SET 5

Situation : Mrs. Andres brought his son, Juanito, age 3 to the Pediatric clinic. She noticed that her son is not speaking and tend to repeat everything she says. The mother also told the nurse that Juanito prefers to be alone, will cry when someone will come near him and tend to rock himself from morning till he will fell asleep. 1. An essential clinical feature of autistic disorder is: A. Inability to concentrate in any task B. Easily Distracted C. Stereotyped motor behaviors D. Poor motor skills 2. Headbanging is a common manifestation of an autistic child. A relevant nursing diagnosis would be: A. Activity intolerance B. Impaired physical mobility C. Risk for Injury D. Impaired skin integrity

3. According to freud, Juanity is at what psychosexual stage? A. Anal Latency 4. Typically, if there is a change in the environment, the child will manifest which of the following? A. Clinging behavior B. Temper tantrums C. Suicide D. Talks incoherently B. Oral C. Phallic D.

5. The best treatment approach for autistic children is encouraging their desired behavior through positive reinforcement. This is: A. Milieu Therapy Therapy 6. There is no definite cause identified for autism, but a strong link has been found on: B. Psychoanalysis C. Play Therapy D. Behavior

A. Environmental factors B. Genetic factors 7. Which of the following is true about Autism?

C. Upbringing D. MMR vaccination

A. Autism is common among boys than girls B. Autism is common among girls than boys C. MMR vaccination has been strongly linked in the development of Autism D. Autistic children usually develops normal social skills 8. The mother of Juanito asked the nurse, When is autism diagnose? The nurse will respond: A. Autism is diagnosed after 3 years old B. Autism is diagnosed after 6 years old C. At 4 years old, Autism is diagnosed D. Autism is diagnosed before 3 years old 9. If a child with autism develops destructive behavior, The drug of choice that the nurse will expect that the physician will give to control self injury is: A. Chlorpromazine [Thorazine] B. Methylphenidate [Ritalin] Anxiolytic 10. Chlorpromazine was given to the child. Which is true with regards to this medication? A. Expect that the child will be unusually alert and hyperactive during the therapeutic period B. The mother should decrease the fluid intake of the child as this drug causes fluid retention C. That the drug is given in order to decrease the childs hyperactivity D. The mother should avoid overexposing the child to sunlight for the child might develop rashes due to photosensitivity Situation : Mastery of Psychotropic medications is necessary for the therapeutic improvement in the health of the psychiatric clients. 11. Lithium is only given: A. P.O B. IM C. IV D. SQ C. Time-out D. Valium, Librium or other

12. The nurse should expect that a client who cheeks the medication is a non-complaint patient. Knowing the non compliance is the single most important factor for exacerbation and rehospitalisation, the doctor ordered Prolixin [Fluphenazine Decanoate]. The nurse knows that is it given: A. Orally B. Sublingually C. IV D. IM

13. Which of the following is an antidepressant? 1. Serenace (Haloperidol) 2. Valium (Diazepam) 3. Tofranil (Imipramine HCl)

4. Trilaton (Pherpenazine)

14. The nurse knows that the relationship between sodium and lithium is that: A. When lithium increases, sodium also increases B. When sodium increases, lithium also increases C. They are inversely proportional D. They are directly proportional 15. Which of the following class of antidepressant is the least sedating? A. SSRI B. MAOI C. TCA D. Neuroleptics

Situation : Mang Cardo, Age 72, is a widower with moderate Alzheimers disease. Was brought to the home for the Aged by his married daughter. On admission, she says to the nurse, I never thought this would happen to us. I really feel guilty about bringing him here, I cant bear to part with him. 16. The nurses therapeutic response to Mang Carlos daughter is: A. You have indeed made a sound decision, Your father needs professional care which you cannot provide at home. B. Why are you feeling guilty bringing him here? C. I know that his has been a difficult time for you. You seemed troubled about bringing him here. D. You have done well everything for your father, Do not be upset. We will take care of him.

