Stroke & BPH Nursing Care Guide
Uploaded by
Angelica Charisse BuliganStroke & BPH Nursing Care Guide
Uploaded by
Angelica Charisse BuliganNP1
6. What is theprioritynursing problem for Kevin?
ituation:A 70 year old male admitted at medicalunit is
S
recovering from Cerebrovascular Accident (CVA) or . Impaired urinary elimination
A
stroke. B. Social Isolation
C. Interrupted sleep pattern
. He exhibits signs of unilateral neglect. Which behavior
1 D. Sexual dysfunction
is suggestive ofunilateral neglect?
. Since the client was diagnosed with BPH, which among
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. The client is observed shaving only one side of his
A the followingmedicationsshould the nursequestionif
face. ordered, except? (+)
B. The client is unable to distinguish between two tactile
stimuli presented simultaneously. . Anticholinergics
A
C. The client is unable to complete a range of vision B. Antihistamines
without turning his head side to side. C. Decongestants
D. The client is unable to carry out cognitive and motor D. 5-alpha reductase inhibitor
activity at the same time. - FINASTERIDE
- DUTASTERIDE
. The chart indicates that a client hasexpressiveaphasia
2
following a stroke. The nurse understands that the client . Non-invasive methods were deemed ineffective for
8
will have difficulty with: Kevin so whichgold standard procedurewas prescribed
to remove the enlarged portion of the prostate through an
endoscope?
. Open prostatectomy
A
B. Transurethral resection of the prostate (TURP)
C. Holmium Laser Enculcatean of the Prostate (HoLEP)
.Speaking
A
D. Contact Laser Prostatectomy (CLP)
B. Comprehending spoken words – RECEPTIVE
C. Carrying out purposeful motor activity – APRAXIA
. Suppose that Kevin had a transurethral resection of the
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D. Recognizing and using an object correctly – AGNOSIA
prostate (TURP) yesterday. The staff nurse notes that the
Hemoglobin is 8.2 g/dL. What is the nurse’s best action?
. Whichdiet selectionwould be suited to the client?
3
→ N:11.7 – 16 G/DLFOR 63 YR OLD MALES
→SOFT FOODS & LIQUID
. Notify the charge nurse as soon as possible.
A
. Roast beef sandwich,potato chips, pickle spear,iced
A
B. Irrigate the catheter with 30 mL of normal saline.
tea
C. Document the assessment in the medical record.
B. Split pea soup, mashed potatoes, pudding, milk
D. Prepare for a blood transfusion.
C. Tomato soup, cheese toast, Jello,coffee
D.Hamburger, baked beans, fruit cup, iced tea
0. Kevin has used sawPalmetto Extract for his urinary
1
symptoms with some relief. What must the nurse teach
. Which nursing intervention would bestimprove tissue
4
the client?
perfusionto prevent skin problems?
. The proper way of using saw palmetto.
A
. Assessing the skin daily
A
B. Scientific evidence to prove they are useful is
B. Massaging any erythematous areas on the skin
lacking.
C. Changing incontinence pads as soon as they become
C. It is an OTC natural substance, hence does not need
soiled
consultation.
D. Performing range-of-motion exercises and turning
D. Use of herbs does not interfere with the action of
and repositioning the client
prescribed drugs as they are natural.
. The nurse is performing an admission history for a client
5
ituation:Appropriate handling, treatment, and disposal
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recovering from a stroke. Medication history reveals the
of waste by type reduce costs and do much to protect
drugClopidogrel (Plavix)→ANTIPLATELET /
public health. The nurse correctly segregates wastes
ANTICOAGULANT. Which clinical manifestation alertsthe
produced while providing care to the patient.
nurse to anadverse effectof this drug?
. Epistaxis
A
B. Abdominal distention
C. Nausea
D. Hyperactivity
ituation:Patient Kevin, a 63-year-old with Benign
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Prostatic Hyperplasia (BPH), is admitted with UTI,
1.Sharps from syringesshould be disposed of ina
1
hematuria, and hydronephrosis. His wife says their sexual
puncture-proof container that is colored:
relationship has been nonexistent due to her husband's
BPH. He has used saw palmetto extract for his urinary
A. Yellow with a black band
symptoms with some relief.
. Orange
B . Carry out arm circles while riding.
A
C. Red B. Perform ankle pumps and range-of-motion
D. Black exercises on your feet.
C. While traveling, elevate your legs.
2. According to the DOHHealth Care Waste
1 D. Take an ambulance to your house.
Management Manual,the guidelines for segregating
sharps include the following,EXCEPT? ituation:Basic Life Support, or BLS, generally thetype
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of care that first-responders, healthcare providers
. Sharps should be collected together, regardless of
A provides to anyone who is experiencing cardiac arrest,
whether or not they are contaminated. (+) respiratory distress or an obstructed airway that requires
B. Containers should be puncture-proof (usually knowledge and skills in cardiopulmonary resuscitation
made ofrubberor high-density plastic) and fittedwith (CPR), using automated external defibrillators (AED) and
covers. → METAL relieving airway obstructions in patients of every age.
