CANOSSA COLLEGE

College of Nursing

NCM 100
PRELIM Examination
Instruction: Choose the best answer. Write the letter of the correct answer on the separate sheet provided. No ERASURE. It
will invalidate your answer.

1. During the admission history, Aling Minda states that she has trouble breathing at night. In obtaining data for a Problem-
Oriented Database, the nurse should first question:
A. The onset and duration of her present breathing problem
B. Her smoking and exercise practices
C. Any family members who have heart disease
D. Changes in other body systems
2. Mang Tasio, 57 years old has come to the ER with chief complaint of chest pain. In this situation, the nurse begins the
assessment by asking the client about:
A. Family history of heart problems
B. Medications taken at home
C. Concerns about hospitalization
D. The severity and duration of chest pain
3. A nurse seeks to organize the data obtained from the client in logical manner. This organization that identifies relations
between factors and symptoms in the database is know as:
A. Clustering data
B. Validating data
C. Formulating a problem statement
D. Performing a peer review
4. The client recently became febrile and stated he felt hot. You take the client’s temperature and found it to be 38.4 C. In
addition, the pulse is 88 beats/minute, and BP is 169/90. Which of the following is an example of subjective data?
A. Pulse of 88 beats/minute
B. BP of 169/90
C. Statement regarding feeling hot
D. The fact that he became febrile
5. The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job and that his
son has newly diagnosed juvenile onset diabetes. Which of the following categories best fits the loss of the job?
A. Family history
B. Psychosocial history
C. Environmental history
D. Biographical history
6. The nurse is going to perform admission history for the newly admitted client on the medical unit. The optimal time for
completion of the history is planned for:
A. In coordination with the physician’s visit
B. The time that the client’s friends and family are visiting
C. Immediately before the client’s laboratory tests
D. After the client has become oriented to the room
7.The nurse has completed an assessment and found that the client has an activity and exercise abnormality. This type of
documentation indicates that the following format has been used.
A. Review of Systems
B. Nursing Health History
C. Gordon’s Functional Health Patterns
D. Biographical Information Database
8. An alert, oriented client is admitted to the medical center for diagnostic testing. The primary source of information when
completing assessment for this client is the:
A. Client himself
B. Physician
C. Family member
D. Nurse on Duty
9. On beginning the process of data collection, the first step the nurse should take is the:
A. PE
B. Client Interview
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 C. Review of Medical Records
D. Discussion with other Health Team Members

10. All are questions when gathering data of history of present illness EXCEPT:
A. Can you give me the reason why you came to the hospital?
B. When did the pain started?
C. What did you do to the pain?
D. How often does the pain occur?
11. Chicken pox. Mumps, measles should be written under what data of past history?
A. Childhood immunizations
B. Allergies
C. Childhood illnesses
D. Accidents and injuries
12. Lifestyle is one of the data a nurse needs to gather from his patient. It includes all EXCEPT:
A. Personal habits
B. Medications
C. Diet
D. Sleep and rest
13. Current employment status is a social data which pertains to:
A. Family relationships
B. Economic status
C. Occupational history
D. Ethnic affiliation
14. A nurse using the problem-oriented approach to data collection will first
A. Complete an observational overview.
B. Disregard cues and complete the database questions in chronological order.
C. Focus on the patient’s presenting situation .
D. Make accurate interpretations of the data
15. This type of assessment is needed to patients admitted in the ICU identifying life threatening problems such as patient’s
airway, breathing and circulation.
A. Time lapsed reassessment
B. Emergency assessment
C. Problem focused assessment
D. Initial assessment
16.  During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are
achieved?
A. Implementation
B. Evaluation
C. Planning
D. Diagnosing
17. What Is the characteristics of Nursing Process?

