Situation b.

Manic episodes with at least one depressive episode

Jimot come to the mental health clinic saying that he c. Alternating cycles between periods of mania,
feels so down and lacking in energy with “loss of interest normal mood, depression, normal mood, mania, and
in everything.” He tells the nurse that he received some so forth.
samples of a new medication from his psychiatrist last d. None of the above
week to relieve his depression.
Situation
1. Nurse Gemma is aware that Jimot has a history of Therapeutic communication is an interpersonal
bipolar I disorder with hospitalization for a significant interaction between the nurse and the client during which
manic episode. With this knowledge, the nurse would the nurse focuses on the client’s specific needs to
draw special concern regarding which category of psych promote an effective exchange of information.
medications?
7. Client: “I had an accident”
a. Atypical antipsychotics Nurse: “Tell me about your accident”
b. Mood stabilizers/antimanics This is an example of which therapeutic communication
c. Antianxiety agents (benzodiazepines) technique?
d. SSRI
a. Making observations
2. Nurse Gemma has observed Jimot who is hyperactive b. Offering self
and intrusive sitting very close to Jerlyn, a female patient c. General lead
with his arm around her shoulders. The nurse hears the d. Reflection
male client cracking sexually explicit joke. Nurse
Gemma approaches Jimot and asks him to walk down the 8. “Earlier today you said you were concerned that your
hallway. Which of the following statements by the nurse son was still upset with you. When I stopped by your
Gemma should be beneficial to the patient? room about an hour ago, you and your son seemed
relaxed and smiling as you spoke to each other. How did
a. “Ayaw ni Jerlyn na nasa tabi mo siya dahil sa things go between the two of you?” This is an example
pananalita mo” of which therapeutic communication technique?
b. “ Ang pag-sasabi ng mga malalaswang bagay at
pag hipo sa iba ay hindi pinahihintulutan dito” a. Encouraging comparison
c. “Kailangan mong maging maingat sa mga sinasabi mo b. Consensual validation
sa ibang tao” c. Accepting
d. “Kinakailangan mo ng pumunta sa iyong kwarto” d. General lead

3. Another young adult client is diagnosed with bipolar 9. “How does Heart Evangelista make you upset?” is a
disorder. He has been religiously taking his medications non-therapeutic communication technique because it
and has managed the disorder effectively. One day, the
client suddenly becomes manic. The nurse reviews the a. Gives a literal response
client’s medication record. Which among the following b. Indicates an external source of the emotion
medications should the nurse expect to have contributed c. Interprets what the client is saying
to the development of his manic state? d. Is just another stereotyped comment

10. what is the best way for the nurse to ask the client to
a. Amitriptyline
describe her relationship with Chiz?
b. Prednisone
c. Gabapentin
a. “Chiz, who?
d. Buspirone
b. “Tell me about Chiz”
4. Which of the following drug is often used in c. “Tell me about you and Chiz”
conjunction with mood stabilizers or anti-depressants to d. “That’s a good Chiz-mis”
treat bipolar disorder?
11. Which of the following is a concrete message?
a. Ziprasidone
a. “Get this our of here.”
b. Aripiprazole
b. “When is she coming home?”
c. Either A or B
c. “They said it is too early to get in.”
d. None of the above
d. “Help me put this pile of books on Jeremy’s desk.”
5. How long would it take for a diagnosis of manic
Situation
episode or mania be made?
Typhoon Egay has recently struck the northern islands of
the Philippines leaving vast damages to the properties.
a. 4 weeks
b. 2 weeks 12. The nurse working at the site of a severe flood sees
c. 3 weeks Janang, standing in knee-deep water, staring at empty lot.
d. 1 week Janang told the nurse, “Masamang panaginip lang lahat
ng ito. Bukas magigising akong nandyan pa ang bahay
6. Which of following described Bipolar type II?
ko.” Which of the following crisis intervention strategies
are most needed at this time? Select that apply.
a. Recurrent depressive episodes with at least one
a. Ask the client about any physical injuries she may
hypomanic episode.
have.
b. Determine if any of her family are injured or missing. d. “I need to get enough sleep and eat well to help
c. Allow the client to talk about her fears, anger, and prevent feeling anxious.”
other feelings
d. Tell her that groups are being formed at the shelter for 18. Which of the following group of symptoms are
flood survivors considered positive symptoms?
e. Refer her to the shelter for dry clothes and food
f. Assess her for risk of suicide and other signs of a. Hallucination, Delusions, and Apathy
decompensation b. Asociality, Catatonia, and Flat affect
c. Inattention, avolition, and apathy
a. abcd d. Perseveration, hallucination, and bizarre behavior
b. bdef
19. Neurochemical studies have consistently
c. adef
demonstrated alterations in the neurotransmitter systems
d. abcf
of the brain in people with schizophrenia. Which of the
13. Nurse Jan is assessing a client who has just following neurotransmitter is not implicated by several
experienced a crisis due to typhoon Egay. Nurse Jan studies to have been associated with schizophrenia?
should first assess this client for which of the following
behaviors? a. GABA
b. Dopamine
a. Effective problem solving c. Serotonin
b. Level of anxiety d. Norepinephrine
c. Attention Span
20. The primary medical treatment for schizophrenia is
d. Help-seeking
psychopharmacology. The firs-generation antipsychotics
14. Which of the following typify a situational crisis? target which manifestation of schizophrenia?