C. Containers should be rigid and impermeable to contain
not only the sharps but also residual liquids from syringes. 8. A client with unstable ventricular tachycardia (VT)
1
(+) loses consciousness and becomes pulseless after an
D. Containers should be tamper-proof and needles and initial treatment with a dose of lidocaine (Xylocaine)
syringes should be rendered unusable. (+) intravenously. Whichitemshould the nurse caringfor the
client immediately obtain? →PULSELESS V TACH
3. General practices insegregationshould be observed
1
in which among the following:
. Accept receptacles for general waste with plastic
A
bag cover
B. Bags and containers for infectious waste should be
marked with the international infectious substance symbol
C. Radioactive wastes should be segregated according to
their physical form (solid & liquid) and according to their
half-life or potency (short-live and lived) in specially
marked containers as prescribed
D. Waste with high content of heavy metals should be
collected separately and sent to waste treatment facility
available in the area
4.Chemical wasteincluding those with heavy metals
1
should be disposed of in a container that is colored:
. Yellow with a black band
A
B. Orange
C. Red
D. Black
. A pacemaker
A
5. Radioactive wasteshould be disposed of in a
1 B. A defibrillator
container that is colored: C. A second dose of lidocaine
D. An electrocardiogram machine
. Yellow with a black band
A
B. Orange 9. A client has been defibrillated at 360 joules
1
C. Red (monophasic) and the attempts to convert the ventricular
D. Black fibrillation (VF) wereunsuccessful. Based on an
evaluation of the situation, the nurse determines that
6. In the emergency room, a loading dose of heparin
1 which action would be best?
was administered, andIV heparinwill be administered
over the next several days. The nurse should create a . Terminating the resuscitation effort
A
care plan for this client that includes: B. Preparing for the administration ofsodium bicarbonate
.Aspirinshould be taken as directed. →
A ✖️ intravenously
C. Performing cardiopulmonary resuscitation (CPR)
B. Increasing the consumption of green leafy veggies. for 5 cycles or about 2 minutes
C. Keeping an eye on the client's prothrombin time (PT). D. Performing cardiopulmonary resuscitation (CPR) for5
D. The client's activated partial thromboplastin time minutes, then defibrillating three more times at400joules
(aPTT) and International Normalized Ratio (INR) are
being monitored. 0. The nurse is assisting to defibrillate a client in
2
ventricular fibrillation. After placing the pads on the client’s
7. A client being discharged from the hospital for
1 chest andbefore dischargingthe device, which
Thrombophlebitiswill be riding in a car toward home. intervention is a priority?
The nurse shouldurge the clientto do the following during
the2-hour ride: . Ensure that the client has beenintubated.
A
B. Set the defibrillator to the “synchronize” mode.
. Administer an amiodarone bolus intravenously.
C
D. Confirm that the rhythm is ventricular fibrillation. . Risk for injury
A
B. Noncompliance
1. Nurse Angie is working in a Sugical Unit. She receives
2 C. Low self-esteem
a telephone call from the post-anesthesia care unit stating D. Impaired social interaction
that a client is being transferred to the surgical unit. She
plans to take whichaction first on arrivalof theclient?→ 8. When working with a healthcare provider to develop a
2
AB
CDE treatment planfor a client, which of the followingis most
likely to be included?
. Assess the patency of the airway.
A
B. Check tubes or drains for patency. . Homeschooling and anti-anxiety drugs such as
A
C. Check the dressing to assess for bleeding. buspirone (BuSpar).
D. Assess the vital signs to compare with preoperative B. Antidepressant drugs, such as imipramine (Tofranil),
measurements. and family counseling are recommended.
C. Monthly blood levels and anticonvulsant drugs such as
Situation:Herniated Lumbar Intervertebral Disc carbamazepine (Tegretol).
D. Methylphenidate (Ritalin) and other stimulant
2. Whichpositionshould the nurse place the clientin to
2 drugs, as well as behavior modification.
minimize the pain?
9. When discussing thecommon side effectsof the
2
. Flat with the knees raised
A medication commonly ordered for ADHD, all of the
B. High Fowler’s position with the foot of thebedflat following are correctEXCEPT:
C. Semi-Fowler’s position with the foot of thebedflat
D. Semi-Fowler’s position with the knees slightly . Suppression of appetite (+)
A
raised B. Insomnia (+)
C. Growth stifling (+)
3. He is conducting health screening for osteoporosis.
2 D. Damage to the spleen
Which client is atgreatest riskof developing thisproblem?
ituation:Individuals face anxiety on a daily basis.