17. Initially, the nursing diagnosis would be: A. Impaired communication B. Impaired social interaction C. Altered thought process D. Altered family process

18. To guide the nurse in planning activities for Mang Carlos, The nurse should prioritize soliciting which information? A. Support system from the significant others B. Coping mechanism C. Routine activities at home D. The extent of memory impairment 19. Cardo appears to be awake and restless throughout the night, Which of the following is the medication you are expecting to be given? A. Diazepam [Valium] B. Chlorpromazine [Thorazine] C. Imipramine [Tofranil] D. Lithium [Lithane]

20. One morning, Mang Cardo has difficulty putting his pyjamas. In Alzheimers disease, this is known as: A. Aphasia C. Apraxia B. Agnosia D. Anomia

21. Which of the following is the cause of Dementia of the Alzheimers type? A. Unknown B. Decreased Acetylcholine 22. The initial sign of Dementia is: A. Aphasia B. Forgetfullness C. Confusion D. Restlessness C. Increasing Age D. Senile plaques deposition

23. Mang Cardo has been talking about how he got his scratch on his left arm, he told you that it was caused by a shard of glass that touches his skin accidentally. The next day, he told you that the scratch was caused by a knife he did not see that it fell from the table towards his arms. The

next day, he said it was bitten by an ant and he scratched it because it was itchy. This is a symptom seen in Dementia known as: A. Confusion C. Aphasia B. Altercation D. Confabulation

24. Tacrine was given to the client and the nurse knows that which of the following enzyme is periodically checked? A. ALT C. AST B. Creatinine D. BUN

25. A client with Alzheimers disease mumbles incoherently and rambles in a confused manner. To help redirect the clients attention, the nurse should encourage the client to: A. fold towels and pillowcases. B. participate in a game of charades. C. play cards with another client. D. perform an aerobic exercise.

Situation : A nurse is working with an aggressive client in the psychiatric unit. 26. All of the following concepts are true EXCEPT: A. Hostility is destructive B. Frustration develops in response to unmet needs, wants and desire C. Anger is always incompatible with love D. Aggression can be expressed in a constructive as well as a destructive manner. 27. Carlo is acting out hostile and aggressive feeling by kicking the chairs in the room. the MOST effective way to deal with Carlos behavior is initially to: A. Set limits on the behavior by verbal command B. Administer PRN tranquilizer C. Remove the chairs from the room D. Restrain the patient and place him in the Isolation Room 28. Mrs. Dizon was visiting her son at the Psychiatry Ward. Which of the following items will the nurse not allow to be brought inside the ward? A. String rosary bracelet B. Box of cake C. Bottle of coke D. Rubber shoes

29. Which of the following will probably be most therapeutic for a patient on a behavioral modification ward? A. If the client is agitated, discuss the feelings especially anger B. Insist to stop obscene language by verbal reprimand C. Give client support and positive feedback for controlling use of obscene language D. Provide a punching bag as an alternative to express upset emotions 30. Which of the following must be considered while planning activities for the depressed patient? A. Activities which require exertion of energy B. Challenging activities to get him out of his depression C. Structured activities that the client can participate D. Variety of unstructured activities 31. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual, the nurse should: 1. keep an eye contact while staring at the client 2. keep his/her hands behind his/her back or in ones pockets 3. fold his/her arms across his/her chest 4. keep an open posture, e.g. Hands by sides but palms turned outwards 32. A patient in the ward suddenly slapped you in the face and spitted on your face and is obviously agitated and violent. Which of the following is the best nursing action? A. Tell the client: Because of that, you are not going to eat your lunch, dinner and breakfast anymore. B. Slap the client back and say I am your nurse, you are a patient and you have no right to hurt me. C. Prepare a 5 member team to restraint the client D. Respond by saying You are losing control of yourself, you slapped me and you spitted on me and you are way out of control 33. Which of the following is an accurate way of reporting and recording an incident? 1. When asked about his relationship with his father, client became anxious.

