RECALLS 1 EXAM (NP5)

Total points45/100
Situation: In a Nursing Practice you are directly involved in conducting a comprehensive
physical assessment especially to older clients with sensory limitations.

1. When formulating nursing care plans for older adults, Nurse Bessy should include special
measures to accommodate for age-related sensory losses such as:
*
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A. difficulty in swallowing
B. increased sensitivity to heat
C. diminished sensation of pain
D. heightened response to stimuli

2. The client with head injury is having problems with several sensory functions. Nurse Bessy should
understand that the structure that acts as a relay center for sensory impulses is the:
*
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A. thalamus
B. cerebellum
C. hypothalamus
D. medulla oblongata

3. After a brain attack a client remains unresponsive to sensory stimulation. Nurse Bessy understands
general sensations such as heat, cold, pain, and touch are registered in the:
*
1/1
A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe

4. The novice nurse who is administering a beta blocker asks the Senior Staff Nurse about its effect
on the Autonomic Nervous System. When formulating a response the nurse should understand which
common misconception about the Autonomic Nervous System?
*
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A. both sympathetic and parasympathetic impulses continually affect most visceral effectors
B. the autonomic nervous systems is regulated by impulses from the hypothalamus and other parts of the brain
C. sympathetic impulses stimulate while parasympathetic impulses inhibit the functioning of any visceral
effector → PARASYMPA CAN ALSO STIMULATE SUCH AS GIT AND GUT. SYMPA WILL INHIBIT GIT AND
GUT.
D. visceral effectors (e.g., cardiac muscle, smooth muscle, glandular epithelial tissue) receive impulses only via
autonomic neurons

5. Visual Acuity declines with age. Presbyopia is a progressive decline in:

*
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A. Distinguishing between blues and greens and among pastel shades
B. Ability to see in darkness
C. The ability of the eyes to accommodate for close detailed work → LOSS OF ELASTICITY
D. Adaptation to abrupt changes from dark areas to light areas

Situation: Injury to one part of the Musculoskeletal system results in malfunction of muscles,
joints and affects mobility of injured area. As an Orthopedic Nurse you devise a nursing care
that addresses the following situations.

6. A 78 year old adult is admitted to the hospital after sustaining hip fracture after a fall from home.
When caring for this client the nurse understands that older adults have a high incidence of hip
fractures because of:
*
1/1
A. carelessness
B. fragility of bone → LOSS OF CALCIUM
C. sedentary existence
D. rheumatoid disease

7. The client is placed in a Buck’s extension traction with a 5 lb. weight and scheduled for surgery the
following morning. Initial assessment of this client would most likely reveal:
* FRACTURE – SADDER
• SHORTENING
• ADDUCTION
• EXTERNAL ROTATION
0/1
A. Internal rotation and abduction of the right leg, which is shorter than the left leg
B. Lateral rotation and adduction of the right leg , which is shorter than the left leg
C. Hat and redness over the fracture site
D. Fever chills and elevated white blood cell (WBC) count

8. A medical Nurse admitted a client with Osteoporosis. Which piece of information from the client’s
history does the nurse identify as a risk factor for developing Osteoporosis? The client:
*
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A. receives long-term steroid therapy
B. has a history of hypoparathyroidism
C. engages in strenuous physical activity
D. consumes high doses of the hormone estrogen

9. Mrs. Lucy, 72 years old with degenerative joint disease asks the nurse, “My doctor mentioned
something about synovial fluid and the joint. What is that?” What is the nurse’s best response?” The
synovial fluid of the joints minimizes:
*
1/1
A. Efficiency.
B. WORK OUT
C,. Friction in the joints.
D. VELOCITY OF MOVEMENTS

10. A Nurse has given dietary instructions to Mrs. Lucy to minimize the risk of Osteoporosis. The
Nurse would evaluate that the client understands the recommended dietary changes if the client
stated she should increase intake of which food?
*
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a. rice
b. yoogurt
c.sardines
d. chicken

Situation; Cataracts develop at any age for a variety of causes. Visual impairment progresses
at the same rate in both eyes over many years or in a matter of months.