S
. A 25-year-old woman who runs
A Anxiety, which provides the motivation for achievement, is
B. A 36-year-old man who has asthma a necessary force for survival.
C. A 70-year-old man who consumes excess alcohol
D. A sedentary 65-year-old woman who smokes 0. Bella knows thatanxietyis correctly distinguished
3
cigarettes from fear in which statement?
4. The nurse is visiting a home health client with
2 . Anxiety iscognitiveprocess.
A
osteoporosis. The client has a new prescription for B.Fearis an emotional process. → ANXIETY
Alendronate (Fosamax). Which instruction should be C. Fear involves the intellectual appraisal of a
given to the client? threatening stimulus.
D. Anxiety involves thethinking responseto that
. Rest in bed after taking the medication for at least 30
A appraisal.
minutes.
B. Avoid rapid movements after taking the medication. 1. Nurse Bella correctly identifies theneurobiologyof
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C. Take the medication with water only. anxiety disorders,EXCEPT:
D. Allow at least 1 hour between taking the medicine and
taking other medication . Serotonin is thought to be decreased in anxiety
A
disorders. (+)
5. Which snack selection by a client with osteoporosis
2 B. Norepinephrine is thought to be increased in anxiety
indicates that the client understands thedietary disorders (+)
managementof the disease? C. GABA is thought to be decreased in anxiety disorders
(+)
. A granola bar
A D. Dopamine is thought to be increased in anxiety
B. A bran muffin disorders
C. Yogurt
D. Raisins 2. Janet has a diagnosis of Generalized Anxiety
3
Disorder. Her physician has prescribed buspirone 15 mg
6. Nurse Athena is knowledgeable about the biochemical
2 daily. Janet says to the nurse,“Why do I have totake
influences of certain neurotransmitters on ADHD. He this every day? My friend’s doctor ordered Xanax for
correctly identifiesbiochemical influences on ADHD: her, and she only takes it when she is feeling
anxious.”Which of the following would be an appropriate
. Norepinephrine appears to be depleted.
A responseby the nurse?
B. Dopamine appears to beincreased. → DEC
C. Serotonin appears to beincreased. → DEC . “Xanax is not effective for generalized anxiety
A
D.Oxytocinappears to be depleted. disorder.”
B. “Buspirone must be taken daily in order to be
7. The nurse identifies the prioritynursing diagnosisfor
2 effective.”
the patient is:
. “I will ask the doctor if he will change your dose of
C . Child aged 9 years old may begin to see death as
C
buspirone to prn so that you don’t have to take it every permanent.
day.” D. Adolescent experiencing grief donotregess.
D. “Your friend really should be taking the Xanax every
day.” 5. The nurse’s role in the grief and loss process includes
3
communicating with the client, family members, and
ituation:Grief is a natural emotional response toloss
S significant other. Which among the following must the
that individuals must experience as they attempt to nurse include in thecommunicationwith patients,
accept the loss. The nurse is caring for various patients EXCEPT?
experiencing grief at some points of their lives.
. If you do not know what to say to a client or family who
A
is talking about death or another loss, listen attentively
and use therapeutic communication techniques, such as
open-ended questions or reflection.
B. Realize that it is acceptable to cry with the client and
family during the grief process.
C. Let the client and family know that the topic of
conversation is a difficult one and that you do not know
what to say.
D. Establish trust with the client and encourage
expression of feelings, concerns, and fears within a
non trusting, supportive, and nonjudgmental
environment.
ituation:Patient Kenzo, a client currently admittedto
S
the Psychiatric Ward, is diagnosed with Schizophrenia.
Nurse Frenny is caring for him.
6.Schizophrenia, as opposed to other psychotic
3
disorders, is described?
. Symptoms lastat least 1 day but less than 1 month,
A
and there is an eventual full return to the premorbid level
of functioning. →PSYCHOTIC DISORDER
B. Characterized by periods of remission and
exacerbation
C. The duration, including prodromal, active, and residual
phases, isat least 1 month but less than 6 months.→
SCHIZOPHRENIFORM
D. With a strong element of symptomatology associated
with the mood disorders (depression or mania). →
SHIZO AFFECTIVE
7. Currently, the most prominent neurochemical theories
3
involve dopamine and serotonin. Nurse Frenny, a
competent nurse, knows theeffects of serotonin and
dopamineon schizophrenia is? →INCREASED
. Serotonin modulates and helps control low levels of
A
dopamine.
3. Web is currently working as a call center agent when
3
B. Serotonin modulates and helps increase lowered
suddenly his dog, Cappuccino,suddenly died. Hecannot
dopamine.
take a leave which resulted short termin what typeof
C. Drugs that decrease activity in the dopaminergic
grief?
system induce schizophrenic-like reactions.
D. Drugs blocking postsynaptic dopamine receptors
. Dysfunctional grief
A
reduce psychotic symptoms.
