Nursing Practice 5

Situation: Sandro 8 years old, 1st grader child has always been the subject of her
mother's prompting and care. He always test his mom's rule in preparing for school.
Although this has been for five months now , Sandro still has to be reminded in getting
dress completely and dilly dally eating his breakfast. He still plays with his toys and
interferes with her sister in playing blocks. The mother is so anxious in reminding Sandro
that his school bus will be arriving in 10 minutes every day.
1. Attention deficit hyperactivity disorder (ADHD) is characterized by NOT of the
following? A. Mental retardation
B. Overactivity
C. Inattentiveness
D. Impulsiveness

2. Which of the following would the nurse expect to see as symptoms in child with
ADHD, except:
A. Moody, sullen and pouting behavior
B. Interrupts others and can’t take turns
C. Excessive running, climbing and fidgeting
D. Easily distracted and forgetful

3. Sandro is taking pemoline(Cylert) for ADHD. The nurse must be aware which of the
following side effects?
A. Decreased thyroid stimulating hormones
B. Decreased red blood cell count
C. Elevated white blood cell count
D. Elevated liver function test results

4. An effective nursing intervention for the impulsive and aggressive behaviors that
accompany conduct disorder is _______.
A. open expression of feelings
B. assertiveness training
C. negotiation of rules
D. consistent limit setting

5. Nursing diagnosis commonly used when working with Sandro is __________.

A. ineffective role performance
B. impaired social interaction
C. compromised family coping
D. risk for injury
Situation: The nurse is teaching a client taking an MAOI about foods tyramine that he
or she should avoid.
6. Which of the following statements indicates that the client needs further
teaching?
A. "I will have to avoid drinking non- alcoholic beer."
B. "I will be able to eat cottage cheese without worrying."
C. "I can eat green beans on this diet."
D. I'm so glad I can have pizza as long as I don't order pepperoni.

7. Patient's health teaching for Lamotrigine (Lamictal) should include which of the
following? A. Take each dose with food to avoid nausea.
B. Eat a balanced diet to avoid weight gain.
C. Report any rashes to your doctor immediately.
D. This drug may cause psychological dependence.

8. Which of the following health teaching concern for the nurse as discharged plan for
suicidal patient who had been taking tricyclic antidepressant drugs for 2 weeks and
now ready to go home?
A. The nurse will need to include teaching regarding signs of neuroleptic malignant
syndrome.
B. The patient will need regular laboratory work to monitor therapeutic drug levels.
C. The nurse will evaluate the risk for suicide by overdose of tricyclic
antidepressant.
D. The patient may need a prescription for Benadryl to use for side effects.

9. A patient is to take regularly Lithium after discharged. The MOST important

information to impart to the patient and his family is that the patient should
_______.
A. not eat foods which has high tyramine content like cheese, wine and liver
B. limit his fluid intake
C. have a limited intake of sodium
D. have an adequate intake of sodium

10. The patient with diagnosis of Schizophrenia who has been taking Clozapine will
inform the patients family that the positive effect of this drug is ______.
A. monthly liver Function studies change
moderately B. b. psychotic symptoms, such as
hearing loss are reduced
C. c. patient develops leukopenia.
D. patients energy level and involvement in activities goes up.
Situation: Patrick, Charge nurse, is aware that the uses of resource essential for patient
care.
11. A safe patient environment includes following factors EXCEPT _______.
A. socio-economic needs
B. basic needs are met
C. sanitation is maintained
D. physical hazards are reduced

12. As an individual, which of the following is an INTERNAL variable affecting health

status, belief, or practices?
A. Genetics C. Family structure
B. Socioeconomic status D. Living situation

13. Falls are one of the leading environmental hazards reported in her facilities. One
of the MOST common occurrences that precipitate a patient fall is _______.
A. experiencing stress, anxiety, and fatigue
B. leaving the side rails down
C. reaching item at the bedside
D. performing activities of daily living

14. If case a patient falls, the nurse FIRST responsibility is to _______.

A. assess the patient's injury
B. write an incident report
C. report the incident to the head nurse.
D. notify the physician at once

15. In healthcare facility, a planned program of loss prevention and liability control
refers to _______. A. quality assurance
B. critical pathways
C. risk management
D. peer review

Situation: Mark, a 25 year old student suddenly had convulsive movements with loss of
consciousness during their lecture. After the episode he was rushed to the nearest
hospital.
16. A nurse is conducting physical assessment, which of the following is
INAPPROPRIATE action in this stage?
A. Insert intravenous cannula
B. Assess patient's lifestyle
C. Assess patient source of stress
D. Identify the patient's daily activity
17. Mark is scheduled for an EEG after having a seizure for the first time. What is the
BEST patient preparation instruction before the procedure?
A. "Avoid thinking and personal matters for 12 hours before the test."
B. "Do not shampoo your hair for 24 hours before the test. "
C. "Do not eat anything for 12 hours before the test.”
D. "Avoid stimulants and alcohol for 24 to 48 hours before the test."

