations must exist
♥ a system of rules covering the rights and duties of each position must be in place.
♥ selection for employment and promotion based on technical competence.
Participative decision making is only allowed in Participative Management which was introduced by Mary Parker
Follet.
SOURCE: Marquis, B. Leadership Roles and Management Functions in Nursing. 5th ed. pp. 271-272, 29

Rationale: The human relations movement began in the 1940s with attention focused on the effect individuals
have on the success or failure of an organization.
B – refers to scientific management
C – refers to bureaucratic management
D – refers to laissez-faire management
SOURCE: Marquis, B. Leadership Roles and Management Functions in Nursing. 5th ed. pp. 26-29, 51

Rationale: Laissez-faire - With this style, executives let subordinates make their own decisions. This style is also
called empowering or delegative. The conventional term 'laissez-faire” has a lax implication, suggesting that
employees are free to do whatever they want. But it is now more constructive to talk of empowerment so that
there is no connotation of losing control.
Because it is non-directed leadership, the laissez-faire leadership style can be frustrating; group apathy and
disinterest can occur. In health care setting, patient care needs collaboration and team work among members of
the health care team, so this kind of leadership style is not suitable in health care settings.
Situational leadership style- it predicts which leadership style is most appropriate in each situation based on the
level of the followers’ maturity. As people mature, leadership style becomes less task focused and more
relationship oriented.
Authoritarian leadership results in well-defined group actions that are usually predictable, reducing frustration in
the work group and giving members a feeling of security. Productivity is usually high, but creativity, self-
motivation, and autonomy are reduced.
Democratic leadership, appropriate for groups that work together fro extended periods, promotes autonomy and
growth in individual workers. This type of leadership is particularly effective when cooperation and coordination
between groups are necessary.
SOURCE: Marquis, B. Leadership Roles and Management Functions in Nursing. 5th ed. pp 50-52

Rationale: Expert power is gained through knowledge, expertise, or experience. Having critical knowledge allows
a manager to gain power over others who need that knowledge.
Option A- Referent (Charismatic) Power- people may develop referent power because others perceive them as
powerful. This perception could be based on personal charisma, the way the leader talks or acts, the
organizations to which he or she belongs, or the people with whom he or she associates.
Option B refers to reward power. Reward power is obtained by the ability to grant favors or reward others with
whatever they value. The arsenal of rewards that a manager can dispense to get employees toward meeting
organizational goals is very broad. Positive leadership through rewards tends to develop a great deal of loyalty
and devotion toward leaders.
Option C- Punishment or coercive power, the opposite of reward power, is based on fear of punishment if the
manager’s expectations are not met. The manager who shuns or ignores an employee is exercising power
through punishment, as is the manager who berates or belittles an employee.
SOURCE: Marquis, B. Leadership Roles and Management Functions in Nursing. 5th ed. pp.306-307

Rationale: A refers to being a change agent. B is a role of patient advocate. C is a case manager, while D
basically summarized functions of a nurse manager. Formulating philosophy and vision is in PLANNING. Nursing
audit is in CONTROLLING. In service education programs are included in DIRECTING. These are the processes
of Nursing Management.
Situation 9- Your head nurse participated in a 2-week seminar. You were designated to be the officer-in-charge of your
unit.

Rationale: Planning encompasses determining unit philosophy, goals, objectives, policies, procedures, and rules;
carrying out long- and short- range projections; determining a fiscal course of action; and managing planned
change.
Controlling functions include performance appraisals, fiscal accountability, quality control, legal and ethical
control, and professional and collegial control.
Directing sometimes includes several staffing functions. However, this phase’s functions usually entail human
resource management and responsibilities, such as motivating, managing conflict, delegating, communicating,
and facilitating collaboration.
Organizing includes establishing structure to carry out plans, determining the most appropriate type of patient
care delivery, and grouping activities to meet unit goals.
Marquis, B. Leadership Roles and Management Functions in Nursing. 5th ed. p. 28
Rationale: Patient classification system also known as workload management group patients according to specific
characteristics that measure acuity of illness in an effort to determine both the number and mix of the staff needed
to adequately care for those patients.
Patient classification system (PCS) is a method of determining, validating, and monitoring individual patient care
requirements over time. A valid and reliable PCS can offer organizations: a way to provide staffing flexibility;
balanced patient assignments; effective staff utilization; a sound method for budget preparation and defense.
http://www.patientclassificationsystem.com/faqpcs.htm

Rationale: Objectives are similar to goals in that they motivate people to a specific end and in addition, are
explicit, measurable, observable or retrievable, and obtainable. Objectives, however, are more specific and
measurable than goals because they identify how and when the goal is to be accomplished. Knowing the
objectives of the unit, you can identify what are the things that should be done and how to do it.
Options B and C are used as resources in attaining the objectives of the unit. They serve as the means by which
the objectives can be met.
D – Mission of the hospital is so general and broad. The question was only referring to nursing unit.
Marquis, B. Leadership Roles and Management Functions in Nursing. 5th ed. p 156

Rationale: Objectives are similar to goals in that they motivate people to a specific end and in addition, are
explicit, measurable, observable or retrievable, and obtainable. Marquis, B. Leadership Roles and Management
Functions in Nursing. 5th ed. p 156
To provide safe nursing care (option D) is the only objective that speaks about patient care.
D- it is an objective regarding unit supplies/ materials
E- it is an objective for documentation/ charting
F- it focuses on the number of nursing staff not on patient care.