a. Natural catastrophe a. Hallucinations

b. Death of a loved one b. Avolition
c. menarche c. Alogia
d. Marriage d. Alopecia

15. The nurse should be aware that which of the 21. One of the side effects of antipsychotic medication is
following is the priority assessment for crisis? neuroleptic malignant syndrome. What should be the
nursing intervention should this occur?
a. Defense mechanism of the person
b. Financial stability a. Stop all antipsychotic medications; notify the
c. Perception of the patient to the crisis along with the physician
presence of support system and coping mechanism b. Administer medications as ordered
d. None of the above c. Assess for effectiveness
d. None of the above
16. A 16-year-old who is being seen by the crisis nurse
after making several superficial cuts on her wrist states Situation
that all her friends are siding with her ex-boyfriend and Nurse John is aware that he has a crucial role in
won’t talk to her anymore. She says she knows that the managing clients with anxiety-related disorders.
relationship is over, but “If I can’t have him, no one else
22. The client reports becoming involved with legislation
will.” Which of the following client problems takes the
that promotes gun safety after the death of the child by
highest priority?
accidental shooting. Which defense mechanism is the
client exhibiting?
a. Risk for other-directed violence
b. Situational low self-esteem
a. Denial
c. Risk for suicide
b. Sublimation
d. Risk-prone health behavior
c. Identification
Situation d. Intellectualization
The nurse is preparing a client with schizophrenia who
23. The client reports becoming physically ill with
has a history of command hallucinations for discharge by
frequent crying episodes, intense feelings of
providing instructions on interventions for managing
worthlessness, and loss of appetite on the anniversary of
hallucinations and anxiety.
the death of the client’s spouse. The client reports that
17. Which statement in response to these instructions this has occurred for the last 5 years- What should be the
suggests to the nurse that the client has a need for nurse’s focus when counseling the client?
additional information?
a. Anticipatory grief
a. “My medication will help my anxious feelings.” b. Uncomplicated grief
b. “I’ll go to support group and talk about what I am c. Delayed grief reaction
feeling.” d. Distorted grief reaction
c. “When I have command hallucinations, I’ll call a
24. The client is being discharged after hospitalization
friend for help.”
for a suicide attempt. Which question asked by the nurse
assesses the learned prevention and future coping c. “Being assaulted is traumatic; in time the anxiety will
strategies of the client? lessen, and you’ll feel more in control.”
d. “By using the skills you’re learning, the goal for
a. “How did you try to kill yourself?” you is to feel better or be back to normal in about 6
b. “Why did you think life wasn’t worth living?” weeks.”
c. “What skills can you utilize if you experience
problems again?” 30. The client presents to the ED reporting that he was
d. “Do you have the phone number of the suicide sexually assaulted by several men he met at a local bar.
prevention center?” Which action should the nurse plan to include when
preparing to assess the client?
25. The nurse is caring for the client with a major
depressive disorder. Which nursing problem should be a. Ask the client if he had been drinking alcohol
priority? excessively.
b. Call the male nurse on duty to assume the care of this
a. Powerlessness client.
b. Attempted suicide c. Do the interview in the same way as for other
c. Anticipatory grieving sexual assaults.
d. Disturbed sleep pattern d. Ask whether the client resisted any of the sexual
advancements.
26. The nurse is interviewing the client at a mental health