18. Which of the following manifestation should the nurse APPROPRIATELY observe
during generalized seizures?
A. Loss of consciousness, dilated pupils, and muscular stiffening
B. Jerking movements of all extremities.
C. Facial grimace with patting and smacking.
D. Vacant stare with a brief loss of consciousness

19. What is the FIRST Priority which the nurse must observe in caring for patient with
seizure?
A. Safety C. Nutrition
B. Airway D. Mobility

20. Phenytoin (Dilantin) has been prescribed for a patient. Based on an understanding
of the medicine, what is the APPROPRIATE nursing instruction of the nurse?
A. Give Dilantin intramuscularly
B. Administer good oral hygiene
C. Dilute IV Dilantin with 5% dextrose
D. Maintain a Dilantin level of 30-50 ug/ml

Situation: Gloria is a nurse researcher in the Department of Health. She is assigned to

conduct research on patient's safety practices of nurses in the psychiatric unit. She is
given 6 months to conduct the study.
21. After formulating and delimiting the research problem, which following will be a
PRIORTTY action of Gloria?
A. Develop the theoretical framework of the study
B. Formulate the hypothesis
C. Plan the research design of the study
D. Conduct a literature search on the topic
22. Gloria decides to include only nurses who have a minimum three year’s experience
as psychiatric nurses. Which of the following terms refer to this?
A. Concept
B. Variable
C. Limitation
D. Delimitation
23. The statement “The length of service is not associated with the degree of patient
safety practices of staff nurses" is an example of a/an ________.
A. Variable
B. Assumption
C. Hypothesis
D. Theory

24. Which of the following research designs is MOST APPROPRIATE for this study if the
aim is to find a relationship between two variables in the study?
A. Phenomenological study C. Exploratory
B. Experimental D. Correlational

25. She plans to interview the Psyche Nurse Manager about the patient safety practices
of the nurses. What type of sampling includes those who happens to be in the
conference room where the activity is scheduled?
A. Random C. Convenience
B. Purposive D. Quota

Situation: Belle is a 30-year-old single mother who is dependent on her family for
support. Her diagnosis is mild mental retardation with post-traumatic disorder with
depressive episodes related to her mother's death. Her current symptoms include
depressed mood with irritability, difficulty tolerating frustration, difficulty falling asleep,
increased appetite and weight gain, hypervigilance, and worry that something terrible
will happen to her child.
26. A cognitive assessment of Belle indicated that according to Piaget's theory she was
functioning at the concrete operational stage. Which of these behaviors would the
nurse observe in Belle? A. Thinks logically and sees possibilities.
B. Understands only her own viewpoint.
C. Feels her own reasoning should agree with the reasoning of others.
D. Makes and tests hypothesis.

27. Belle has difficulty tolerating frustration. The GOAL of the nurse is to assist Belle to
________. A. increase her self-esteem
A. cope with anxiety
B. recognize her needs
C. mobilize her resources

28. Which of the following historical data MOST probably led to a post-traumatic stress
disorder? A. Unstable relationship with ex-fiancé.
B. Suicide of her mother.
C. No gang-relationship with peers
29. Given her problems of hyper vigilance and worry that something terrible will
happen to her child, nursing interventions should be aimed at addressing her needs
for _________.
A. love and belongingness C. psychological security
B. biological integrity D. self-esteem

30. In terms of social support therapy, which of these is the MOST APPROPRIATE and
therapeutic?
A. with appropriate support, lives in the community, either Independently
or in supervised setting.
B. Individualized relationship with a caregiver.
C. High structured environment with constant aid and supervision.
D. Vocational training with moderate supervision but not beyond second grade
academic challenges.

Situation: The following scenarios are potential routines that could check work ethics of
a professional nurse.
31. A patient asks to be discharged from the health care facility against medical
advice(AMA). What should the nurse do?
A. Notify the physician.
B. Prevent the patient from leaving.
C. Have the patient sign an AMA form.
D. Call a security guard to help detain the patient.

32. A nursing assistant in assigned to provide morning care to a patient. How should
the nurse document care given by the nursing attendant? A. "Morning care
rendered".
B. "Morning care rendered by Grace Go, NA"
C. "Morning care provided by G.G., nursing assistant".
D. "Morning care refused to be given by nursing assistant.

33. A nurse administers the wrong intravenous fluid to a patient. She should
accomplish which of the following documents to be submitted to her immediate
supervisor?
A. Patient Kardex C. Progress report
B. Incident report D. Endorsement record

34. When developing a care plan for a patient with a do-not-resuscitate order, the
nurse should NOT Include which intervention on the care plan?
A. Allow access to individuals who can provide spiritual care.
B. Administer pain medications as ordered by physician.
C. Provide usual routine nursing care as ordered by physician.
 D. Administer lethal doses of medication as patient request.