Rationale: Performance appraisal- an appraisal of how well employees perform the duties of their job as
delineated by the job description. (Marquis, B. Leadership Roles and Management Functions in Nursing. 5th ed.
p. 616)
Performance assessment is a measure of assessment based on authentic tasks such as activities, exercises, or
problems that require students to show what they can do.
(http://www.ascd.org/portal/site/ascd/menuitem.4427471c9d076deddeb3ffdb62108a0c/)
Performance audit refers to an examination of a program, function, operation or the management systems and
procedures of a governmental or non-profit entity to assess whether the entity is achieving economy, efficiency
and effectiveness in the employment of available resources. The examination is objective and systematic,
generally using structured and professionally adopted methodologies.
(http://en.wikipedia.org/wiki/Performance_audit)
Performance standards provide the employee with specific performance expectations for each major duty. They
are the observable behaviors and actions which explain how the job is to be done, plus the results that are
expected for satisfactory job performance.
(http://www.indiana.edu/~uhrs/training/performance_management/define.htm)
Situation 10 - As a registered nurse, nurse Nina will assume accountability for her nursing actions.

Rationale: Battery is an intentional, unconsented touching of another person. It is therefore, important that before
a patient can be touched, examined, treated or subjected to medical/surgical procedures, he must have given
consent to this effect.
Negligence refers to the commission or omission of an act, pursuant to a duty, that a reasonably prudent person
in the same or similar circumstance would or would not do, and acting or the non-acting of which is the proximate
cause of injury to another person or his property.
Assault is the imminent threat to harmful or offensive bodily contact.
A tort is a legal wrong, committed against a person or property independent of a contract which renders the
person who commits it liable for damages in a civil action.
SOURCE: Venzon.Professional Nursing in the Philippines.10th ed.pp.160, 178

Rationale: The elements of professional negligence: (1) existence of a duty on the part of the person charged to
use due care under circumstances, (2) failure to meet the standard of due care, (3) the foreseeability of harm
resulting from failure to meet the standard, and (4) the fact that the breach of this standard resulted in an injury to
the plaintiff.
SOURCE: Venzon.Professional Nursing in the Philippines.10th ed. p. 161

Rationale: Res ipsa Loquitor – “the thing speaks for itself
Three conditions are required to establish a defendant’s negligence without proving specific conduct. These are:
That the injury was of such nature that it would not normally occur unless there was a negligent act on the part of
someone;
That the injury was caused by an agency within control of the defendant; and
That the plaintiff himself did not engage in any manner that would tend to bring about the injury.
SOURCE: Venzon. Professional Nursing in the Philippines.10th ed. p. 163
Option C is an example of malpractice.
Option D is an example of negligence.

Rationale: Prudence- permits us to live with good sense and perspective. Guides one’s action of here and now.
Reliability- it is dependability and involves one’s use of sound judgment based upon careful observation and an
understanding of any given situation in which one is required to act.
Honesty- being truthful, trustworthy and upright in one’s dealings with others as well as refraining from lying,
cheating, and stealing.
Resourcefulness- involves a person’s ability to recognize and deal promptly and effectively with difficulties or
problems that arise.
Source: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 8-10

Rationale: According to RA 9173 (The Philippine Nursing Act of 2002) Article III Section 9.Powers and Duties of
the Board – the Board shall supervise and regulate the practice of the nursing profession and shall have the
following powers, duties and functions: issue, suspend or revoke certificates of registration for the practice of
nursing.
SOURCE: Venzon. Professional Nursing in the Philippines.10th ed. P 251
Situation11- The role of the Nurse is bounded by several ethico-moral responsibilities

Rationale: Autonomy- it involves self-determination and freedom to choose and implement one’s decision, free
from deceit, duress, constraint or coercion.
Beneficence- the principle of beneficence promotes doing acts of kindness and mercy that directly benefit the
patient.
Nonmaleficence- in some way the principle of nonmaleficence is similar to the principle of beneficence. The
distinction lies in the fact that the principle of beneficence is stated in a positive form while nonmaleficence is
stated in a positive form while non maleficence is stated as an admonition in the negative form to remind health
practitioners to do no harm.

Rationale: Parents, or someone standing in their behalf, gives the consent to medical or surgical treatment of a
minor. For a mentally incompetent person, the consent must be taken from the parents or legal guardian.
SOURCE: Venzon. Professional Nursing in the Philippines.10th ed. pp. 174-175

Rationale: Double-effect. An action that is good in itself that has two effects--an intended and otherwise not
reasonably attainable good effect, and an unintended yet foreseen evil effect--is licit, provided there is a due
proportion between the intended good and the permitted evil.
http://www.ascensionhealth.org/ethics/public/key_principles/double_effect.asp
Justice- refers to the right to demand to be treated justly, fairly, and equally. (Venzon.Professional Nursing in the
Philippines.10th ed. p. 103)
Autonomy- it involves self-determination and freedom to choose and implement one’s decision, free from deceit,
duress, constraint or coercion. (Venzon.Professional Nursing in the Philippines.10th ed. p. 99)
Paternalism in the context of health care is constituted by any action, decision, rule, or policy made by a physician
or other care-giver, or a government, that dictates what is best for the patient(s) without considering the patient’s
own beliefs and value system and does not respect patient autonomy.
http://www.ascensionhealth.org/ethics/public/issues/paternalism.asp