2. When asked about his relationship with his father, client clenched his jaw/teeth, made a fist and turned away from the nurse. 3. When asked about his relationship with his father, client was resistant to respond 4. When asked about his relationship with his father, his anger was suppressed

34. To encourage thought, which of the following approaches is NOT therapeutic? 1. Why do you feel angry? 2. When do you usually feel angry? 3. How do you usually express anger? 4. What situations provoke you to be angry?

35. A patient grabs and about to throw it. The nurse best responds saying. 1. Stop! Put that chair down. 2. Dont be silly. 3. Stop! The security will be here in a minute. 4. Calm down.

Situation: In your professional nursing role, it is essential to establish a meaningful nurse-patient relationship. 36. A helping nurse patient relationship is characterized by which of the following? A. Recovery promoting B. Growth facilitating C. Mutual interaction D. Health enhancing

37. Demonstrating a helping relationship enables you to establish in the patient: A. Compliance to treatment B. Positive response to illness C. Gratitude to your services D. Some sense of trust in you 38. Therapeutic communication begins with: A. Knowing the patient B. Trust C. Interacting with the patient D. Knowing yourself

39. Which of the following approaches will most likely make your patient accept your help? A. Attending to all his needs attitude B. Calling him by first name information 40. The client said I am troubled that my Son is starting to use drugs. The nurse replied, Its troubling and painful for you, I feel sorry about this. The nurses reply is an example of: A. Empathy C. Telepathy B. Sympathy D. Self awareness D. Asking personal questions for health C. Demonstrating a relaxed and attending

41. Preparation for termination of the nurse-patient relationship begins during the: A. Termination phase B. Working phase C. Pre-orientation phase D. Orientation phase

42. The clients past reactions to ending relationships is withdrawal. The nurse assists her to practice better ways of coping termination by providing opportunities to: A. Test new patterns of behavior B. Plan for alternatives C. Conceptualize her problem D. Value and find meaning in experience

9. A male nurse reminds the client that is already time for group activities, The client responded by yelling to the nurse You are always telling me what to do! Just like my father! This is an example of: A. Symbolization B. Transference C.Reaction Formation D. Counter Transference

44. The longest and the most productive phase of the NPR is: A. Termination phase B. Working phase C. Pre-orientation phase D. Orientation phase

45. The objection of the nurse-patient relationship is to provide an opportunity of the patient to: A. Clarify problems B. Develop insights C. Have a corrective emotional experience D. Develop interpersonal relationship

Situation: Mental Retardation is an increasingly common childhood disorder that impairs learning. 46. Mental retardation is: A. a delay in normal growth and development caused by an inadequate environment B. a lack of development of sensory abilities C. a condition of subaverage intellectual functioning that originates during the developmental period and is associated with impairment in adaptive behavior D. a severe lag in neuromuscular development and motor abilities 47. An important principle for the nurse to follow in interacting with retarded children is: A. seen that if the child appears contented, his needs are being met B. provide an environment appropriate to their development task as scheduled C. treat the child according to his chronological age D. treat the child according to his developmental level 48. The child was classified as having an IQ of 55. This is said to be: A. Mild Mental Retardation B. Moderate Mental Retardation C. Severe Mental Retardation D. Profound Mental Retardation

49. Which of the following is true with regards to Mild Mental Retardation? A. Trainable, Can reach up to 2nd grade and can reach the maturity of a 7 year old B. Custodial and barely trainable C. Requires total care throughout life, Mental age of a young infant D. Educable, can reach up to grade 6 and has a maturity of a 12 year old 50. A child with an IQ of 35-49 is: A. Barely trainable B. Trainable C. Educable D. Requires total care

51. Which of the following is true with regards to mental retardation? A. Mental retardation is always accompanied by physical features B. Hereditary and perinatal factors do not result to mental retardation C. Mental retardation is a mental illness

D. Hereditary and perinatal factors are known to result to impaired intellectual functioning 52. The onset of mental retardation is before the child reaches what particular age? A. 17 B. 16 C. 15 D. 18