11. A client’s child asks Nurse Mami what a cataract is. What explanation should the nurse provide?
“A cataract is a / an:
*
1/1
A. Opacity of the lens.”
B. Thin film over the cornea.”
C. Crystallinization of the pupil.”
D. Increase in the density of the conjunctiva.”

12. In preparation for cataract surgery Nurse Mami is to administer a prescribed medication. The
Nurse reviews the Physician’s orders, expecting which type of eye drops to be prescribed?
*
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A. An Osmotic diuretic
B. A Miotic agent
C. A Mydriatic medication → PHACOEMULSIFICATION
D. A thiazide diuretic

13. After a client has cataract surgery, what should Nurse Mami do?
*
0/1
A. instruct the client to avoid driving for 2 weeks
B. teach the client coughing and deep-breathing techniques
C. encourage eye exercises to strengthen the ocular musculature
D. advise the client to refrain from vigorous brushing of teeth and hair.

14. Nurse Mami is performing an admission assessment to Mr. King with diagnosis of detached
retina. Which of the following is associated with this eye disorder?
*
0/1
A. Pain in the affected eye
B. Total loss of vision
C. A sense of curtain falling across the field of vision
D. A yellow discoloration of the sclera

15. Mr. King is scheduled for surgery for a detached retina. Which client statement indicates that
Nurse Mami’s preoperative teaching is effective? “The goal of surgery is to :
*
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A. Promote growth of new retinal cells.”
B. Adhere the sclera to the choroid layer.”
C. Graft a healthy piece of retina in place.”
D. Create a scar that aids in healing retinal holes.” → SCLERAL BUCKLING

Situation: Mrs. Mona, 48 years old is admitted because of extreme fatigue on exertion . Her
Physician suspects Myasthenia Gravis.

16. A client with Myasthenia Gravis asks the nurse, “What is going to happen to me and to my
family?” When formulating a response, the nurse should understand that the prognosis for
Myasthenia Gravis generally is:
*
0/1
A. excellent with proper treatment
B. slowly progressive without remissions
C. chronic with exacerbations and remissions
D. poor, with death occurring in a few months

17. Mrs. Mona asks the nurse why the disease has occurred. What pathology underlies the nurse’s
reply?
*
1/1
A. a genetic defect in the population of acetylcholine
B. an inefficient use of the neurotransmitter acetylcholine
C. a decreased number of functioning acetylcholine receptor sites
D. an inhibition of enzyme AChE, leaving the end-plates folded

18. Nurse Nica is leading a support group for clients affected by Myasthenia Gravis. For what group
of individuals does Nurse Nica understand that the incidence of Myasthenia Gravis is highest?
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A. males ages 15 to 35
B. children ages 5 to 15
C. females ages 20 to 30
D. both sexes equally before age 40

19. Mrs. Mona becomes increasingly weaker. The Physician prepares to identify whether the client is
reacting to an overdose of medication (Cholinergic Crisis)or an increasing severity of the disease
(Myasthenic Crisis ). An injection of the Edrophonium (Tensilon) is administered . Which of the
following indicate that the client is in cholinergic crisis?
*
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A. An improvement of the weakness
B. A temporary worsening of the condition
C. No change in the condition
D. Complaints of muscle spasm

20. What does Nurse Nica understands that clients with Myasthenia Gravis, Guillain-Barre syndrome,
and Amyotropic Lateral Sclerosis share in common?
*
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A. progressive deterioration until death
B. deficiencies of essential neurotransmitters
C. increased risk for respiratory complications
D. involuntary twitching of small muscle groups
Situation: Many patients with problems in Central Nervous System will result to disruption of
normal sensory and motor pathways. Nurses can better manage the needs of the client if they
understand the course of the disorders. Neurologic assessment and diagnostic tests are
conducted to plan effective nursing interventions.