Rationale: As a nurse, we are bound to respect the patients’ or clients’ autonomy - their right to decide whether or
not to undergo any health care intervention – even where a refusal may result in harm or death to themselves or a
fetus, unless a court of law orders to the contrary. (Burnard, P. Professional and Ethical Issues in Nursing. 3rd ed.
p. 126)
Justice- refers to the right to demand to be treated justly, fairly, and equally.
Beneficence- means doing good. Nurses are obliged to do good, that is, to implement actions that benefit clients
and their support persons.
Nonmaleficence- is duty to “do no harm”

Rationale: Nonmaleficence- commonly translated as "first, do no harm," is often considered being an outcome to
the principle of beneficence. In this respect, it shares the same characteristics of beneficence considered as a
middle principle. Considered in its own right, nonmaleficence is sometimes interpreted to imply that if one cannot
do good without also causing harm, then one should not act at all (in that particular circumstance).
http://www.ascensionhealth.org/ethics/public/key_principles/beneficence.asp
Veracity- telling the truth. (Venzon.Professional Nursing in the Philippines.10th ed. p. 100)
Beneficence- The principle of beneficence requires us, other things being equal, to do good, or what will further
the patient's interest. http://www.sewanee.edu/Philosophy/bioethics/principles.html#beneficence
Autonomy- it involves self-determination and freedom to choose and implement one’s decision, free from deceit,
duress, constraint or coercion. (Venzon.Professional Nursing in the Philippines.10th ed. p. 99)
Situation 12 - In RA 9173, health education is the major responsibility of the nurse.

Rationale: Option D encompasses all the choices given. Green defined health education as “any combination of
learning experience designed to facilitate voluntary adoptions of behaviors conducive to health. (Public health
nursing in the Philippines p. 61)

Rationale: Cognitive domain pertains to the mental processes of knowing, perceiving, or being aware. Explaining
the rationale for taking new medications shows that the client has understood why he/she is taking the
medication.
Options B and D - psychomotor domain.
Option C – affective domain

Rationale: According to Philippine Nursing Act of 2002 Article VI Section 28- Scope of Nursing. - It shall be the
duty of the nurse to: Provide health education to individuals, families and communities. ()
The Code of Ethics for Nurses as promulgated by the BON states that the primary responsibility of the Filipino
registered nurse is to preserve health at all cost. This responsibility encompasses promotion of health, prevention
of illness, alleviation of suffering, and restoration of health. However, when the foregoing are not possible,
assistance towards a peaceful death shall be his/her obligation. (Venzon.Professional Nursing in the
Philippines.10th ed.p 285)
The by-laws of the PNA is about the guiding rules of or the principles by which the PNA must operate or function.

Rationale: The best way to disseminate information to the publicis by television followed by radio. This is how the
DOH establish its IEC Programs other than publishing posters, leaflets, and brochures. An emerging new way to
disseminate is through the internet.
http://pinoybsn.blogspot.com/2006/09/fundamentals-of-nursing-infection_12.html
Situation13- You took over the nursing care of Paolo with an infected wound. He is an accountant and asks nurse Jarred
about his condition

Rationale: Most, if not all, epithelial tissues contain stem cells. They are responsible for normal tissue renewal or
for regeneration following damage. (http://cmbi.bjmu.edu.cn/cmbidata /stem/specific/epithelial)
Macrophage: A type of white blood that ingests (takes in) foreign material. Macrophages are key players in the
immune response to foreign invaders such as infectious microorganisms.
http://www.medterms.com/script/main/art.asp?articlekey=4238
Neutrophil: A type of white blood cell, specifically a form of granulocyte, filled with neutrally-staining granules, tiny
sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis.
http://www.medterms.com/script/main/art.asp?articlekey=4561
Platelets or thrombocytes are the cell fragments circulating in the blood that are involved in the cellular
mechanisms of primary hemostasis leading to the formation of blood clots
http://en.wikipedia.org/wiki/Platelets

Rationale: Stress launches a sequence of events that constrict blood vessels and deprive the tissues of oxygen.
Without sufficient oxygen, tissues can't heal. Oxygen activates the inflammatory cells of the immune system that
help healing. Also, oxygen derivatives like bleach and peroxide are part of the arsenal of noxious products that
these cells use to kill the bacteria in wounds. (http://www.sciencedaily.com/releases/2005/07/050729063608.htm)
In ischemia, there is a restriction of blood supply. Blood brings oxygen and nourishment to the wound, therefore
when there is ischemia, wound healing is delayed.
Wound healing places additional demands on the body. Clients require a diet rich in protein, carbohydrates, lipids,
Vitamins A and C, and minerals. Malnourished clients may require time to improve their nutritional status for faster
wound healing.
SOURCE: Kozier. Fundamentals of Nursing.7th Edition. p. 862