clinic who recently attempted suicide and continues to 31. The 10—year-old who was sexually abused by a
report active suicidal ideation. Which care setting is most family member experiences flashbacks of a disagreement
appropriate for this client? with that adult and the resulting sexual assault. Which
suggestion should the nurse make to the parents in order
a. An acute care hospital unit to help minimize this reaction?
b. An inpatient mental health unit
c. An outpatient mental health clinic a. Have the child avoid arguments with adults until this
d. A community detoxification center reaction is unlearned.
b. Ask the HCP to prescribe a medication to minimize
Situation the child’s aggressiveness.
The recently discharged veteran who served in active c. Adults in your family should learn to recognize and
combat reports symptoms of recurring intrusive thoughts, diffuse arguments effectively.
insomnia, and hyper vigilance. d. You and your child should regularly discuss bad
memories to decrease their effect.
27. Which question would be most helpful in
establishing a diagnosis? Situations
The Philippines is home to many destructive typhoons.
a. “Do you find yourself falling asleep while working?”
b. “Are you also having nightmares when you do 32. The client’s home was destroyed by a major flood.
sleep?" The client is attending a support group and says, “I will
c. “Your hair seems thin. Are you also pulling at your rebuild my home as good as new and be back in it in a
hair?” few months.” What should be the nurse’s initial
d. “Have you ever been diagnosed with obsessive response?
compulsive disorder?”
a. “That’s a very ambitious plan to undertake at this
28. The nurse is caring for a victim of sexual assault time.”
brought to the ED by a roommate. How should the nurse b. “I’m proud of your resiliency and willingness to start
respond when the client begins to angrily insist upon over.”
reporting the details of the assault? c. “Have you given thought to what may happen if it
floods again?”
a.Ask the roommate to sit with the client until the d. “Can you tell me how many months you think
examination can be resumed. rebuilding will take?”
b. Redirect the client to the physical tasks related to
securing any existing evidence. 33. The client is being treated after surviving a major
c. Encourage the client to use deep breathing techniques hurricane that took the lives of many neighbors. Which
to regain emotional control. statement by the client provides the nurse with the [best
d. Listen quietly as the client expresses the anger and evidence that therapy has been successful?
rage currently being experienced
*
29. The young adult after being robbed is attending a. “Therapy has been a very good thing for me since the
counseling sessions to address anxiety issues. What is the hurricane ruined things.”
nurse’s best response when the client asks, “When will b. “I’m ready and able to move on with my life in
things get better for me?” spite of all that has happened.”
c. “Nothing can happen to me that is worse than what
a. “These types of crises are self-limiting, and usually I’ve been through already.”
things are better in 4 to 6 weeks.” d. “I’ve learned a lot about myself since agreeing to
b. “Try not to worry; it is best for you to think about the attend crisis therapy sessions.”
future and not focus on the past.”
34. The nurse in the ED is assessing the client who was d. bcde
injured in a car accident. The nurse considers that the
client may have psychogenic amnesia when the client is 39. The female client tells the nurse, “I usually have a
unable to recall any personal information. Which few drinks after work, but I always limit it to three. I’m
statement that reflects the nurse’s critical thinking about not risking becoming addicted, am I?” What is the
psychogenic amnesia is correct? nurse’s best response?