21. When performing a Neurologic assessment of a client, Nurse Lengleng identifies that the client
has a dilated right pupil. The nurse understands that this suggests a problem with which Cranial
nerve?
*
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A. third cranial nerve
B. second cranial nerve

C. fourth cranial nerve

D. seventh cranial nerve

22. The mouth of a client is drawn over the left. Nurse Lengleng understands that this suggests injury
to which cranial nerve?
*
1/1
A. left facial nerve

B. right facial nerve

C. left abducent nerve
D. right trigeminal nerve

23. Nurse Lengleng is assigned in a special unit with clients having problems in Neurologic disorders
like Meningitis. A Physician performs a Lumbar Puncture. The client asks if the needle goes into the
spinal cord. Nurse Lengleng bases a response on the understanding that the Physician must insert a
needle into the:
*
1/1
A. pia mater
B. foramen avale
C. subarachnoid space

D. aqueduct of sylvius

24. A client is having lumbar puncture performed. Nurse Lengleng would plan to place the client in
which position for the procedure?
*
1/1
A. Side lying with legs pulled up and head bent down onto chest

B. Side lying with a pillow under the hip

C. Prone in slight Trendelenburg position
D. Prone with a pillow under the abdomen

25. Nurse Lengleng assists the Physician in performing a lumbar puncture. When the pressure is
placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase.
What sign should the nurse expect the physician to document?
*
1/1
A. Abadie’s sign
B. Hannington-Kiff’s sign
C. Peabody’s sign
D. Queckenstedt’s sign

Situation: Impaired Sensorineural function (vision , hearing , balance disorders ) may

affect the clients independence in self care work and lifestyle choices. Nurses in all setting
assess patients at risk and implement measures to prevent further complications. Nurse Vita
is assigned to these clients.

26. Mr. Louie, 68 years old is admitted with Glaucoma. Which desired effect of therapy should Nurse
Vita explain to the client with primary Angle-Closure Glaucoma?
*
1/1
A. dilating the pupil
B. resting the eye muscles
C. controlling intraocular pressure

D. preventing secondary infections

27. Which clinical indicator would Nurse Vita most likely to identify when exploring the history of Mr.
Louie with Open-angle glaucoma?
*
1/1
A. constant blurred vision
B. sudden attacks of acute pain
C. impairment for peripheral vision

D. sudden, complete loss of vision

28. Nurse Vita notice that many of the patients whom she had interviewed have some type of hearing
impairment. One of the clients has a conductive hearing loss. Nurse Vita explains that the bones that
transmit vibrations to the oval window of the cochlea are located in which structure?
*
1/1
A. earlobe
B. eardrum
C. inner ear
D. middle ear

29. Joey, a 68 year old with a hearing loss asks Nurse Vita to explain the cause of nerve deafness.
The nurse explains that deafness is most likely caused by an injury or infection that damages the:
*
1/1
A. vagus nerve
B. cochlear nerve

C. vesticular nerve
D. trigeminal nerve

30. Nurse Vita is caring for an older adult with a hearing loss secondary to aging. What can the nurse
expect to identify when assessing this client?
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A. copious, moist cerumen

B. tears on the tympanic membrane

C. difficulty hearing in women’s voices
D. overgrowth of the epithelial auditory lining

Situations: The diverse Neurologic disorders present a unique challenges of nursing care. The
Nurse must have a clear understanding of the pathologic processes for appropriate nursing
management. Nurse Kim is attending to clients in the ward with Multiple Sclerosis.

31. Which statement by a client with Multiple Sclerosis indicates to Nurse Kim that the client needs
further teaching?
*
1/1
A. “I use a straw to drink liquids.”
B. “I will take a hot bath to help relax my muscles.”
C. “I plan to use an incontinence pad when I go out.”
D. “I may be having a rough time now, but I hope tomorrow will be better.”

32. A recently hospitalized client with Multiple Sclerosis is concerned about generalized weakness
and a fluctuating physical status. What is the priority nursing intervention for this client?
*
0/1
A. encourage bed rest

B. space activities throughout the day

C. teach the limitations imposed by the disease
D. have one of the client’s relatives stay at the bedside

33. Kim is excited to be assigned in a Neuro –Ward after his extensive training. He is preparing to
conduct a Neurologic examination. What nursing intervention is anticipated for a client in the plateau
phase of Guillain-Barre syndrome?
*
0/1
A. providing a straw to stimulate the facial muscles
B. inserting an indwelling catheter to monitor urinary output
C. encouraging aerobic exercises to avoid muscle atrophy

D. administering antibiotic medication to prevent pneumonia

34. Mr. Rod a 48 year old client carpenter admitted after a spinal cord injury and the Physician
indicates that a client is a Paraplegic. The family asks Nurse Kim what this means. What explanation
should the nurse give to the family?
*
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A. upper extremities are paralyzed
B. lower extremities are paralyzed
C. one side of the body is paralyzed

D. both lower and upper extremities are paralyzed

35. Which clinical indicator does Nurse Kim identify when assessing a client with hemiplegia?
*
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A. paresis of both lower extremities
B. paralysis of one side of the body
C. paralysis of both lower extremities
D. paresis of upper and lower extremities

Situation: Caring for a patient with Spinal Cord Injury (SCI) requires a patient centered
collaborative approach to help meet the patient’s expected outcomes.