Rationale: at the start of the first stage of inflammation, constriction of the blood vessels occurs at the site of
injury, lasting only a few moments.the initial constriction is rapidly followed by dilation of small blood vessels. Thus
more blood flows to the injured area. This marked increase in blood supply is referred to as hyperemia and is
responsible for the characteristic signs of redness and heat. Vascular permeability increase at the injured site with
the dilation of the vessels in response to cell death, the release of chemical mediators, and the release of
histasmine. The result of this altered permeability is an outpouring of fluid, proteins, and leukocytes into the
interstitial spaces, clinically manifested by the characteristic inflammatory signs of swelling and pain. In the
second stage of inflammation, the inflammatory exudate is produced, consisting of fluid that escaped from the
blood vessels, dead phagocytic cells, and dead tissue cells and products that they release.
Source:Kozier. Fundamentals of Nursing.7th Edition.p. 634

Rationale: The present epidemiology approach is based on the interaction of the host, the causative agent, and
the environment. A change in any of the component will alter an existing equilibrium to increase or decrease the
frequency of the disease. Essentially epidemiology patterns depend upon these factors which influence the
probability of contact between an infectious agent and a susceptible host. (Public health nursing in the Philippines
pp. 63-64)
Option A refers to the agent.
Options B and C refers to the attributes of the host.

Rationale: Vascular permeability increases at the injured site with the dilation of the vessels in response to cell
death, the release of chemical mediators (Bradykinin, serotonin, and prostaglandin), and the release of histamine.
The result of this is altered permeability is an outpouring of fluid, proteins, and leukocytes (white blood cells) into
the interstitial spaces, clinically manifested by the characteristic inflammatory signs of swelling (edema) and pain.
The pain is caused by the pressure of accumulating fluid on local nerve endings and the chemical mediators,
which are thought to irritate the nerve endings. (Kozier. Fundamentals of Nursing.7th Edition.p. 634)
Situation 14 - Lucky is a college student who went to a clinic for check up. Nurse Nancy attended to his needs.

Rationale: SIGNS OF GOOD NUTRITION
Alert, responsive
Weight is normal for height, age and body build
Posture-erect, arms and legs straight
Muscles-well developed, firm, good tone; some fat under skin
Lips-smooth, good color, moist, not chapped or cracked
Mouth and oral membranes-reddish pink mucous membranes
Nails-firm, ink
SIGNS OF POOR NUTRITION
Listless, apathetic, and cachectic
Weight-overweight or underweight
Posture-sagging shoulders, sunken chest, humped back
Muscles-Flaccid, poor tone; underdeveloped; tender; "wasted" appearance; cannot walk properly
Lips-dry, scaly, swollen, redness and swelling,or angular lesions at corners of mouth; fissures; scars.
http://www.rscc.cc.tn.us/faculty/Freeman/Nutrition.pdf

Rationale: Accurate assessment of the client’s height, current body weight, and usual body weight is essential.
Although the client’s current body weight can be compared with an ideal body weight, the IBW is based on healthy
people and does not account for changes in the client’s body composition that accompany illness or reflect any
changes in weight. The client’s usual body weight better reflects weight change and the possibility of malnutrition.
The nurse should describe any weight loss or gain, the duration of the change, and whether the weight change
was intentional or unintentional.
A sample of his daily diet (Option B) and foods he ate yesterday (Option C) only provides information about the
types of foods eaten but not the quantities. These data are not reliable in determining the level of nutrition of the
client.
Kozier. Fundamentals of Nursing.7th Edition. p. 1193

RATIONALE: the measurement and recording of all fluid intake and output (I&O) during a 24-hour period provides
important data about the client’s fluid and electrolyte balance. To determine whether the fluid output is
proportional to fluid intake or whether there are any changes in the client’s fluid status, the nurse compares the
total 24-hour fluid output measurement with the total fluid intake measurement and compares both to previous
measurements.
Kozier. Fundamentals of Nursing.7th Edition.pp. 1373-1374
OPTION A – Not all fluid intake becomes urine output, some of the fluid filtered in the kidneys are reabsorbed and
used by the body and some are excreted through urine.
OPTIONC- Although the proportion of body water decreases as age increases, we can still measure accurately
the intake and output of the patient.

RATIONALE: Gelatin is classified as a clear liquid; ice cream and cream soup are examples of full liquid. Porridge
contains oats and rice, therefore it can’t be classified as liquid.
Kozier. Fundamentals of Nursing. 7th Edition. p. 1201

RATIONALE: Maintaining a healthy diet is the practice of making choices about what to eat with the intent of
improving or maintaining good health. Usually this involves consuming necessary nutrients by eating the
appropriate amounts from all of the food groups, including an adequate amount of water. Offer a wide variety of
foods, such as grains, vegetables and fruits, low-fat dairy products, and lean meat or beans.
(http://en.wikipedia.org/wiki/Balanced_diet)
OPTION B – decrease in fat and increase in carbohydrates is good but protein intake must be increased also
because protein is essential for cell growth. Option C is also wrong because foods served at fast food chains are
high in fat. A healthy diet consist fruits and vegetables, therefore option D is incorrect.
Situation 15 - As a graduate of BSN program, you are expected to demonstrate basic nursing skills for safe and quality
care.