a. Psycho genie amnesia is a long—lasting condition. a. “There is no harm in social drinking as long as you
b. Psychogenic amnesia is seen more often in men than know your limits and you are not driving while
women. intoxicated.”
c. Psycho genie amnesia is categorized with memory b. “As long as you don’t have any social problems
loss and dementia. associated with your use of alcohol, you do not need to
d. Psycho genie amnesia symptoms include wandering be concerned.”
and disorientation. c. “If you are concerned about the frequency and the
number of drinks consumed, then you might be
35. Which among the following options correctly developing a dependency.”
describe debriefing? d. “Three drinks a day or seven drinks in a week is
high-risk drinking for women. You seem concerned
a. Participants are asked about their emotional that you might have an alcohol dependency.”
reactions to the incident, what symptoms they may be
experiencing and other psychological medications. 40. The nurse is preparing to administer thiamine
b. Is a process by which the person receives education (vitamin B,) to the client receiving treatment for alcohol
about recognition of stress reactions and management dependence. Which statement best describes the rationale
strategies for handling stress. for the use of thiamine?
c. Either A or B
d. None of the above a. Thiamine improves the absorption of other essential
vitamins and folic acid.
36. The 10—year-old who was sexually abused by a b. Thiamine helps to reverse the malnutrition often
family member experiences flashbacks of a disagreement associated with alcohol abuse.
with that adult and the resulting sexual assault. Which c. Thiamine reduces the risk of seizures occurring during
suggestion should the nurse make to the parents in order withdrawal from alcohol.
to help minimize this reaction? d. Thiamine prevents neuropathy and confusion
associated with chronic alcohol use.
a. Have the child avoid arguments with adults until this
reaction is unlearned. 41. The hospitalized client has a history of weekly
b. Ask the HCP to prescribe a medication to minimize moderate alcohol use. Which symptoms assessed by the
the child’s aggressiveness. nurse indicate that the client may be experiencing alcohol
c. Adults in your family should learn to recognize and withdrawal? Select all that apply.
diffuse arguments effectively.
d. You and your child should regularly discuss bad a. Agitation
memories to decrease their effect. b. Hypotension
c. Tachycardia
Situation d. Hallucinations
The client is hospitalized after sustaining a head injury e. Tongue tremor
and a fractured wrist from a fall. The client admits to
drinking alcohol in moderation several times per week. a. bcde
b. abcd
37. Which assessment finding should the nurse associate c. abcde
with early alcohol withdrawal? d. acde
a. Agitation
b. Somnolence Situation
c. Slightly elevated BP Nurse Mira is assigned to care for a patient with
d. Delirium tremens (DTs) Parkinson’s Disease.

38. The nurse is caring for the client who is 2 days 42. Nurse Mira has admitted a patient with PD with a
postadmission to a medical unit and has a long history of fever and patchy infiltrates in the lung fields on the chest
heavy alcohol abuse. The nurse should monitor for which x-ray. Which clinical manifestations of PD would
acute complications related to alcohol abuse? Select all explain these assessment data?
that apply
a. Seizures a. Maskliek facies and shuffling gait.
b. Pancreatitis b. Difficulty swallowing and immobility.
c. GI bleeding c. Pill rolling of fingers and flat affect
d. Exophthalmos d. Lack of arm swing and bradykinesia
e. Delirium tremens
43. The client diagnosed with PD is being discharged on
a. edcb carbidopa/levodopa (Sinemet), an antiparkinsonian drug.
b. abcd Which statement is the scientific rationale for combining
c. abce these medication?
 b. Avoid eating or drinking at least 6 hours prior to the
a. There will be fewer side effects with this combination test.
than with carbidopa alone. c. Some hair will be removed with a razor to place
b. Dopamine D requires the presence of both of these electrodes.
medications to work. d. Have blood drawn for a glucose level 2 hours before
c. Carbidopa makes more levodopa available to the the test.
brain.
d. Carbidopa crosses the BBB to treat Parkinson’s 50. The nurse in the ED documents that the newly
disease. admitted client is “postictal upon transfer." What did the
nurse observe?
44. Which is a common cognitive problem associated
with Parkinson’s disease? a. Yellowing of the skin due to a liver condition
b. Drowsy or confused state following a seizure
a. Emotional lability c. Severe itching of the eyes from an allergic reaction
b. Depression d. Abnormal sensations including tingling of the skin
c. Memory deficits
d. Paranoia 51. The nurse asks the male client with epilepsy if he has
auras with his seizures. The client says, “I don’t know
45. A new medication regimen is prescribed for a client what you mean. What are auras?” Which statement by
with Parkinson’s disease. At which time should the nurse the nurse would be the best response?
make certain that the medication is taken?
a. “Some people have a warning that the seizure is
a. At bedtime about to start.”
b. All at one time b. “Auras occur when you are physically and
c. Two hours before mealtime psychologically exhausted.”
d. At the time scheduled c. “You’re concerned that you do not have auras before
your seizures?”
46. The nurse has asked the nursing assistant to ambulate d. “Auras fight for her friend in the bar.”
a client with Parkinson’s disease. The nurse observes the
nursing assistant pulling on the client’s arms to get the Situation
client to walk forward. The nurse should: A nurse is caring for several patients who are suffering
from meningitis.
a. Praise the nursing assistant as this is appropriate.
b. Explain how to overcome a freezing gait by telling 52. The wife of the client diagnosed with septic
the client to march in place. meningitis asks the nurse, “I am so scared. What is
c. Assist the NA with getting the client back in bed. meningitis?” Which statement would be the most
d. Give the client a muscle relaxant as studies have appropriate response by the nurse?
proved that this is effective in this situation.
a. “There is bleeding into his brain causing irritation of
Situation the meninges.”
The male client is sitting in the chair and his entire body b. “A virus has infected the brain and meninges, causing
is rigid with his arms and legs contracting and relaxing. inflammation.”
The client is not aware of what is going on and is making c. “This is a bacterial infection of the tissues that
guttural sounds. cover the brain and spinal cord.”
d. “This is an inflammation of the brain parenchyma
47. Which action should the nurse implement first? caused by a mosquito bite.”