36. A client with a spinal cord injury has Paraplegia. Nurse Kim assesses for which major problem the
client may experience early in the recovery period?
*
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a. bladder control
b. nutritional intake

c. quadricepes
d. use aids for ambulation

37. Another client has Paraplegia as a result of a motorcycle accident. What is the reason the nursing
care plan should include turning the client every 1 to 2 hours?
*
1/1
A. prevent pressure ulcers

B. keep the client comfortable

C. prevent flexion contractures of the extremities
D. improve venous circulation in the lower extremities

38. Sophie, a 48 year old, fell from a 5 steps staircase and was diagnosed of a spinal cord injury.
Nurse Kim encourages the client to drink fluids primarily to prevent:
*
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A. dehydration

B. skin breakdown
C. electrolyte imbalances
D. urinary tract infections

39. In a Rehabilitation Center a client with quadriplegia is placed on a tilt table daily. Each day the
angle of the head of the table is gradually increased. When the client asks the reason for the tilt table,
what is the nurse’s best response? “The tilt table is used to:
*
0/1
A. Facilitate turning.”
B. Prevent pressure sores.”
C. Promote hyperextension of the spine.”

D. Limit loss of calcium from the bones.”

40. The nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive
wheelchair. Why is it important that the nurse provide this instruction?
*
1/1
A. it prepares them for bracing and crutch walking
B. they usually are not, and never will be, functional walkers

C. they have the strength in the upper extremities for self-transfer

D. it assists them in overcoming orthostatic hypotension

Situation: Anxiety is a subjective and individual experience characterized by feelings of

apprehension and uncertainty. A Psychiatric Nurse is preparing to interview a client with
anxiety disorders.

41. The nurse teaches the client that the level of anxiety that best enhances an individual’s power of
perception is:
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A. Mild

B. Panic
C. Severe
D. Moderate

42. A client attending a Mental Health facility is scheduled for several diagnostic studies. Which client
behavior best indicates to the nurse that the client has received adequate preparation for these
studies?
*
1/1
A. The client requests that the tests be reexplained
B. The client checks the appointment card repeatedly
C. The client paces the hallway the morning before the tests
D. The clients arrives early, waiting quietly to be called for the tests

43. Before discharge, the nurse should teach the family of an anxious client that anxiety can be
recognized as:
*
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A. A totally unique feeling
B. Consciously motivated thoughts and wishes
C. Fears that are related to the total environment

D. A behavior pattern observed in ourselves and others

44. Another client a 35 year old is admitted for an amputation of the left leg. Before surgery the nurse
observes that the clients is diaphoretic, voiding frequently, having difficulty understanding what is
being said, and complaining of palpitations. What should the nurse do first after making these
assessments?
*
1/1
A. Have a stat ECG done on the client
B. Ask the client to talk about feelings

C. Obtain a urine specimen for culture and sensitivity

D. Ask the physician for a stat order for an IM tranquilizer

45. When planning care for a group of children, the nurse understands that the problem of separation
anxiety becomes most problematic for children hospitalized during the age of:
*
1/1
A. 5 to 11 ½ years
B. 12 to 18 years
C. 6 to 30 months

D. 36 to 59 months

Situation: Nurse Kivs is aware that seizures are the results of abnormal paroxysmal small
discharges in the cerebral cortex which then manifest as an alteration in sensation, movement
and perceptions.