RATIONALE: When performing perineal care in a female client, use front to back technique. This prevents
contamination of urethral meatus and vaginal orifice by microorganisms from the anus. Cleanse perineum with
soap/antiseptic solution. Include the inner thigh. Rinse the area with copious amount of water to remove soap
adequately and prevent irritation of the perineal area. Dry perineum thoroughly; moisture supports bacterial
growth.
SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 287-288, 296, 299)

RATIONALE: Mouth care for unconscious client: (1) Place in side-lying position to prevent aspiration; (2) Have
suction apparatus readily available; (3) Use padded tongue blade to open the mouth; (4) Brush teeth and gums,
using toothbrush or soft sponge-ended swab; (5) Apply thin layer of petroleum jelly to lips to prevent drying or
cracking.
SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. p. 290)

RATIONALE: Options A, B, and D all pose danger to the safety of the client. Only option B provides a safe
environment for clients.

RATIONALE: IM injection (Z- tract technique)-
•Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of
the skin.
• Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the
needle is withdrawn.
• Do not massage the site of injection. To prevent irritation of the site and to prevent
leakage into subcutaneous.
Source: Mastering Fundamentals of Nursing by Quiambao-Udan. p. 360

RATIONALE: Male: laterally upward over the lower abdomen to prevent penoscrotal pressure.
Female: inner aspect of the thigh, so it will not pull when the legs move.
SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. p. 271

RATIONALE: It was concluded that even suberythemal doses of UV significantly reduce delayed type
hypersensitivity responses to purified protein derivative, and that an adaptive mechanism appears to counteract
the immunosuppressive effects of chronic irradiation.
http://www.nature.com/jid/journal/v110/n5/full/5600071a.html
Scratching the test site will cause an infection, so it is best not to touch it. Bandaids, bandages and ointments can
affect the test results, so it is important to keep the skin clear and uncovered (long sleeves and jumpers
[sweaters] can be worn) http://www.masongross.rutgers.edu/music/handbook/tb.htm.
Usually the test is interpreted after 30 minutes except the Mantoux test (which is checked after 24 or 48 hours).
Instruct the client not to wash, rub or scratch the injection site. The site should be kept dry.
Situation 16 - A significant milestone influencing the development of nursing concepts and theories was the
establishment of the Journal of Nursing Research. Several nursing theorists have published the framework for practice
according to their perspective nursing theory.

RATIONALE: Martha Rogers conceptualized the Science Of Unitary Human Beings. To Rogers, unitary man is an
energy field in constant interaction with the environment. She asserted that human beings are more than and
different from the sum of their parts; the distinctive properties of the whole are significantly different from those of
its parts. Furthermore, she believed that human being is characterized by the capacity for abstraction and
imagery, language and thought, sensation and emotion.
Dorothea Orem developed the Self-Care and self Care Deficit Theory. She defined self-care as “the practice of
activities that individuals initiate and perform on their own behalf in maintaining life, health and well-being.
Florence Nightingale developed and described the first theory of nursing. Notes on Nursing: What It Is, What It Is
Not. She focused on changing and manipulating the environment in order to put the patient in the best possible
conditions for nature to act.
Faye Abdellah introduced Patient-Centered Approaches to Nursing Model. She identified 21 nursing problems.
She defined nursing as service to individuals and families; therefore to society.
SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 16-19)

RATIONALE: Self-Care Deficit Theory (Dorothea Orem) - she defined self-care as “the practice of activities that
individuals initiate and perform on their own behalf in maintaining life, health and well-being.” She conceptualized
three nursing systems as follows: 1. Wholly Compensatory- when the nurse is expected to accomplish all the
patient’s therapeutic self-care or to compensate for the patient’s inability to engage in self-care or when the
patient needs continuous guidance in self-care; 2. Partially Compensatory- when both nurse and patient engage
in meeting self-care needs; 3. Supportive-Educative- the system that requires assistance in decision making,
behavior control and acquisition of knowledge and skills.
Theory of the Unitary Man (Martha Rogers) - unitary man is an energy field in constant interaction with the
environment. She asserted that human beings are more than and different from the sum of their parts; the
distinctive properties of the whole are significantly different from those of its parts.
(Transcultural Nursing Model (Madeleine Leininger) - advocated that nursing is a humanistic and scientific mode
of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or
maintain a health condition.
Adaptation Theory (Sister Callista Roy) - she viewed each person as a unified biopsychosocial system in constant
interaction with a changing environment. She contended that the person as an adaptive system, functions as a
whole through interdependence of its parts. Accordingly Roy believed that adaptive human behavior is directed as
an attempt to maintain homeostasis or integrity of the individual by conserving energy and promoting the survival,
growth, reproduction and mastery of human system.
SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 17-20)

RATIONALE: King's Goal Attainment Theory involves the nurse and the patient mutually communicating
information, establishing goals, and taking action to obtain goals. The goal attainment theory is based on personal
and interpersonal systems, including interaction, communication, transaction, role, stress, growth and
development, time and space. http://www.muw.edu/nursing/tupelo/NU433KING'S.htm
Technical skills and environmental management skills are not mentioned in Imogene King’s Goal Attainment
Theory.
Assessment is also not apart of the above theory.