53. The possible nursing diagnosis for a mentally retarded child who is hyperactive is: A. Impaired physical mobility B. Potential for injury C. Impaired social adjustment D. Ineffective coping 54. A tranquilizing agent given in calming a hyperactive mentally retarded is: A. Chlorpromazine [Thorazine] B. Haloperidol [Haldol] C. Imipramine [Tofranil] D. Diazepam [Valium]

55. This form of psychotherapy allows the child to experience and express intense or troubling emotion in a safe environment with a caring individual: A. Play therapy B. Milieu therapy C. Behavior therapy D. Gestalt therapy

Situation : Margie has been diagnosed with Bipolar I disorder. The client demonstrates extreme psychomotor agitation, flight of ideas, loud talking and elated mood. 56. Which of the following is true about manic reaction? A. It is an expression of destructive impulse B. A means of coping with frustrations and disappointments C. A means of ignoring reality D. An attempt to ward of feelings of underlying depression 57. Nursing care plan for a client with Mania like Margie should give priority to: A. Discourage him from manipulating the staff B. Prevent him from assaulting other patient

C. Protect him against suicidal attempts D. Provide adequate food and fluid intake 58. During a nurse patient interaction, Margie jumps rapidly from one topic to another, This is known as: A. Flight of Ideas B. Clang association C. Ideas of reference D. Neologism

59. Which of the following is a suitable activity that a nurse should assign for a Manic client? A. delivering supply of linen to other rooms B. conducting a drama workshop C. engaging in activity therapy and group exercises D. painting a mural with other patients 60. The doctor ordered lithium. You know that this is indicated in patients with: A. Depression B. Mania 61. Lithium has a narrow therapeutic range of: A. 0.1 to 1.0 mEq/L B. 0.6 to 1.2 mEq/L C. 10 to 50 mEq/L D. 50 to 100 mEq/L C. Schizophrenia D. Anxiety disorders

62. Which of the following is a side effect of lithium toxicity? A. Anuria B. Oliguria C. Sudden burst of muscle strength D. Polyuria

63. What specimen is taken from a client when checking the lithium level of the body? A. Blood B. Stool C. Urine D. Sweat

64. Which of the following is NOT a drug use to augment lithium toxicity? A. Urea C. Aminophylline B. Mannitol D. Acetylcysteine

65. The nurse has a standing order of Lithium for Margie. If the lithium level is 1.5 mEq/L, the nurse knows that she should: A. Administer the next dose and continue monitoring the client B. Report this to the physician C. Recheck the lithium level and validate first before doing any action D. Withhold the next dose and notify the physician Situation : Nursing informatics is a way of using information technology, computers and the internet in the improvement of nursing care. The first nursing informatics conference was held during 1977. 66. The ANA recognized nursing informatics heralding its establishment as a new field in nursing during what year? A. 1992 B. 1994 C. 2001 D. 2004

67. When is the first certification of nursing informatics given? A. 1992-1993 B. 1994-1995 C. 2001-2002 D. 2004-2005

68. Which of the following is the 3 integrated components of the nursing informatics? 1. Nursing science 2. Computer science A. 1,2,3 3,4,5 69. A textbook publisher wants to store large amount of data in a computer format that cannot be changed by other people. Which of the following would best serve this purpose? A. CD ROM B. Floppy disk C. RAM D. Network B. 1,3,4 3. Health science 4. Information science C. 1,2,4 D.