B. Disenfranchised grief →NOT ACKNOWLEDGED
C. Anticipatory grief
8. Patient Kenzo is being given Clozapine (Clozaril), a
3
D. Perceived grief
second-generation antipsychotic. Nurse Frenny correctly
identifies thedifferencesbetween typical and atypical
4. Grief being experienced by children is inevitable.
3
neuroleptics,except:
Which among is a true response ofgrief in children?
. First-generation neuroleptics are dopamine
A
. Toddler may see death asirreversible.
A
antagonists.
B. Child aged6 years oldhas a sense of loss and is
B. Second-generation neuroleptics are both dopamine
concerned about who will provide care. →2-5 YRS
and serotonin antagonists.
. Second-generation neuroleptics only diminish
C
negative symptoms. →DIMINISH BOTH (+) & (–)
D. First-generation neuroleptics only diminish positive
symptoms.
9. One morning, while Nurse Frenny is making rounds,
3
patient Kenzo verbalized“Someone is trying to geta
message to me through the news in this TV program;
I must break the code so that I can receive the
message.”Nurse Frenny knows that the client may be
experiencing whichtype of delusion?
. Administer IV hydration, as ordered in case of severe
A
. Persecution – “TO BE HARMED BY OTHERS”
A
vomiting.
B. Reference
B. Keep in abright-lit roomin a comfortable position.
C. Grandeur – SUPERIORITY
C. Monitor intake/output and daily weights.
D. Control or influence
D. Implement fall precautions.
0. The primary focus in working with the actively
4
5. The intratympanic injection of Gentamicin has been
4
psychotic client in all cases would be to:
prescribed for patient Pierre. Gentamicin is an antibiotic
that is toxic and poisonous to the cells of the inner ear.
. Promote interaction with others
A
Nurse Manny needs towatch out for?
B. Establish a relationship with others
C. Encourage participation in therapy activities
. Hearing loss
A
D. Decrease his anxiety and increase trust
B. Vertigo
C. Tinnitus
ituation:Ménière’s disease is an abnormality ininner
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D. Aural fullness
ear fluid balance caused by malabsorption in the
endolymphatic sac or a blockage in the endolymphatic
ituation:Before partaking in their clinical dutiesat the
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duct. Nurse Manny is caring for patient Pierre diagnosed
psychiatric facility, nursing students are required to
with Meniere’s disease.
participate in a set of lectures by their respective clinical
instructors to gear them up for their duties.
1. Aglycerol test→HAS OSMOTIC PROPERTYaided
4
the diagnosis of Meniere’s disease for patient Pierre who
6. The newly arrived nursing student was asked to
4
received an oral dose of glycerol, followed by serial
enumerate about the differentCluster B Personality
audiograms over 3 hours. Which expected finding
Disorders. She isincorrectwhen she includes what
supports the diagnosis of Meniere’s disease?
disorder in the list?
. Improved speech discrimination
A
. Antisocial Personality Disorder (+)
A
B. Impaired speech discrimination
B. Narcissistic Personality Disorder (+)
C. Improved verbalization
C. Paranoid Personality Disorder → CLUSTER A
D. Impaired verbalization
D. Histrionic Personality Disorder (+)
2. Nurse Manny attends to client Pierre who is currently
4
7. The clinical instructor emphasized the importance of
4
experiencingvertigo. What medication would Nurse
being aware of the different barriers in dealing with
Manny expect to be ordered for Pierre?
psychiatric patients. Which of the following isNOTa
barrier in the treatmentof clients with personality
. Aspirin
A
disorders?
B. Streptomycin
C. Metoclopramide →ANTIEMETIC
. Personality characteristics and behavioral patterns are
A
D. Furosemide
deeply ingrained (+)
B. Course of TX is usually quick →LONG TERM
3. Nurse Manny attends to client Pierre who is currently
4
C. There is difficulty in modifying and changing one’s
experiencing vertigo. Banking on the answer to the
personality (+)
previous question, thechronic use or high doses ofthe
D. Clients with personality disorders see their behaviors
dopamine antagonistthat Nurse Manny expects for
as a source of pride. (+)
patient Pierre carry the risk for?
8. Personality develops through the interaction of
4
. Extrapyramidal Syndrome (EPS)
A
hereditary dispositions and environmental influences.
B. Akathisia
Which of the following isNOTincluded in thefour
C. Neuroleptic Malignant Syndrome
temperament traitsof a human being?
D. Tardive dyskinesia
4. In preparing his care for patient Pierre with Meniere’s
4
disease, nurse Manny includes the followinginterventions
in his nursing care plan,EXCEPT?