RATIONALE: Faye Abdellah- introduced Patient-Centered Approaches to Nursing Model. She identified 21
nursing problems. She defined nursing as service to individuals and families; therefore to society.
Dorothy Johnson- conceptualized the Behavioral System Model.
Virginia Henderson- introduced The Nature of Nursing Model. Identified 14 basic needs.
Sister Callista Roy- presented the Adaptation Model. She viewed each person as a unified biopsychosocial
system in constant interaction with a changing environment. (Source: Mastering Fundamentals of Nursing by
Quiambao-Udan. pp. 16-20)

RATIONALE: Kohlberg suggested 3 levels of moral development. He focused on the reasons for the making of a
decision, not on the morality of the decision itself. At first level called the premoral or the preconventional level,
children are responsive to cultural rules and labels good and bad. However, children interpret these in terms of
the physical consequences of their actions, i.e., punishment or reward. At the second level, the conventional level,
the individual is concerned about maintaining the expectations of the family, groups or nation and sees this as a
right. At the third level called the postconventional, autonomous, or principled level. At this level, people make an
effort to define valid values and principles without regard to outside authority or to the expectations of others.
These involve respect for other humans and belief that relationships are based on mutual trust.
Erickson’s theory on the development of virtues or unifying strengths of the “good man” suggests that moral
development continues throughout life. He believed that if the conflicts of each psychosocial development stages
are favorably resolved, then an ‘ego-strength’ or virtue emerges.
Freud- believed that the mechanism for right and wrong within the individual is the superego, or conscience. He
hypothesized that a child internalizes and adopts the moral standards and character or character traits of the
model parent through the process of identification. The strength of the superego depends on the intensity of the
child’s feelings of aggression or attachment toward the model parent rather than on the actual standards of the
parent.
Schulman and Mekler- believed that morality is a measure of how people treat fellow humans and that a moral
child is one who strives to be kind and just. They believed that morality has two components, namely: 1. the
intention of the person acting must be good in the sense that the goal of the act is the well-being of one or more
people; 2. the person acting must be fair or Justin the sense that the person considers the rights of others without
prejudice or favoritism. Furthermore, the aforementioned authors asserted that the theory of moral development is
based on three foundations, which they believed can be taught, as follows: internalizing parental standards of
right and wrong; developing emphatic reactions; acquiring personal standards.
Situation 17 - Nurse Jill is in the ward and was given a patient, Noel, 90 years old who recently experienced a CVA. In
order to provide proper care, you need to do a physical assessment

Rationale: The nurse should give highest priority to the psychological preparation of the client. Most people need
an explanation of the physical examination. The nurse should explain when and where it will take place, why is it
important, and what will happen during the examination. This is done to lessen anxiety and to gain the patient’s
cooperation. Psychologically preparing the client is just like getting an informed consent from the client.
OPTION A: in establishing priorities, it is a rule that patient should be dealt first before the equipments. As nurses,
our focus is the safety of the patient.
OPTION B: Physical preparation of the client includes emptying the bladder before the examination if it is
required, draping the client and positioning. This is not as important as preparing the client psychologically.
OPTION C: it is important to prepare the environment before starting the assessment. The environment needs to
be well-lighted and the equipment should be organized for use. The room should be warm enough to be
comfortable for the client.
SOURCE: Kozier. Fundamentals of Nursing.7th Edition.pp. 525-526

RATIONALE: When assessing the abdomen, the nurse performs inspection first, followed by auscultation,
percussion, and/or palpation. Auscultation is done before palpation and percussion because palpation and
percussion cause movement or stimulation of the bowel motility and thus heighten bowel sounds, creating false
results. (Kozier. Fundamentals of Nursing.7th Edition.p. 593)
It is not necessary to wear gloves in assessing abdomen except if the patient has drainage in the abdomen.
Place small pillows beneath the knees and the head to reduce tension in the abdominal muscles. (Kozier.
Fundamentals of Nursing.7th Edition.p. 594)

RATIONALE: Respiratory quality or character refers to those aspects of breathing that are different from normal,
effortless breathing. Two of these are the amount of effort a client must exert to breathe and the sound of
breathing.
The respiratory rate is normally described in breaths per minute. Breathing that is normal in rate and depth is
called eupnea.
The depth of a person’s respirations can be established by watching the movement. Respiratory depth is
generally described as normal, deep, or shallow.
SOURCE: Kozier. Fundamentals of Nursing. 7th Edition. p. 506

RATIONALE: Romberg's test is a neurological test that is used to assess the dorsal columns of the spinal cord,
[1] which are essential for joint position sense (proprioception). Ask the subject to stand erect with feet together
and eyes closed. Stand close by as a precaution in order to stop the person from falling over and hurting
themselves. Watch the movement of the body in relation to a perpendicular object behind the subject. A positive
sign is noted when a swaying, sometimes irregular swaying and even toppling over occurs.
(http://en.wikipedia.org/wiki/Romberg's_test)
Option A and B refers to Forward Bend Test, this is used in screening for scoliosis. The examiner is behind the
standing client, then instructs the client to stand with feet and shoulder-width apart and bend forward slowly to
touch the toes.

RATIONALE: Collecting subjective data is an integral part of nursing health assessment. Subjective data consist
of: sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal
information. These types of data can be elicited and verified only by the client. Subjective data provide clues to
possible physiologic, psychological, and sociologic problems. They also provide the nurse with information that
may reveal a client’s risk for a problem as well as areas of strengths or the client.
(http://connection.lww.com/Products/weber3e/documents/PDF/ch03.pdf)
OPTIONS A, C, and D are all examples of objective data.
Situation 18 - The nursing process is an immeasurable tool used by the nurse for proper intervention.