46. What is the primary responsibility of Nurse Kivs during a client’s generalized motor seizure?
*
1/1
A. inserting a plastic airway between the teeth
B. determining whether an aura was experienced
C. administering the prescribed PRN anticonvulsant
D. clearing the immediate environment for client safety
47. A male client who has a history of seizure is scheduled for an anteriogram at 10 AM and he is to
receive Phenytoin (Dilantin) at 9 AM. What should Nurse Kivs do?
*
1/1
A. omit the 9 AM dose of the drug
B. give the same dosage of the drug rectally
C. ask the physician if the drug can be given IV

D. administer the drug with 30 mL of water at 9 AM

48. Nurse Kivs is planning to institute a seizure precaution. Which of the following measures would
the Nurse avoid in planning for the client’s safety?
*
1/1
A. Placing an airway , oxygen and suction equipment at the bedside
B. Padding the side rails of the bed
C. Putting a padded tongue blade at the head of the bed

D. Having intravenous equipment ready for insertion of an intravenous catheter

49. A client, who is receiving Phenytoin (Dilantin) to control a seizure disorder, questions Nurse Helen
regarding this medication after discharge. Which is the nurse’s best response? “This medication:
*
1/1
A. Prevents the occurrence of seizures.”

B. Will probably have to be continued for life.”

C. Needs to be taken during periods of emotional stress.”
D. Can usually be stopped after a year’s absence of seizures.”

50. Nurse Kivs is preparing an intravenous infusion of Dilantin as Prescribed by the Physician for
clients with seizures. Which of the following solutions will the Nurse plan to use to dilute this
medication?
*
1/1
A. Lactated Ringer’s solution
B. 5% Dextrose
C. 5% Dextrose and ½ Normal Saline
D. Normal Saline Solution
Situation: Nurse Liz has been taking care of patients in Ward A with different personality
disorders.

51. In determining the plan of care for clients with schizoid personality disorder, which of the
following should the nurse consider? The client
*
1/1
a. Quickly become attached to the group leader
b. Displays behavior lacking social tact or grace in a group

c. Becomes overly emotional in the group setting

d. Attempts to build intimate relationships with other group members

52. Which of the following should the nurse consider when planning the care of a client who has
antisocial personality disorder?
*
0/1
a. The client’s lack of ability to engage with the nurse

b. The client’s attempts to manipulate the nurse

c. The client’s hindered ability to justify actions
d. The client’s openness and honesty about past experiences

53. The nurse is caring for a client who is seeing UFOs, and asks if the nurse is also afraid of the
UFOs. Which of the following would be an appropriate response from the nurse?
*
0/1
a. “I don’t know what are you talking about, I don’t see any UFOs”
b. “I can tell that what you’re seeing frightens you, how can I help to make you more comfortable?’

c. “I see the UFOs too, and they scare me, what are we going to do?”
d. “I don’t see the UFOs, too, are you ready to come to group?”

54. Which of the following is an appropriate goal for the nurse caring for the client who has a
diagnosis of the borderline personality disorder?
*
1/1
a. To identify irrational thoughts and beliefs that the client’s decision- making is founded on

b. To eliminate boundaries between the client and nurse so the client can more easily share problems
c. To eliminate the immediate focus on the client by encouraging the client to focus on the relationships with
others
d. To eliminate the clients involvement in the treatment planning because of the accompanying irrational
thoughts and beliefs.

55. The nurse is collecting a nursing history on a client suspected of having narcissistic personality
disorder. Which of the following assessments would the nurse expect to find?
*
1/1
a. A style of speech that lacks detail
b. An unconscious dependent to others
c. A lack of empathy for others

d. Attempts to promote self-esteem in others

56. A patient is due to undergo tonometry for confirmation of the diagnosis of glaucoma. The nurse
advices the patient against which of the following, except:
*
0/1
a. Squinting
b. Breathing through open glottis
c. Coughing
d. Bending at the hips

57. In the clinic, the school health nurse is conducting a vision screening to incoming Grade 1 and
Grade 4 students. One of the students was able to read at 10 ft, what a normal eye sees at 20 feet.
She documents this finding as:
*
1/1
a.10/20

b. 20/10
c. 2/1
d. 1/2

58. A student was not able to read the letters in the 20/20 level. How should the nurse proceed with
the visual assessment?
*
0/1
a. Document this finding as visual impairment.
b. Allow the student to come nearer at a distance of 10 ft.
c. Ask the student to squint, and try reading the level again.
d. Remind the student to avoid guessing at letters to have an accurate finding.