a. Push aside any furniture 53. The client is at risk for septic emboli after being
b. Place the client on his side diagnosed with meningococcal meningitis. Which action
c. Assess the client’s v/s by the nurse directly addresses this risk?
d. Ease the client to the floor
a. Monitoring vital signs and oxygen saturation levels
48. The client who just had a three minute seizure has no hourly
apparent injuries and is oriented to name, place, and time b. Planning to give meningocoeeal polysaccharide
but is lethargic and just wants to sleep. Which vaccine
intervention should the nurse implement? c. Assessing neurological function with the Glasgow
Coma Scale q2h
a. Perform a complete neurological assessment
d. Completing a thorough vascular assessment of all
b. Awaken the client every 30 minutes
extremities q2h
c. Turn the client to the side and allow the client to
sleep 54. The nurse is assessing the client with a tentative
d. Interview the client to find out what caused the seizure diagnosis of meningitis. Which findings should the nurse
associate with meningitis? Select all that apply.
49. The nurse is teaching the client who is scheduled For
an outpatient EEG. Which instruction should the nurse
I. Nuchal rigidity
include?
II. Severe headache
III. Pill-rolling tremor
a. Remove all hairpins before coming in for the EEG
IV. Photophobia
test.
V. Lethargy c. Compare results of performance to standards and
objectives
a. I, II, III d. Identify possible courses of action
b. I, III, IV, and V
c. I and III only 61. Which of the following statements refers to criteria?
d. I, II, IV and V
a. Agreed on level of nursing care
55. The nurse is assessing the client diagnosed with b. Characteristics used to measure the level of
meningococcal meningitis. Which assessment data would nursing care
warrant notifying the HCP? c. Step-by-step guidelines
d. Statement which guide the group in decision making
a. Purpuric lesions on the face and problem solving
b. Complaints of light hurting the eyes
c. Dull, aching, frontal headache Situation
d. Not remembering the day of the week Using Maslow's need theory, Airway, Breathing and
Circulation are the physiological needs vital to life. The
56. Which type of precautions should the nurse nurse's knowledge and ability to identify and
implement for the client diagnosed with septic immediately intervene to meet these needs is important
meningitis? to save lives.

a. Standard precautions 62. Which of these clients has a problem with the
b. Airborne precautions transport of oxygen from the lungs to the tissues?
c. Contact precautions
d. Droplet precautions a. Carol with a tumor in the brain
b. Theresa with anemia
Situation c. Sonny Boy with a fracture in the femur
The Mariano Marcos Memorial Hospital and Medical d. Brigette with diarrhea
Center just opened its new Performance Improvement
Department. Mr. Greg is appointed as the Quality 63. Laboratory tests are prescribed for the client who has
Control Officer. He commits himself to his new role and a smooth and reddened tongue and ulcers at the corners
plans his strategies to realize the goals and objectives of of the mouth. Which result would the nurse find if the
the department. client has iron-deficiency anemia?