RATIONALE: Diagnosing is a process which results to a diagnostic statement or nursing diagnosis. It is the
clinical act of identifying problems. To diagnose in nursing, it means to analyze assessment information and
derive meaning from this analysis.
Mastering Fundamentals of Nursing by Quiambao-Udan. p. 176)
OPTION A-possible health risk or potential health problem is an example of nursing diagnosis.
OPTIONS B and D- both refer to data gathered through assessment; these data should be analyzed for a nurse to
formulate a nursing diagnosis.

RATIONALE: the force of the pulse shows the strength of the heart’s stroke volume. The pulse force is recorded
using a three-point scale:
3+ - full, bounding
2+ - normal
1+ - weak, thready
0 - absent
A weak, thready pulse reflects a decreased stroke volume, as occurs with hemorrhagic shock.
SOURCE: Carolyn Jarvis Physical Exam and Health Assessment.3rd Edition. p. 187
The nurse should first assess the condition of the patient before notifying the physician so that the nurse can give
a clear picture of the status of the patient to the physician.
Changing the client’s position is an intervention, assessment comes first before intervention. Assessing the client
will help the nurse decide what appropriate interventions should be done.

RATIONALE: in establishing priorities for client care these should be considered: 1. Airway, Breathing, and
Circulation; 2. Maslow’s Heirarchy of Needs; 3. The Nursing Process (ADOPIE); 4. Safety of the patient always; 5.
Attend to client first before the equipment; 6. Actual problems are usually more important than potential problems;
7. Assess first clients who are unstable and needing nursing care.

RATIONALE: Goal/desired outcome statements should usually have the following components:
Subject. The subject, a noun, is the client, any part of the client, or some attribute of the client, such as the client’s
pulse or urinary output.
Verb. The verb specifies an action the client is to perform, for example, what the client will do, learn, or
experience. Verbs that denote directly observable behaviors, such as administer, walk, show, must be used.
Conditions or modifiers. Conditions or modifiers may be added to the verb to explain the circumstances under
which behavior is to be performed.
Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the
level at which the client will perform the specified behavior. These criteria may specify time or speed, accuracy,
distance, and quality. To establish a time-achievement criterion, the nurse needs to ask “How long?” To establish
an accuracy criterion, the nurse asks “How Well?”
SOURCE: Kozier. Fundamentals of Nursing. 7th Edition. pp 302-303
Subject- Client
Verb- will state
Condition- pain is less than or equal to 3 on a 0-10 pain scale

RATIONALE: Evaluation- is assessing the client’s response to nursing interventions and then comparing the
response to predetermined standards or outcome criteria. The purpose of this is to appraise the extent to which
goals and outcome criteria of nursing care have been achieved.
Planning- involves determining beforehand the strategies or course of action to be taken before implementation of
nursing care. To be effective, involve the client and his family in planning.
Assessment- is collecting, validating, organizing and recording data about the client’s health status.
Implementation- is putting the nursing care plan into action. Its purpose is to carry out planned nursing
interventions to help the client attain goals and achieve optimal level of health.
Situation 19 - There are different roles of a nurse can assume in various health care setting where competency as well
as knowledge is of importance.

RATIONALE: In promotion of health nurses assist individuals in increasing well being and attain self-actualization.
Health promotion activities include exercise, immunization, healthy lifestyle, good food, self responsibility and
other factors that minimize if not totally eradicate risks and threats of health.
(http://pinoybsn.blogspot.com/2006/09/fundamentals-of-nursing-history_06.html)

Rationale: As a client advocate, the nurse promotes what is best for the client, ensures that the client’s needs are
met, and protects the client’s rights.
Udan. Mastering Fundamentals of Nursing. 2nd Ed. p. 13
OPTION A: Communicator. In the role of the communicator, nurses identify client problems and then
communicate these verbally or in writing to other members of the health team.
OPTION B: The caregiver role has traditionally included those activities that assist the client physically and
psychologically while preserving the client’s dignity.
OPTION D: Registered nurses are bound to safely practice nursing in any health care setting and in giving care to
all clients. To safely practice nursing is not a role of the nurse but a duty of the nurse.

RATIONALE: You can never provide nursing care if you don’t know what are the needs of the client. How can you
provide an effective postural drainage if you do not know where is the bulk of the patient’s secretion. Therefore,
the best description of a care provider is the accurate and prompt determination of the client’s needs to be able to
render safe and effective nursing care.
SOURCE: (http://pinoybsn.blogspot.com/2006/09/fundamentals-of-nursing-history_06.html)

RATIONALE: the nurse manager coordinates and delegates patient care, set standards of performance and
design staff schedule. Performing bedside nursing care is a caregiver role.
The nurse plans, gives directions, develops staff, monitors operations, gives reward fairly, and represents both
staff members and administration as needed. The nurse manager delegates nursing activities to ancillary workers
and other nurses and supervises and evaluates their performance.
SOURCE: Mastering Fundamentals of Nursing by Quiambao-Udan. pp. 13, 43-45

RATIONALE: The nurse acts as a change agent when assisting others, that is, clients, to make modifications in
their own behavior. Nurses also often act to make changes in a system, such as clinical care, if it is not helping a
client return to health. Nurses are continually dealing with change in the age of client population, and changes in
medications are just a few of the changes nurses deal with daily.
Kozier. Fundamentals of Nursing.7th Edition.pp. 10-11
OPTIONS A and B- these two are not the responsibilities of a nurse
OPTION D- it is an example of a managerial role of the nurse
Situation 20 - Nursing as a profession has various historical perspective and theoretical foundation that can be applied in
health care situations. A sense of history gives you better understanding of nursing as a profession.