A. Harm avoidance
. Novelty seeking
B . There is a lack of symptoms and a normal peripheral
B
C. Intelligence quotient blood smear, but there is still evidence of disease in the
D. Reward dependence bone marrow. →PARTIAL REMISSION
C. There is no evidence of disease on physical
9. Although temperament is largely inherited, there are
4 assessment, the bone marrow and peripheral blood
other factors that play a huge part in influencing a appear normal, and molecular analysis shows no
person’s character. Which of the following describes the residual problems.
extent to which a person considers him or herself to be an D. All molecular studies are negative for residual
integral part of the universe? leukemia.
. Self-control
A 5. Nurse Kia is aware that thepathophysiologyofAML
5
B. Self-transcendence is?
C. Self-directedness
D. Cooperativeness . Abnormal proliferation of monoclonal immunoglobulins
A
B. Uncontrolled proliferation of the precursors of
ituation:Patient Lou, aged 68 years old, is diagnosed
S granulocytes
with Leukemia. Nurse Kia is assigned to him. C. The proliferation of immature small B-lymphocytes
D. Excessive development of neoplastic granulocytes
0. Patient Lou was diagnosed with the type of leukemia
5
that is referred to as the most common form andmost ituation:Another patient of Nurse Kia is Paloma,who is
S
common cause of death from all leukemias. Nurse Kia diagnosed with Multiple Myeloma.
knows this is?
6. Nurse Kia is aware that the pathophysiology ofMultiple
5
. Acute Lymphocytic Leukemia (ALL)
A Myelomais? →ABNORMAL PROLIFERATION OF
B. Chronic Lymphocytic Leukemia (CLL) B-CELLS
C. Acute Myelocytic Leukemia (AML)
D. Chronic Myelocytic Leukemia (CML) . Abnormal proliferation of monoclonal
A
immunoglobulins
1. Nurse Kia knows that thehallmarkof the diagnosisof
5 B. Uncontrolled proliferation of the precursors of
AML is? granulocytes
C. The proliferation of immature small B-lymphocytes
. Decreased erythrocytes and platelets in a complete
A D. Excessive development of neoplastic granulocytes
blood count
B. Excess of blast cells (more than 20%) in a bone 7. Patient Paloma complains of which among the
5
marrow analysis following, as identified by Nurse Paloma as theclassic
C. Normal total leukocyte count in a complete blood and major manifestationof Multiple Myeloma?
count
D. Percentage of normal cells is vastly decreased . Polyuria → D/T HYPERCALCEMIA
A
B. Nausea and vomiting → D/T HYPERCALCEMIA
2. Nurse Kia identifies the diagnostichallmark ofCML
5 C. Fractures → COMPLICATION
and an important indicator of residual disease or relapse D. Skeletal pain → BONE DEGRADATION
after treatment is?
8. Nurse Kia expectsZoledronic acid and Denosumabto
5
. Montgomery chromosome
A be ordered for patient Paloma for which purpose,
B. Juneau chromosome EXCEPT?
C. Phoenix chromosome
D. Philadelphia chromosome . Inhibits bonebreakdown
A
B. Inhibits boneresorption
3.Overlapexists between leukemia and non-Hodgkin
5 C. Increase serum calcium
lymphoma (NHL) because both involve proliferation of D. Alleviate skeletal pain
lymphocytes or their precursors. What distinguishes
leukemia and NHL from each other? 9. The prioritynursing diagnosisfor patient Paloma
5
diagnosed with Multiple Myeloma is?
. There are fewer circulating abnormal cells in
A
lymphoma . Impaired mobility related to bone pain and skeletal
A
B. There is more extensive nodal involvement in complications
leukemia B. Fatigue related to anemia, pain, and the effects of
C. There are many blast forms in the marrow in cancer treatment
lymphoma C. Risk for infection related to immunosuppression and
D. There is bone marrow involvement in NHL. myeloma-induced immune dysfunction
D. Risk for injury related to weakness and skeletal
4. Themanagement goal for patient Lou is to attain
5 complications
completeremission or disease control. This means:
ituation:Lucy, a 23- year old college student hadbeen
S
. When tumor cells cannot be detected by morphologic
A brought to the psychiatric hospital by her parents.
examination but can be identified by molecular testing. Her admitted diagnosis is paranoid personality disorder
0. The admitting nurse knows that which of the following
6 5. You learned that their ward nurses utilize an approach
6
CANNOT be seenin a client with a paranoid personality that addresses the issue of conflict with a resolution that
disorder? satisfies both of the parties involved. Which refers to this
approach implemented by the ward?