57. Which of the following is a primary task that they a. Low hemoglobin and hematocrit
should perform to have an effective control system? b. Elevated red blood cells (RBCs)
c. Prolonged prothrombin time (PT)
a. Make an interpretation about strengths and weaknesses d. Elevated white blood cells (WBCs)
b. Identify the values of the department
c. Identify structure, process, outcome standards & 64. The nurse is teaching the client who is a strict
criteria vegetarian how to decrease the risk of developing
d. Measure actual performances megaloblastic anemia. Which information should the
nurse provide?
58. Ms. Valencia develops the standards to be followed.
Among the following standards, which is considered as a a. Undergo an annual Schilling test.
structure standard? b. Increase intake of foods high in iron.
c. Supplement the diet with vitamin B12
a. The patients verbalized satisfaction of the nursing care d. Have a hemoglobin level drawn monthly.
received
b. Rotation of duty will be done every four weeks for 65. The nurse assesses that the client with hemolytic
all patient care personnel. anemia has weakness, fatigue, malaise, and skin and
c. All patients shall have their weights taken recorded mucous membrane pallor. Which finding should the
d. Patients shall answer the evaluation form before nurse also associate with hemolytic anemia?
discharge
a. Scleral jaundice
59. When she presents the nursing procedures to be b. A smooth, red tongue
followed, she refers to what type of standards? c. A craving for ice to chew
d. A poor intake of fresh vegetables
a. Process
b. Outcome 66. The client is being admitted with folic acid
c. Structure deficiency anemia. Which would be the most appropriate
d. Criteria referral?

60. The following are basic steps in the controlling a. Alcoholics anonymous
process of the department. Which of the following is b. Leukemia society of the PH
NOT included? c. A hematologist
d. A social worker
a. Measure actual performance
b. Set nursing standards and criteria Situation
The nurse's understanding of ethico-legal responsibilities 74. The spouse of a client dying from lung cancer states,
will guide his/her nursing practice. “ I don’t understand this death rattle. She has not had
anything to drink in days. Where is the fluid coming
67. The principles that -govern right and proper conducts from? Which is the hospice care nurse’s best response?
of a person regarding life, biology and the
health professions is referred to as: a. “The body produces about two teaspoons of fluid
every minute on its own.”
a. Morality b. “Are you sure someone is not putting ice chips in her
b. Religion mouth?”
c. Values c. “There is no reason for this, but it does happen from
d. Bioethics time to time.”
d. “I can administer a patch to her skin to dry up the
68. The purpose of having nurses' code of ethics is:
secretions if you wish.”
a. Delineate the scope and areas of nursing practice 75. The hospice care nurse is conducting a spiritual care
b. Identify nursing action recommended for specific assessment. Which statement is the scientific rationale
healthcare situations for this intervention?
c. To help the public understand professional
conduct, expected of nurses a. The client will ask all of his or her spiritual questions
and get answers.
69. You inform the patient about his rights which include
b. The nurse is able to explain to the client how death
the following EXCEPT:
will affect the spirit.
c. Spirituality provides a sense of meaning and
a. Right to expect reasonable continuity of care
purpose for many clients.
b. Right to consent to or decline to participate in research
d. The nurse is the expert when assisting the client with
studies or experiments
spiritual matters.
c. Right to obtain information about another patient
d. Right to expect that the records about his care will be 76. The client who is terminally ill called the significant
treated as confidential others to the room and said good-bye, then dismissed
them and now lies quietly and refuses to eat. The nurse
70. The principle states that a person has unconditional
understands the client is in what stage of the grieving
worth and has the capacity to determine his own destiny.
process?
a. Bioethics
a. Denial
b. Justice
b. Anger
c. Fidelity
c. Bargaining
d. Autonomy
d. Acceptance
71. Standards of nursing practice serve as guide for:
Situation
Nursing research is considered essential to the
a. Nursing practice in the different fields of nursing
achievement of high-quality patient care and outcomes.
b. Proper nursing approaches and techniques
c. Safe nursing care and management 77. Which of the following is a method of non-
d. Evaluation of nursing cared rendered probability sampling?
Situation
a. Cluster sampling
You are taking care of Mrs. Gil, 65 years old, who is
b. Snowball sampling
terminally ill with ovarian cancer stage IV.
c. Simple random sampling
72. When caring for a dying client you will perform d. stratified random sampling
which of the following activities?
78. The data on the family’s number of children is
appropriate for what level of measurement?
a. Encourage the client to reach optimal health
b. Assist client perform activities of daily living
a. Interval
c. Assist the client towards a peaceful death
b. Ordinal
d. Motivate client to gain independence
c. Ratio
73. The client prepares for eventual death and discusses d. Nominal
with the nurse and her family how she would like her
79. A nurse researcher wants to study the response of
funeral to look like and what dress she will use. This
patients who suffer from dysrhythmia to pacemaker. The
client is in the stage of:
appropriate research design would be?