A. Systematic
B. Inflexible
C. Goal oriented
D. Stagnant

18. What is the order of Nursing Process?

A. Assessing, Diagnosing, Evaluating, Implementing, Planning

B. Diagnosing, Planning, Assessing, Implementing, Evaluating
C. Assessing, Diagnosing, Planning, Implementing, Evaluating
D. Assessing, Planning, Diagnosing, Implementing, Evaluating

19. Objective Data is also known as:

A. Covert
B. Inference
C. Overt
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 D. Symptoms

20. Data obtained from the assessment of a patient is primarily used by a nurse to:

A. Ascertain the patient’s responses to health problems

B. Assist in constructing the taxonomy of nursing interventions
C. Determine the effectiveness of the Doctors order
D. Identify the patients disease process

21. The primary source of data collection in the assessment phase of nursing process is:

A. Chart
B. Patient
C. Doctor
D. Family

22. What is the example of a subjective data?

A. Color of wound drainage

B. Odor of breath
C. Respirations of 14 breath/min
D. Patient statement of “I feel sick”

23. Which of the following is included in a psychosocial assessment of clients?

A. Doing the examination in a cephalocaudal approach
B. Gathering information on the personal, social and environment history of the patient
C. Getting the general date and chief complaints of her patients
D. Obtaining past medical history of the patient
24. Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective
25. A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also
be relevant with the client’s needs.
A. Organized and Systematic
B. Humanistic
C. Efficient
D. Effective
26. Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment?

1. Rhina is giving an objective data

2. Rhina is giving a subjective data
3. The source of the data is primary
4. The source of the data is secondary
A. 1,3
B. 2,3
C. 2.4
D. 1,4

27. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing
dyspnea, diaphoresis(sweating) and asks lots of questions. Angela made a diagnosis of Anxiety related to upcoming
procedure. This is what type of Nursing Diagnosis?
A. Actual
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 B. Syndrome
C. Possible
D. Risk

28. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE
R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis.
This is what type of Diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk

29. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific
with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on
gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which
type of Diagnosis is this?
A. Actual
B. Probable
C. Possible
D. Risk

30. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm.
She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?
A. Actual
B. Probable
C. Possible
D. Risk
31. Which of the following Nursing diagnosis is INCORRECT?
A. Fluid volume deficit R/T Diarrhea
B. High risk for injury R/T Absence of side rails
C. Possible ineffective coping R/T Loss of loved one
D. Self esteem disturbance R/T Effects of surgical removal of the leg

32. Among the following statements, which should be given the HIGHEST priority?
A. Client is in extreme pain
B. Client’s blood pressure is 100/70mmhg
C. Client’s temperature is 38.5 deg. Centigrade
D. Client is cyanotic

33. Which of the following need is given a higher priority among others?
A. The client has attempted suicide and safety precaution is needed
B. The client has disturbance in his body image because of the recent operation
C. The client is depressed because her boyfriend left her all alone
D. The client is thirsty and dehydrated

34. Which of the following is TRUE with regards to Client Goals?

A. They are specific, measurable, attainable and time bounded
B. They are general and broadly stated
C. They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.
D. Example is: After discharge planning, Client demonstrated the proper psychomotor skills for insulin injection.

35. Which of the following is a NOT a correct statement of an Outcome criteria?

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 A. Ambulates 30 feet with a cane before discharge
B. Discusses fears and concerns regarding the surgical procedure
C. Demonstrates proper coughing and breathing technique after a teaching session
D. Reestablishes a normal pattern of elimination
36. Which of the following is a OBJECTIVE data?
A. Dizziness
B. Chest pain
C. Anxiety
D. Blue nails

37.A patient’s chart is what type of data source?

A. Primary
B. Secondary
C. Tertiary
D. Can be A and B

38. All of the following are characteristic of the Nursing process except:
A. Dynamic
B. Cyclical
C. Universal
D. Intrapersonal

39. Which of the following is true about the NURSING CARE PLAN?
A. It is nursing centered
B. Rationales are supported by interventions
C. Verbal
D. Atleast 2 goals are needed for every nursing diagnosis

40. A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation
with the ability of the client to perform ADL.
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

41. Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this
situation?
A. Functional health framework
B. Head to toe framework
C. Body system framework
D. Cephalocaudal framework

42. Ronnie was in a vehicular accident where he sustained injury to his left ankle. In the Emergency Room, you notice how
anxious he looks. You establish rapport with him and to reduce his anxiety you initially:
A. Take him to the radiology section for X-ray of affected extremity
B. Identify yourself and state your purpose in being with the client
C. Talk to the physician for an order of Valium
D. Do inspection and palpation to check extent of his injuries
43. While doing your assessment, Ronnie asks you “Do I have a fracture? I don’t want to have a cast.” The most
appropriate nursing response would be:
A. “You have to have an x ray first to know if you have a fracture”.
B. “Why do you sound so scared? It is just a cast and it’s not painful”.
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 C. “You seem to be concerned about being in a cast”.
D. “Based on my assessment, there doesn’t seem to be a fracture”.