. They maintain a considerable distance from the nurse
A
(+) . Ignoring
A
B. They usually choose to sit with their backs against the B. Competing
wall (+) C. Compromising
C. They areunwaryof others →WARY OF OTHERS D. Avoiding
D. They appear aloof and withdrawn (+)
6. Nurse Ren stated that he wants to aid the hospital
6
1. While endorsing Lucy’s case to the incoming charge
6 workforce through improving the collaborative
nurse, the admitting nurse is also discussing charge nurse decision-making process and skills with the other
indicates anunderstandingof the teaching? healthcare professionals. Which of the following actions
will promote the collaboration between the nurses and the
. "I should be aware that patients like Lucy really love to
A interprofessional team?
overreact about different things. I should not care about
any of her complaints,” . Delaying the feedback on results
A
B. “Client manipulation is common in patients with B. Excluding the patient from their decision-making
personality disorders, I should make sure to always process
set limits whenever dealing with them.” C. Depending on the attending physician alone in making
C. "Restrainsare always the first choice of treatment all the decision
when these clients become too much to handle,” D. Sharing responsibility of the outcome of the
D. “Patients with personality disorders can be left on their decision
own,”
7. A collaborative team treating a patient may include the
6
2. Lucy suddenly becomes violent during lunch time.
6 cardiologist, social services, dieticians, and nurse case
She insists that the nurses serving their food are trying to manager as explained by the unit manager. The
poison and kill her. Which nursing intervention is most healthcare team, together with the patient, works together
appropriate to provide to her? to establish a plan of care based on the patient’s goals.
This type of collaboration would result into which of the
. Scold Lucy because she is disturbing other patients
A following outcomes for the patient?
B. Initially restrain Lucy to promote safety
C. Use clear, calm statements and a confident . Enhanced continuity of care
A
physical stance. B. Decreased adherence with the plan of care
D. Ignore Lucy and her violent behavior C. Increased healthcare costs
D. Better relationship between the physician and the
3. Lucy was prescribedRisperdal. After how manydays
6 patient
of taking the medication, the nurse notes that Lucy
becamerestless.Droolingis also seen and there isalso 8. Which communication style should the nurse manager
6
weaknessin her lower extremities. Which nursing implement if she wants to promote communication skills
intervention would be most important to implement? for a successful collaboration among the nursing team?
. Document the assessment findings
A . Parallel communication
A
B. Restrain the client B. Active listening
C. Give the ordered as needed dose of Cogentin C. Passive communication
D. Panic and inform the resident on duty D. Dominance in conversation
ituation:Ren, a newly hired nurse, was part of thetour
S 9. After the tour, Nurse Ren is then assigned to Nurse
6
of the whole hospital during the morning shift. While on Sasha who is a seasoned nurse for training on a medical
tour, the unit manager emphasized the of the hospital. What type of nurse-to-nurse collaboration
importance of presence of collaboration in the workplace. technique demonstrates this assignment?
4. Conflicts in the ward are common among the
6 . Interprofessional collaboration
A
healthcare team members according to the unit manager. B. Shared governance collaboration
The unit manager stated some situations including C. Inter-organizational collaboration
disagreement between two employees. The manager D. Mentoring collaboration
highlighted the importance of having an arranged time
agreed mutually by the involved parties to talk about the 0. During Nurse Ren’s training, he overheard a few
7
whole situation with all the involved members. This also negative comments said by his co-nurses about other
pertains to as which of the following? nurses on the same unit as well. He was a bit bothered
upon hearing the things they say about the others. Nurse
. Conflict Resolution
A Ren recognizes the type of behavior the other nurses are
B. Finding blame exhibiting which is detrimental to collaboration?
C. Using scapegoat
D. Incident Report . Vertical violence
A
B. Descending violence
. Lateral violence
C D. Empathizing with other people
D. Personal violence
6. During the morning rounds, Ryan began acting
7
1. Another topic emphasized by the nurse manager
7 sexually and asked Nurse Shey for her phone number.
refers to sentinel events. Nurse Ren is aware and Which of the following is the most appropriate response of
comprehends that sentinel events are scenarios that refer Nurse Shey in this situation?
to which of the following?
. “Later, when we’re all alone, I’ll give it to you.”
A
. An event worthy of celebrating in the unit
A B. "Kiss me first and then, I’ll give it you.”
B. A personal milestone in the patient’s life. C. "I am not going to give you my number. What we
C. Harms a patient by omission or commission. have is a professional relationship only.”
D. Signals the need for immediate investigation and D. "I don’t usually go dating younger men.”
response.
7. After the rejection from Nurse Shey, you learned in
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ituation:Bernie was recently admitted to the psychiatric
S another assessment interview with Ryan that he began
unit with a diagnosis of Histrionic Personality acting out to another nurse. He started spitting, cursing,
Disorder. and refusing to answer questions. What is the most
appropriate statement to address this behavior?
2. As a nurse assigned to Bernie, which of the following
7
is considered a characteristic behavior of a client . "Sir, you are being disrespectful. This is why the nurse
A
diagnosed with histrionic personality disorder? did not give her phone number.”
A. Having odd beliefs and magical thinking → B. "Stop this right now. You are starting to get on my
SCHIZOTYPAL nerves.”