70. The challenge most associated with the utilization of an electronic record system is which of the following? A. Cost B. Accuracy C. Privacy D. Curability

71. A client insists that the practitioner use a treatment method discovered on an internet data base. Which of the following response is most appropriate? A. The treatment must be examine to see if it is appropriate B. Most website treatments have not been studied or researched C. The person establishing the website is the only one who can use it on clients D. Websites are like advertising, they are biased and may not be legitimate. 72. This is a type of a computerized recording system that enables hospitals to organize various data such as admission, records, clinical laboratory, pharmacy, inventory and finance. A. Management information system B. Hospital information system C. University information system D. Government information system 73. A nurse, who is proficient in computers and information technology that uses these advantages to promote effective and secured use of computerized record is referred to as: A. Information technician B. Nursing IT C. Nursing information technician D. Nurse Informaticist

74. One advantage of a computerized recording system is that: 1. The nursing diagnoses for a clients data can be accurately determined 2. Cost of confinement will be reduced 3. Information concerning the client can be easily updated 4. The number of people to take care of the client will be reduced

75. You are to research the different types of oxygen delivery system. From the nasal cannula up to the venturi mask. Using nursing informatics, you found out different sources of information. One of the question that needs to be answered in your research is What type of oxygen delivery system is the most comfortable? you will answer: A. Nasal cannula, according to the American journal of nursing and medicine B. Face masks, according to a nursing blog site C. Venturi mask, according to Wikipedia D. Oxygen tents, according to a personal website from yahoo search engine

Situation: Celina age 25, a ramp model, suddenly became blind after her boyfriend broke off with her. A thorough work up did not reveal any pathological findings. 76. The loss or alteration of physical functioning without organize cause bit is an expression of a psychological needs is known as: A. Somatization B. Depersonalization C. Hypochondriasis D. Conversion

77. Initially, the relevant nursing diagnosis the nurse includes in her care plan is: A. Self esteem disturbance B. Impaired adjustment C. Ineffective individual coping D. Ineffective denial 78. The defense mechanism commonly used by these clients is: A. Projection B. Rationalization C. Repression D. Sublimation

79. An appropriate nursing intervention which can help Celina is: A. Establishing a trusting relationship B. Encourage her to verbalize her feelings C. Reinforce reality D. Accept her limitation as a person 80. An effective modality of treatment for Celina would be: A. Milieu therapy B. Systematic desensitisation C. Cognitive-Behavioral therapy D. Psychopharmacology Situation : Records and Records management is one of the core of professional nursing practice.

81. The National Archives of the Phils. (NAP) is mandated by R.A. 9470 of 2007 to plan, formulate and implement records management and archival administration program for the efficient action, utilization, maintenance, retention, preservation, conservation and disposal of public records including the adoption of security measures and vital records protection program for the government and give technical assistance to all branches of government. Hospitals should safe keep their record and coordinate with which of the following agency for its disposal? A. National Archives of the Philippines B. Metropolitan Manila Development Authority C. Record Management and Archive Office D. Department Of Health 82. If The research team finished the research about Anas case and they are done disseminating data and after the report has been completed and written, Pre-processed data about Ana should be: A. Preserved B. Destroyed by Burning or Shredding C. Stored for future use D. Keep in a private file nobody can access

83. All of the following are purposes of the chart EXCEPT: A. To document the quality of care B. A vehicle for communication C. For the prerecording of nursing actions D. For research and education 84. What is an example of a subjective data? A. Color of wound drainage B. Odor of breath C. Respiration of 14 breaths/minute D. The patients statement of I feel sick to my stomach 85. Charting should be legible and include only standard abbreviations. Which of the following is NOT a standard abbreviation? A. PRN B. OD C. NNO D. NPO

Situation: A nurse should be aware that some problems in the emergency setting are not always physiologic. Sometimes, Crisis can affect the patient in an emergency setting. 86. Which of the following statements best describes acquaintance rape? A. Sexual intercourse when one person engaging in the activity is unsure about wanting to do so B. When two people dont love each other and engage in sexual activities C. When someone on a date tricks the other person into having sexual intercourse D. Sexual intercourse committed with force or the threat of force without a persons consent 87. Male to male rape is also another problem that a nurse can encounter. The nurse knows that in male to male rape, The perpetrator is usually: A. An effeminate male homosexual C. A heterosexual who believes that he is superior D. A passive homosexual male