44. Ronnie is very anxious and is unaware of the extent of his injury. The nurse can best assist him by:
A. Asking the doctor to give an order for a sedative to call him down
B. Informing him that he is being treated by a very competent health team so he has nothing to worry about
C. Identifying his level of anxiety to determine how much information he can understand
D. Allaying his anxiety by telling him that he only sustained a minor injury

45. Meldy. 40 years old. is waiting for her doctor’s  appointment at the clinic where you work. You are to interview her as an
initial nursing action so that you can.
A. Document important data in her client records for health team to read.
B. Gather data about her lifestyle, health needs , lifestyle,   health   needs and problems to develop plan   of care
C. provide solutions to her immediate health concern
D. identify the most appropriate nurse diagnosis for her heath problem

46. During the interview, Meldy experiences a sharp abdominal pain on the right side of her abdomen. She further tells you
that an hour ago, she ate fatty food and this had happened many times before. You will record this as:
A. Client complains of intermittent abdominal pain an hour alter eating fatty foods
B. After eating fatty food the client experienced severe abdominal pain
C. Client claims to have sharp abdominal pains after eating fatty food unrelieved by pain medication
D. Client reported sharp abdominal pain on the right upper  quadrant of abdomen an hour after .ingestion of fatty
foods.

47. Meldy  tells you that she has been on a high protein / high fat / low carbohydrate diet order to lose weight and that she
has successfully lost 8 lbs during the past two weeks. In planning a healthy balanced diet for her, you will:
A. Encourage her to eat well-balanced diet with a variety of food from the major food groups and take plenty of fluids.
B. Ask her to shift to a macrobiotic diet rich in complex carbohydrates.
C. Encourage her to cleanse her body toxins by changing a vegetarian diet with regular exercise.
D. Encourage her to eat a high carbohydrate, low protein diet and low fat diet.

48. You notice a rash on the patient’s skin. Which of the following observational sources did you use?
A. Auditory
B. Olfactory
C. Visual
D. Tactile

49. The writing of care plan occurs on what process?

A. Diagnosis
B. Assessment
C. Planning
D. Evaluation

50. What are the three parts of the Nursing Diagnosis?

A. Medical Diagnosis, etiology, signs & symptoms
B. Problem, intervention, evaluation
C. Problem, etiology, signs and symptoms
D. Problem, etiology, goal

51. A nurse is caring for a client in a facility. Which intervention should the nurse perform to measure the effectiveness of
nursing care?
A. Document observable evidence
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 B. Reassess needs
C. Focus on actual problem
D. Set goals for client

52. When prioritizing nursing dx's, what should you keep in mind?
A. Rank nursing diagnosis
B. Focus on clients concerns
C. Actual nursing diagnosis may not be prioritized
D. Focus on psychosocial concerns of the client

53. A client with frequent chest pain that disappears after time. Assessment reveals non-acute pain and the doctor suspects
heartburn. Which question would the nurse ask to validate this interpretation?
A. Do you see blood in your stool?
B. Do you have digestive problems?
C. When was your last menstrual period?
D. What immunizations did you have?

54. The primary purpose of the nursing care plan is:

A. Ensure consistency among staff
B. Substitute nursing care plan for policy and procedures
C. Organize the Laboratory works
D. Tell nurses what is to be done

55. A nurse is planning for discharge. What steps should he/she take?
A. Note unresolved problems in the nursing care plan
B. Set new goals after the old ones are met
C. Review if client has helped realize self care goals
D. Change goals that were unmet
56. The nurse observes and monitors the client's v/s and listens carefully when interacting with the client. The nurse also
uses critical thinking skills to determine if her nursing orders are effective. the nurse knows that performing these
interventions will help in which aspect of care?
A. Increase client interaction
B. Prepare a discharge plan
C. Collect data for the continuity of care
D. Analyzing client responses

57. The nurse in charge identifies a patient’s responses to actual or potential health problems during which step of the
nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating

58. A Female patient is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority care
at this time?
A. Impaired gas exchange related to increase blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to trauma
D. Altered potential tissue perfusion related to venous congestion
***Deep vein thrombosis (DVT) is the formation of a blood clot “thrombus” in a deep vein***