35. A patient is to undergo a laminectomy in the morning. The physician asks the
nurse to witness the patient's signing of the consent form. What is the BEST action the
nurse?
A. Provide emotional support for the patient while the patient signs the consent.
B. Make sure the physician explains the risks of undergoing the procedure.
C. Make sure the physician thoroughly describes the procedure.
D. Make sure the patient is competent, awake and alert before he/she
signs the consent form.
Situation: Charge Nurse Tessie works at the surgical ward. She ensures g record
management is implemented in her unit at all times.
36. A patient is having elective surgery under general anesthesia. Who is responsible
for obtaining the informed consent?
A. Surgeon
B. Nurse
C. Nurse anesthetist
D. Anesthesiologist

37. Which statement by the patient indicates that the he understands the explanation
of the surgeon?
A. "I refuse to sign the consent form; another family member can sign for me."
B. “Now I know what alternative treatments and procedure are.”
C. "If I refuse to sign the consent form, other treatment will be
withdrawn.” D. "I can't refuse the procedure after the consent is
signed."

38. The wait secretary who transcribes the physicians order asks the to interpret an
order because she cannot read the writing. The nurse BEST action in to _______.
A. Clarify the order with the pharmacies
B. clarify the order by calling the physician
C. interpret the order according to the patient’s previous
medication record D. clarify the order with junior staff

39. The physician orders to transfuse 500ml packed RBC blood post-operatively. The
nurse must check the name on the label of the blood with the name on the patient’s
_____.
A. Medication administration record
B. Wristband in the presence of another nurse
C. Medical Chart
D. Wristband
40. The patient's wife is so anxious about the condition of her husband. The MOST
appropriate INITIAL intervention for the nurse to make is to _____.
A. Describe her husband's medical treatment since admission
B. reassure her that the important fact is her presence
C. explain the nature of the injury and reassure her that husband's condition is
stable D. allow her to verbalize her feelings and concern

Situation: Quality and safety are rooted in the daily work of a health care professional.
Nurses in the Orthopedic Unit attends monthly quality assurance meeting. The following
questions were discussed.
41. Who should be involved in quality improvement measure?
A. Everyone C. Professional staff
B. Management staff D. Consumers

42. To start a nursing improvement project, what is the FIRST step that nurse most
keep in mind?
A. Implement plan to correct the problem
B. Determine the nursing standards
C. Determine findings if warrant correction
D. Collect data, determine if standards are set
43. To achieve organized work flow in the unit the staff must be aware of the head
nurse's role.
What is the PRIMARY purpose of supervision
delegation? A. Enhances the delivery
of quality nursing care
B. Influences organization's approach in personnel evaluations
C. Improves staff attendance in seminars
D. Assigns any staff to do the tasks or project.

44. To ensure quality nursing care to a patient in skin traction, what in the PRIORITY
Intervention that a nurse has to assess frequently?
A. Signs of infection around the pin site.
B. Signs of skin breakdown
C. Urinary incontinence
D. Presence of bowel sounds

45. The nursing team plans to do chart audit project on post-op patients who had
developed pressure sores at the Orthopedic unit over the past year to present. What
type of audit is?
A. Retrospective C. Concurrent
B. Process D. Outcome.
Situation: Incidence of drug abuse has greatly increased overtime. Korino has been
using drugs for the past three years.
46. You are a Drug Abuse Treatment and Rehabilitation Center Nurse. During the
assessment of a newly admitted Person Who Uses Drugs(RWUDS) named Korino,
which of the following is the MOST APPROPRIATE question to ask?
A. Ask Korino how long he thought that he could take drugs without someone
finding it.
B. Ask Korino why he started taking illegal drugs.
C. Do not ask any questions for fear Korino will deny and may become assaultive.
D. Ask Korino about the amount of drug used and its effect and how long
he had been using.
47. Upon data collection he had been falling three times in his math class and Korino
was known for substance dependent for three years. What is the MOST
APPROPRIATE nursing diagnosis for him? A. Alteration in perception. C. Ineffective
individual coping.
B. Alteration in social interaction. D. Impaired judgement.

48. Korino has been using meperidine and codeine for personal consumption. Which of
the following does the nurse understand as the effect of these drugs? A. Increases
sexual stimulation.
B. Relieves pain by increasing pain threshold.
C. Decrease craving for alcoholic intake.
D. Heightens concentration and alertness

49. Which assessment by the nurse would cause a concern for Meperidine overdose?
A. Respiration rate of 12 bpm. C. Dryness of the skin.
B. Hypercapnia D. Pinpoint pupils.

50. What drug should the nurse prepare for administration to reverse all signs of
toxicity?
A. Digibind (Digoxin) C. Atropine sulfate
B. Naloxone (Narcan) D. Diazpam (Valium)