B. Preoccupation with perfectionism → OCD C. "I understand that you are angry, but this behavior
C. Preoccupation with orderliness will not be tolerated."
D. Attention-seeking flamboyance D. “Why can’t you just stay in the correctional unit?”
3. The unit manager teaches Nurse Lea about the
7 8. After being reprimanded about his behavior towards
7
patients diagnosed with histrionic personality disorder and the nurses, Ryan came to the facility’s garden and
the quality of their relationships with others. Which decided to smoke to let off some steam. Ryan was also
statement confirmed by Nurse Lea shows correct observed to be lazy and was reported that he refused to
understanding about it? do other activities and chores along with the other
patients. With the data presented, what is the primary
. "They are known to be strong and independent
A focus of Ryan’s care plan?
people.”
B. "Everything they do is to manipulate us all." . Consistent enforcement of the unit rules and
A
C. "Their interpersonal relationships tend to be facility policy.
shallow and fleeting, serving their dependency B. Restrain the client.
needs." C. Let Carl do whatever he wants.
D. "Their relationships with other people tend to be long D. Making sure other clients will not follow Carl’s
lasting and genuine” behavior.
4. During the nursing process, while Nurse Lea is
7 ituation:Ria, the nurse-on-duty, was assigned toCristy,
S
working with Bernie, which clinical picture should she a client with borderline personality disorder.
expect to be evident with Bernie?
9. Nurse Ria began to do her personal research with
7
. Uses her physical appearance to gain attention.
A borderline personality disorder. Which is a characteristic
B. Shows empathy to others. description of a pervasive mood for these clients?
C. Washes hand for more than three times. → OCD
D. Always suspicious of the nurses in the unit. → . Anisocoric
A
PARANOID B. Dysphoric
C. Contented
ituation:Ryan, a twenty-three-year-old male, was
S D. Perfectionist
sentenced for a fifteen-year sentence to correctional unit
in Manila. He was recently transferred to a psychiatric 0. What is Nurse Ria’s priority nursing intervention for
8
facility after not adapting well in the correctional unit. He Cristy?
was diagnosed with Anti-social Personality Disorder.
. Maintaining consistent and realistic limits
A
5. The nurse-on-duty, Nurse Shey, notices that Ryan has
7 B. Having Cristy assigned to different nurses.
difficulty relating to others in the ward. Nurse Shey is C. Making sure Cristy forms a friendship with other
aware that patients with anti-social personality disorder people or patients.
have this characteristic behavior because of never having D. Putting restraints from time to time.
learned which of the following?
1. During a group activity, Cristy suddenly mentions a
8
. Being friendly
A conflict about doing personal activities with three other
B. Being dependent on others nurses in the ward. Other patients in the ward began
C. Talking with other people their age nodding their heads and showed agreement with Cristy’s
tatements. They started to develop unreasonable
s including the healthcare team. What should Nurse Ria
demands about modifying the policies. How can Nurse do?
Ria best deal with the situation at hand?
. “Okay, your secret is safe with me.”
A
. Listen to the demands of the patients and modify the
A B. “You can count on me. I dislike gossips anyway.”
policies. C. “Why don’t you want me to tell them? I thought you
B. Allow patients to modify only two of the rules they are wanted the concern.”
asking for as compromise. D. “Whenever something important occurs, the team
C. Maintain consistency of care by open needs to know about it. I will have to tell the others,
communication to avoid staff manipulation. but let’s talk about it first.”
D. Enforce lockdown as punishment of the patients’
defiance. ituation:Nurse Geri is starting his first work asa novice
S
nurse tomorrow. The day before, he starts scanning
2. For clients diagnosed with borderline personality
8 through nursing books and recalling common
disorder, which nursing approach should be used by terminologies to fully prepare himself.
Nurse Ria to maintain a therapeutic relationship with the
client? 7. Nurse Geri is aware that the term to characterize
8
moving a part away from the midline is referred to as?
. Using authoritative leadership to help clients learn to
A
conform to society norms . Pronation
A
B. Being firm, consistent, and empathic, while B. Adduction
addressing specific client behavior. C. Rotation
C. Promoting client self-expression by implementing D. Abduction
laissez-faire leadership
D. Overlooking inappropriate behaviors to avoid 8. In contrast, when the nurse is moving a part towards
8
promoting secondary gains . the midline, it is referred to as:
3. As Nurse Ria is about to leave the ward, Cristy
8 . Pronation
A
suddenly approaches her, crying along with blood on her B. Adduction
wrists. She explained how Cristy cut herself due to the C. Rotation
nurse leaving her soon. What should Nurse Ria do? D. Abduction
. Panic and immediately call the unit manager as there
A 9. It refers to the action of turning the hand in which the
8
is injury involved. palm is facing posteriorly.