59. A nurse is revising a client’s care plan. During which step of the nursing process does a revision tke place?
A. Assessment

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 B. Planning
C. Intervention
D. Evaluation

60. Which intervention should the nurse in charge try first for a client that exhibits sigs of sleep disturbance?
A. Administer sleeping medication as ordered?
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques such as guided imagery
D. Provide client normal sleep aids such as pillows, back rubs

61. A nurse is assigned to care for postoperative male client who has DM. During the assessment interview, the client
reports he is impotent and says hes concerned about the effect on his marriage. In planning the client’s care, the most
appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or appropriate professional
D. Provide support for the spouse

62. Using Maslow’s Hierarchy of needs, a nurse assigns the highest priority to which client need?
A. Elimination
B. Security
C. Safety
D. Belonging

63. A female client who receive a general anesthesia returns from surgery. Postopeartivly,. Which nursing diagnosis takes
highest priority?
A. Acute pain related to surgery
B. Deficient Fluid volume related to fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
***general anesthesia may impaired gag and swallow reflex***

64. A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority
for this client would be to:
A. Assess the clients airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint chest wall with a pillow

65. When 2 nursing diagnosis appear closely related, what should the nurse do first to determine which diagnosis is most
accurately reflects the needs of a patient?
A. Reassess the patient
B. Examine related factors
C. Analyze the secondary factors
D. Review the defining characteristics

66. The nurse performs an assessment of a newly admitter patient. The nurse understands that his admission assessment
is conducted primarily to:
A. Diagnose the patient is at risk
B. Ensure the patient’s skin is intact
C. Establish a therapeutic relationship
D. Identify important data
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67. The guidelines for writing an appropriate nursing diagnosis include all of the following except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient’s response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patients response

68. While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the
procedure, he tells her that he is very thirsty. An appropriate nursing diagnoss would be:
A. Potential for impaired skin integrity related to altered gland function
B. Potential for impaired skin integrity related to dehydration
C. Impaired skin integrity related to dehydration
D. Impaired skin integrity related to altered circulation

69. Which of the following is an appropriately written nursing diagnosis?

A. Pain related to insufficient use of medication

B. Pain related to difficulty ambulating

C. Anxiety related to cardiac monitor

D. Bedpan required frequently as a result of altered elimination pattern

70. Accountability is a critical aspect of nursing care. An example of accountability is demonstrated by:

A. Selecting the medication schedule for the client

B. Implementing discharge teaching plans that meet individual needs

C. Evaluating the client's outcomes after implementation of care

D. Promoting participation of all staff members in unit meetings

71. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse
she wants to have her hair shampooed. How would the nurse prioritize this client need?

A. Immediate priority
B. High priority

C. Intermediate priority

D. Low priority

72. Nursing interventions should be documented according to specific criteria so they are clearly understood by other
members of the nursing team. The most appropriate of the following intervention statements is:

A. Offer fluids to the client q 2 hours

B. Observe the client's respirations

C. Change the client's dressing daily

D. Irrigate the nasogastric tube q 2 hours with 30 mL normal saline

73. A nurse who specializes in care of clients with ostomies shows a client's significant other how to assist with the
manipulation of ostomy equipment. The nurse demonstrating the technique to the client is using what type of nursing skill?

A. Cognitive
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 B. Interactive

C. Affective

D. Psychomotor

74. During an interview, the nurse needs to obtain specific information about the signs and symptoms of a health problem.
To obtain these data most efficiently, the nurse should use:

A. Active listening
B. Open-ended questions

C. Closed-ended questions

D. Seeking clarification

75. Which of the following is classified as subjective data?

A. Client appears sleepy

B. No distress noted

C. Abdomen soft and non-tender

D. States feels anxious and tense

76. The nurse uses a variety of skills in the application of the nursing process. An example of a cognitive nursing skill is:

A. Providing a soothing bed bath

B. Communicating with the client and family

C. Giving an injection to the client per physician’s orders

D. Recognizing the potential complications of a blood transfusion

77. Which of the following is an appropriate ethology for a nursing diagnosis?

A. Incisional pain
B. Poor hygienic practices

C. Needs bedpan frequently

D. Inadequate prescription of medication by the physician

78. Nursing interventions should be documented according to specific criteria so they are clearly understood by other
members of the nursing team. The intervention statement “Nurse will apply warm, wet soaks to the client's leg while the
client is awake” lacks which of the following components?