B. A young, newcomer heterosexual male

88. An 18 year old male client was rushed to the hospital due to burns, bruises and cuts on the face and body. The teenager confessed that he was raped by 4 of his classmates, all of which are also male. Male to male rape also occurs and the nurse must know that: A. If there is an erection, the male victim also consents to the rape itself. B. That all male to male rape cases occurs at home, which is statutory most of the time. C. That male rape victims are usually homosexuals. Which are very much deserving to be raped. D. Most victims of male to male rapes never dare to report the incident. 89. One of four factors describing the experience of sexually abused children and the effect it has on their growth and development is stigmatization. Stigma will occur when: A. A child blames him or herself for the sexual abuse and begins to withdraw and Isolate B. Newspapers and the media dont keep sexual abuse private and accidentally or on purpose reveal the name of the victim C. The child has been blamed by the abuser for his or her sexual behaviors, saying that the child asked to be touched or did not make the abuser to stop D. The childs agony is shared by other members of the family or friends when the sexual abuse becomes public knowledge 90. Which of the following is an example of hostile environment in terms of sexual harassment?

A. the boss assures you of a big promotion if you go out on a couple of dates with him B. your supervisor makes masturbatory gestures every time you walk pass him C. the personnel manager hints that the job will be yours if you cooperate sexually with him D. your boss suggests that your raise is dependent upon having sex with him Situation : You are a nurse working in the medical ward. 91. Mr. E.O. age 52 had a laryngectomy due to cancer of the larynx. Discharge instructions are given to Mr.F.O. and his family. Which response by written communication from Mr. F.O. or verbal response from the family, will be a signal to the nurse that the instructions need to be reclarified? a. it is acceptable to take over-the-counter medications now that condition is stable b. the suctioning at home must be a clean procedure, not sterile. c. report swelling, pain or excessive drainage d. cleans skin around stoma BID, use hydrogen peroxide and rinse with water, pat dry. 92. Dr. Tuazon scheduled Mrs. Poe for a right breast mass incision with frozen section and possible mastectomy on Monday, first case. As the nurse in-charge for scheduling you will collaborate with the following departments EXCEPT: a. pathology b. dietary c. anesthesia d. surgery

93. A mother who is pregnant and has ovarian cancer has to undergo surgery to treat the cancer. In the process the fetus died. The doctrine that justifies the death of the fetus is: a. justice b. anatomy c. exception to the role d. double effect

94. A nurse is waiting for a report to be sent by fax. The machine activates but instead of the report, the nurse received a sexually oriented photograph. The MOST appropriate nursing action is to: a. call the nursing supervisor and report the incident b. cut the photograph and throw it away. c. call the police d. call the unit who sent it and ask for the name of person who sent the photograph 95. Ms. F.X.. has been admitted with right upper quadrant pain and has been placed on a low fat diet. Which of the following trays would be acceptable for her?

a. liver, fried potatoes and avocado b. whole milk, rice and pastry c. ham, mashed potatoes, cream peas d. skim milk, lean fish, tapioca pudding Situation : Some equipments and materials in our hospital are color coded, this is to increase the safety and proficiency of rendering patients care. 96. If a nurse has been ordered to prepare a spinal set gauge 16, the nurse knew that the color for that spinal set is coded at: A. Red B. Pink C. Yellow D. Blue

97. If the anaesthesiologist asked for a 22 gauge spinal set, the nurse knew that the color of the set that she will obtain is: A. Red B. Pink C. Yellow D. Blue

98. For pediatric patients, the spinal set is coded with color: A. Red B. Pink C. Yellow D. Blue

99. An anesthesiologist is preparing to do a spinal anesthesia to a 220 lb, 30 year old athlete she request the circulating nurse to prepare a pink spinal set with another blue set as stand by. What gauge spinal sets will make available in the OR suite? A.Gauge 16 and 22 B. Gauge 18 and 16 C. Gauge 16 and 20 D. Gauge 5 and 22 100. Medical gases are used a lot in the OR. Some gases are used to operate equipment and some are used to administer general anesthesia through inhalation. What is the identifying color of the tank which contains laughing gas? A. Yellow B. Green C. Black D. Blue