B. Reprimand the client for inflicting injury to herself.
C. Assess the injury and the need for treatment in a . Pronation
A
calm and matter of fact manner. B. Adduction
D. Leave and go home since the shift is over. Let the next C. Rotation
nurse on shift handle the crisis since it’s their D. Abduction
responsibility already.
0. The action that involves moving a part of the body
9
4. For clients with borderline personality disorder, what
8 around an axis. This is referred to as:
technique is described in shifting the patterns of thinking
by helping clients recognize negative thoughts and . Pronation
A
feelings, and replacing them with positive patterns of B. Adduction
thinking? C. Rotation
D. Abduction
. Fantasy Thinking
A
B. Cognitive Restructuring ituation:COVID-19 is caused by the virus known as
S
C. Dependability SARS-CoV-2. As a public health nurse, you should know
D. Thought Stopping the updates regarding the disease, as well as
recommendations for preventing the virus issued by
5. Cristy was observed to demonstrate splitting after
8 different public health groups such as the CDC and WHO.
several days of assessment in the unit. Nurse Ria is
aware that splitting is characterized as: 1. Melissa, a patient diagnosed with cancer who is
9
undergoing chemotherapy, has been found to be
. The client is showing signs of early indication of a
A COVID-positive. She is observed to have fever and
panic attack and a referral is necessary. cough. According to the guidelines,isolationis required
B. The client is using a defense mechanism in which for a minimum number of days starting from the
all objects are seen as good or bad. appearance of signs and symptoms which is:
C. The client is having an intense psychotic episode.
D. The client is turning herself to another personality. . 7 days
A
B. 10 days
6. While Cristy and Nurse Ria are having a private
8 C. 14 days
nursing interaction, Cristy asks the nurse to not divulge D. 21 days →FOR IMMUNOCOMPROMISED
about her self-harm incident that she had to anyone,
2. Maddie is a fitness coach who developed a cough
9 D. Women’s early cancer detection behavior
after having a close contact with a gym client. The gym
client, Chloe, reported to the gym that she has tested 7. From the statement of purpose in question #106, the
9
positive for COVID-19. Maddie took a rapid antigen test considereddependent variableis:
which had a negative result. What is Maddie’s next step?
. Decisions about seeking treatment and screening.
A
. Does not need to isolate since she is negative for
A B. Women’s perceptions about barriers in the health care
COVID-19 system.
B. Should undergo RT-PCR test. C. Women’s ethnicity, race, gender, homosexual
C. Repeat rapid antigen test. orientation.
D. Proceed to the quarantine facility for further D. Women’s early cancer detection behavior .
assessment.
8. Obet and Tanya conducted an in-depth study about a
9
3. In relation to the topic, the nurse can best provide
9 twin and mother facing a member’s death through suicide.
protection to herself by: Data were collected over a 1-year period through
interviews, diary notations, and conversations with all the
. Using alcohol or alcogel
A family members. This is characterized by which type of
B. Avoiding mass gatherings qualitative research?
C. Wearing of PPE
D. Eating meals in non-clinical area . Case study
A
B. Participatory action research
94. The reasons for Nurse Geri to wear PPE is/are: C. Narrative analysis
D. Phenomenological study
. To protect the nurse
A
B. To protect the patient 9. This refers to the process of selecting a portion of the
9
C. A and B population to represent the entire population.
D. None of the above
. Sampling bias
A
5. Among the following statements, which isnot false
9 B. Representative sample
regarding the COVID-19 vaccination and the special C. Sample
population of pregnant clients: (+) D. Sampling
. The safety and efficacy of COVID-19 vaccination
A 00. The following are undernon-probability sampling
1
during pregnancy contribute to the benefits outweighing except:
any potential risks of vaccination.
B. Because pregnancies affected by COVID-19 are . Purposive sampling
A
associated with an increased risk of stillbirths or pre- term B. Convenience sampling
birth, it is recommended by the CDC that pregnant C. Quota sampling
individuals receive COVID-19 vaccination. D. Cluster sampling
C. Recent studies have revealed that the antibodies
produced in the pregnant individual following vaccination
are transferred to the newborn, reducing the risk of
COVID-19 hospitalization in children less than 6 months
of age.
D. All of the above
ituation:As development never ceases, it is important
S
for nurses to adopt a mindset of continuous learning,
allowing them to assess, study, and adjust their
clinical-approach based on the
latest evidence-based findings from systematic research
in healthcare and the
nursing field.
6. The present study’s purpose is to examine theimpact
9
of perceived barriersin healthcare delivery in relationto
ethnicity, nationality, and sex on women’searly cancer
detection and women’s decision to seek carefor illness
symptoms. (Facione & Facione, 2007).
rom this statement of purpose, we can say that the
F
independent variableis:
. Decisions about seeking treatment and screening
A
B. Women’s perceptions about barriers in the health
care system
C. Women’s ethnicity, nationality, and sex
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