A. Method
B. Quantity

C. Frequency

D. Qualifications of the person who will perform the task

79. Of the following statements, which one is an example of an appropriately written nursing diagnosis?

A. Acute pain related to left mastectomy

B. Impaired gas exchange related to altered blood gases

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 C. Deficient knowledge related to need for cardiac catheterization

D. Need for high protein diet related to alteration in nutrition

80. Mr. Anderson says that his head has been hurting for 3 weeks.  The nurse knows this is what kind of data?
A. Primary objective data
B. Primary subjective data
C. Secondary objective data
D. Secondary subjective data

81. The guidelines for writing a nursing diagnosis includes all except the following:
A. State the diagnosis in terms of a problem, not a need
B. Use of nursing terminology to describe the patients response
C. Use of statements’ that assist in planning independent nrsing interventions
D. Use of medical terminology

82. The first thing to do when admitting a patient is;

A. Orient the patient to the unit
B. Ascertain and meet the patients immediate needs
C. Take the vital signs
D. Make a baseline statement

83. Mrs. Loyola, 72 years old, post colostomy (A colostomy is a surgical procedure in which a stoma is formed by drawing
the healthy end of the large intestine or colon through an incision in the anterior abdominal wall and suturing it into place.) is
having adjusting to it. Which of the following nursing diagnosis is most applicable?
A. Anxiety
B. Pain
C. Low self esteem
D. Alteration in Body Image

84. Which of the following characteristics of the client goal in the plan of care is correct?
A. Nurse focused, flexible, measurable and realistic
B. Client focused, flexible, measurable and realistic
C. Nurse focused, time limited, realistic and measurable
D. Client focused, time limited, realistic and measurable

85. In taking care of Mang Iko, who is for cardiac catherization, the nurse noted that he is manifesting fear related to the
procedure, the nurse is making:
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation

86. Mrs. Dee is seeking for health respiratory problem. The nurse carefully listens to Mrs., Dee and documented it as part
of:
A. Health history
B. Chief complaint
C. Medical diagnosis
D. Review of system
89. Readiness for Enhanced Spiritual Well-being -Enhanced Family Coping is an example of:
A. Wellness diagnosis
B. Actual diagnosis
C. Risk diagnosis
D. Potential diagnosis
90. Possible Nursing Diagnosis is used when:
A. evidence about health problem is incomplete or unclear.
B. Problems are associated with a a cluster of different problems
C. A problem is likely to develop unless a nurse intervenes
D. The problem is present at that time

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92. Constipation related to prolonged laxative use is an example of a :
A. One part statement diagnosis
B. Two part statement diagnosis
C. Three part statement diagnosis
D. Problem label only
93. Life threatening problems should be considered:
A. Medium priority
B. High priority
C. Low priority
D. Less priority
94. The components of a Goal shall include:
A. Subject
B. Verb
C. Condition
D. All of the above
95. The use of Impaired in a nursing diagnosis means:
A. Inadequate in amount
B. Made worse or weaken
C. Lesser in size
D. Not producing the desired effect
96. Nurse Ana met 2 goals out of 3 goals: It means goals were:
A. Completely met
B. Partially met
C. Completely unmet
D. Unresolved
97. The nurse writes an expected outcome statement in measurable terms. An example is:
A. Client will have less pain
B. Client will be pain free.
C. Client will report pain acuity less than 4 on a scale of 0-10.
D. Client will take pain medication every 4 hours around the clock
98. After assessing the client, the nurse formulates the following diagnoses. Which of the following should be in a high
priority?
A. Constipation
B. Anticipated grieving
C. Ineffective airway clearance
D. Ineffective tissue perfusion.
99.  The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free
from infection throughout hospitalization. This statement is an example of a (an):
A. Nursing diagnosis
B. Short-term goal
C. Long-term goal
D. Expected outcome
100.  After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal:
A. Encourage client to implement guided imagery when pain begins.
B. Determine effect of pain intensity on client function.
C. Administer analgesic 30 minutes before physical therapy treatment.
D. Pain intensity reported as a 3 or less during hospital stay .

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