a. Acceptance a. Experimental research design

b. Resolution b. Descriptive-correlational
c. Denial c. Comparative descriptive
d. bargaining d. Correlational

80. Which of the following are qualitative data sources?

 a. Assessing the client using the Glasgow Coma Scale
(GCS)
a. Interview and observation. b. Assessing the level of sensation in the client‘s
b. Primary sources and secondary sources extremities
c. Books and journals c. Checking that the cervical collar was correctly
d. Questionnaires and survey placed by EMS
d. Applying antiembolism hose to the client‘s lower
81. All of the following are advantages of using
Extremities
questionnaires EXCEPT:
Situation
a. Easy to test data for reliability and validity Nurse Oni is caring for patients with Multiple Sclerosis.
b. Facilitates data gathering
c. Less time consuming than interview and observation 87. Nurse Oni should conduct a focused assessment with
d. Respondents may provide socially acceptable client with multiple sclerosis for risk of which of the
answers following?

Untitled Title I. Dehydration

II. Falls
Situation
III. Seizures
Nurse Jenny arrives at the site of a one-car motor-vehicle
IV. Skin breakdown
accident and stops to render aid. The driver of the car is
V. Fatigue
unconscious.

82. After stabilizing the client’s cervical spine, which a. II, III, IV, V
action should the nurse take next? b. I, II, III, IV
c. II, IV, V
a. Carefully remove the driver from the car. d. I and II
b. Assess the client’s pupil for reaction.
88. Which of the following is not a typical clinical
c. Assess the client’s airway.
manifestation of MS?
d. Attempt to wake the client up by shaking him.

83. In assessing the client with T12 SCI, which clinical a. Double vision
manifestations would the nurse expect to find to support b. Sudden bursts of energy
the diagnosis of spinal shock? c. Weakness in the extremities
d. Muscle tremors
a. No reflex activity below the waist
89. Nurse Oni should know that the primary reason why
b. Inability to move upper extremities
she find it difficult to evaluate the effectiveness of the
c. Complaints of a pounding headache
drugs the client has used for 15 years is?
d. Hypotension and bradycardia