RATIONALE: Florence Nightingale- upgraded the practice of nursing and made nursing an honorable profession.
(Mastering Fundamentals of Nursing by Quiambao-Udan. p. 40)
Clara Barton- founded the American Red Cross. (Mastering Fundamentals of Nursing by Quiambao-Udan. p. 39)
Anastacia Giron-Tupaz- founder of the Philippine Nurses Association. (Mastering Fundamentals of Nursing by
Quiambao-Udan. p. 31)
Betty Neuman- proposed the Health Care System model. She asserted that nursing is a unique profession in that
it is concerned with all the variables affecting an individual’s response to stresses, which are intrapersonal,
interpersonal, and extrapersonal in nature.
SOURCE: (Mastering Fundamentals of Nursing by Quiambao-Udan. p. 18)
RATIONALE: Florence Nightingale was born on May 12, 1820 in Florence, Italy. Raised in England in an
atmosphere of culture and affluence.

RATIONALE: in 1919, Act 2808 was passed. This was known as the First True Nursing Law. It created, among
others, a board of examiners for nurses. However, it was in 1920 that the first board examination in the
Philippines was given.
The first law that had to do with the practice of nursing was contained in Act No. 2493 of 1915, which regulated
the practice of medicine. This act provided for the examination and registration of nurses in the Philippine Islands.
Congress enacted The Philippine Nursing Law, otherwise known as Republic Act 877, on June 19, 1953.
Provisions included the organization of the Board of Examiners for nurses, provisions regarding nursing schools
and colleges, examination, registration of nurses including sundry provisions relative to the practice of nursing.
SOURCE: Venzon.Professional Nursing in the Philippines.10th ed. P 137

RATIONALE: In 1919, Act 2808 was passed. This was known as The First True Nursing Law.
Republic Act 877 otherwise known as The Philippine Nursing Law.
SOURCE: Venzon.Professional Nursing in the Philippines.10th ed.p. 137

RATIONALE: Contemporary Nursing – this covers the period after World War II to the present. Scientific and
technological developments as well as social changes mark this period.

June 2007-NPT 1 - Rationale

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ANSWERS WITH RATIONALE

10. CORRECT ANSWER: C

11. CORRECT ANSWER: D

12. CORRECT ANSWER: C

13. CORRECT ANSWER: C

14. CORRECT ANSWER: D

15. CORRECT ANSWER: C

16. CORRECT ANSWER: B

17. CORRECT ANSWER: B

18. CORRECT ANSWER: C

19. CORRECT ANSWER: B

20. CORRECT ANSWER: A

Situation 5 - Communication between patient-nurse and nurse-health team is very important

21. CORRECT ANSWER: D

22. CORRECT ANSWER: C

23. CORRECT ANSWER: D

24. CORRECT ANSWER: B

25. CORRECT ANSWER: A

26. CORRECT ANSWER: D

27. CORRECT ANSWER: C

29. CORRECT ANSWER: C

30. CORRECT ANSWER: B

Situation 7- Record management is another responsibility of the nurse

31. CORRECT ANSWER: A

32. CORRECT ANSWER: D

33. CORRECT ANSWER: C

34. CORRECT ANSWER: C

35. CORRECT ANSWER: D

36. CORRECT ANSWER: C

37. CORRECT ANSWER: A

38. CORRECT ANSWER: A

39. CORRECT ANSWER: D

40. CORRECT ANSWER: D

41. CORRECT ANSWER: A

43. CORRECT ANSWER: A

44. CORRECT ANSWER: D

45. CORRECT ANSWER: D

46. CORRECT ANSWER: C

47. CORRECT ANSWER: B

48. CORRECT ANSWER: B

49. CORRECT ANSWER: D

50. CORRECT ANSWER: B

Situation11- The role of the Nurse is bounded by several ethico-moral responsibilities

51. CORRECT ANSWER: D

52. CORRECT ANSWER: C

53. CORRECT ANSWER: B

54. CORRECT ANSWER: C

55. CORRECT ANSWER: C

Situation 12 - In RA 9173, health education is the major responsibility of the nurse.

57. CORRECT ANSWER: A

58. CORRECT ANSWER: B

59. CORRECT ANSWER: D

60. CORRECT ANSWER: D

61. CORRECT ANSWER: A

62. CORRECT ANSWER: A

63. CORRECT ANSWER: D

64. CORRECT ANSWER: D

65. CORRECT ANSWER: A

66. CORRECT ANSWER: D

67. CORRECT ANSWER: D

68. CORRECT ANSWER: A

69. CORRECT ANSWER: A