84. The client with a C6 SCI is admitted to the a. The client exhibits intolerance to many drugs.
emergency department complaining of a sever pounding b. The client experiences spontaneous remissions
headache and has BP of 180/110. Which intervention from time to time.
should the emergency department nurse implement? c. The client requires multiple drugs simultaneously.
d. The client endures long periods of exacerbation before
a. Keep the client flat in bed the illness responds to a particular drug.
b. Dim the lights in the room
90. The client with MS tells the nurse about extreme
c. Assess for bladder distention
fatigue. Which assessment findings should the nurse
d. Administer a narcotic analgesic.
identify as contributing to the client's fatigue? Select all
85. The nurse assesses the client, who was injured in a that apply.
diving accident 2 hours earlier. The client is breathing
independently but has no movement or muscle tone from I. Hemoglobin 9.5 g/dL and hematocrit is 31.8%
below the area of injury. A CT scan reveals a fracture of II. Taking baclofen 15 mg 3 times per day
the C4 cervical vertebra. The nurse should plan III. Working 4 to 8 hours per week in the family business
interventions for which problem? IV. Stopped taking amitriptyline 8 weeks earlier
V. Presence of a cardiac murmur at the tricuspid valve.
a. Complete spinal cord transection VI. Bilateral leg weakness noted when walking in room
b. Spinal shock
c. An upper motor neuron injury a. I, II, III
d. Quadriplegia b. I, II, III, IV
c. I, II, IV, V, VI
86. Spinal precautions are ordered for the client. Who d. I, II, III, IV, V
sustained a neck injury during an MVA. The client has
yet to be cleared that there is no cervical fracture. Which 91. The home-care nurse is counseling the client who has
action is the nurse’s priority when receiving the client in MS. The client is experiencing weakness, ataxia,
the ED? intermittent adductor spasms of the hips, and occasional
incontinence from loss of bladder sensation. Which self-
care measures should the nurse recommend? Select all C. Decreased erythrocyte sedimentation rate
that apply. D. Increased protein in the cerebrospinal fluid
I. “Adductor spasms can be relieved by taking a hot
bath." Situation
II. “If a muscle is in spasm, stretch and hold it, and then Nurse Mira works as a nurse in a rehabilitation center for
relax.” individuals who abuse a certain substance.
III. “Rest first and then walk as able using a walker for
97.The spouse of the client who is currently in inpatient
support.“
treatment for substance abuse tells the nurse, “We’ve
IV. “When walking, keep feet close together, legs
done this so many times. I don’t think my spouse is ever
slightly bent.”
going to change. Do you think it’s time for me to get a
V. “Set an alarm to remind you to void 30 minutes After
divorce?” Which response by the nurse is most helpful?
fluid intake."
a. “You don’t think your spouse is ever going to
a. II, III, V
change?”
b. II, III, IV
b. “Sounds like you’re feeling discouraged in your
c. II, III, I
marriage.”
d. II, III
c. “Your spouse will likely continue to use and need
Situation treatment again.”
Nurse Carla is caring for a patient with Guillain-Barré. d. “That’s your decision; I can’t tell you whether you
should get a divorce.”
92. The client diagnosed with Guillain-Barré syndrome is
scheduled to receive plasmapheresis treatments. The 98. The nurse is in the working phase of a relationship
client’s spouse asks the nurse about the purpose of with the client being treated for substance abuse. Which
plasmapheresis. Which explanation is correct? intervention would be appropriate during this phase of
treatment?
a. “Plasmapheresis removes excess fluid from the
bloodstream.” a. Assessing the client’s readiness to change substance-
b. “Plasmapheresis will increase the protein levels in the abusing behavior
blood.” b. Evaluating the effectiveness of the client’s newly
c. “Plasmapheresis removes circulating antibodies adapted coping skills
from the blood.” c. Confronting the client’s denial that substances have
d. “Plasmapheresis infuses lipoproteins to restore the negatively impacted daily life
myelin sheath.” d. Determining the extent to which substances have
impaired the client’s functioning
93. The nurse is caring for the client experiencing
Guillain-Barré syndrome (GBS). It is most important for 99. The nurse is assessing the college student who
the nurse to monitor the client for which complication? presents with generalized fatigue, dry mouth,
tachycardia, and an increased appetite. Which additional
a. Autonomic dysreflexia finding from the client’s history and physical exam
b. Septic emboli should alert the nurse to explore possible
c. Cardiac dysrhythmias marijuana abuse?
d. Respiratory failure
a. Paranoia
94. Nurse Carla learns that the pathophysiology of b. Flashbacks
Guillain-Barré syndrome includes segmental c. Gastric disturbances
demyelination. The nurse should understand that this d. Conjunctival infection
causes what?
100. The client states, “I don’t see any problem with
smoking a little weed. It isn’t addictive.” Which
a. Delayed afferent nerve impulses
response by the nurse is most accurate?
b. Paralysis of affected muscles
c. Paresthesia in upper extremities
a. “Marijuana is a natural chemical that has many
d. Slowed nerve impulse transmission
therapeutic uses, but it is still illegal to use.”
95. Which assessment finding is most indicative of b. “Marijuana is not addictive. The danger is that. it often
Guillain-Barré syndrome (GBS)? leads to abuse of more illicit drugs.”
c. “Marijuana has effects similar to alcohol,
hallucinogens, and sedatives that are addictive.”
A. Pupillary dilation d. “There are no withdrawal symptoms, so it is
B. Expressive aphasia controversial whether marijuana is addictive.”
C. Loss of bowel and bladder control
D. A sudden onset of muscle weakness and pain

96. Which laboratory result is consistent with the

diagnosis of Guillain-Barré syndrome (GBS)?

A. Positive rheumatoid factor

B. Decreased serum albumin