59. The nurse is performing an admission assessment on a client with a diagnosis of detached
retina. Which of the following is associated with this eye disorder?
*
0/1
a. Total loss of vision

b. Pain in the affected eye

c. A yellow discoloration of the sclera
d. A sense of a curtain falling across the field of vision

60. The nurse is caring for a client following enucleation. The nurse notes the presence of bright red
drainage on the dressing. Which nursing action is appropriate?
*
0/1
a. Notify the physician.
b. Document the finding.

c. Continue to monitor the drainage.

d. Mark the drainage on the dressing and monitor for any increase in bleeding.

Situation: In the PGH Ear Unit, the staff nurse is attending to several outpatient clients seeking
follow-up care.

61. The nurse assists in an ear irrigation. Which of the following statements by the nurse is correct?
*
0/1
a. “Tilt the head towards the unaffected ear.”
b. “Direct the stream of irrigate at the sides of the ear canal.”
c. “After the procedure, lie on the unaffected side to allow the irrigate to soften any hardened mass.”

d. “This procedure is allowed for otitis media to clean the canal.”

62. In administering ear drops, the nurse observes which of the following principles?
*
1/1
a. In a child, pull pinna upward and backward.
b. Let the ear drops fall on the middle space of the canal.
c. Lie on the unaffected side to facilitate absorption.
d. Position unaffected ear uppermost.

63. Otosclerosis, a disorder of labyrinth function, constitutes which type of hearing loss?
*
1/1
a. Perceptive loss
b. Conductive loss

c. Sensorineural loss
d. Mixed loss

64. Which of the following is a characteristic sign of acute otitis media in children?
*
0/1
a. Jumping in pain
b. Ear tugging
c. Painless inflammation
d. Difficulty awakening

65 What makes children more predisposed to chronic otitis media?

*
1/1
a. Shorter Eustachian tube
b. Horizontal orientation of the ear canal
c. Primary diaphragmatic breathing
d. Both A and B

Situation: Addiction disorders are unnecessarily common in the modern lifestyle of Filipinos,
especially with the rise of establishments selling products with caffeine. Because of the
various “improvements” in performance, this industry is still unwavering.

66. Which of the following do not have the potential of addiction, if consumed frequently and in large
amounts?
*
1/1
a. Chocolate-flavored Cola
b. Apple juice
c. Green tea
d. Common cold preparations
67. Caffeine greatly affects which part of the heart, as reflected in an ECG?
*
0/1
a. Atrium
b. Ventricles
c. Purkinje fibers
d. Interventricular septum

68. The nurse suspects caffeine intoxication in a young professional if he notes which finding?
*
0/1
a. Decreased flow of thought and speech
b. Psychomotor agitation
c. Urinary retention
d. Pale face

69. In the previous situation of the young professional intoxicated with caffeine, he suddenly was
unable to take any caffeine source for 24 hours already. The nurse expects to note the following
findings, except?
*
0/1
a. Headache
b. Difficulty in stimulating
c. Nausea and vomiting
d. Muscle pain

70. The following are the reasons why many people abuse caffeine. Choose the exception.
*
1/1
a. Relieve fatigue
b. Increase mental alertness
c. Both A and B
d. Neither A nor B

Situation: The ICU nurse assigned to a 60-year old acutely ill client with Parkinson’s disease
who was hospitalized frequently. The initial confinement was due to electrolyte imbalance.
The following confinement was due to injury sustained from fall, he became to have
incontinent of stools that further lead to development of skin irritation and breakdown.
Currently he was admitted due to respiratory infection.
71. Related literatures included case situations similar to the case of the client. The nurse is
interested in gaining further knowledge that can help the client at risk for fecal incontinence. The
nurse should use which of the following method to strengthen this report?
*
0/1
a. Historical research method
b. Qualitative research method
c. Experimental research method
d. Quantitative research method

72. The review of literature does not only include published research studies but also theory. In this
case which theory is least related to the study?
*
0/1
a. Neuman’s system model
b. Lazarus’ theory of stress and coping
c. Nightingale’s environmental theory
d. Roy’s theory of adaptation

73. While the nurse was able to identify the cases that were studied, it is important to understand the
phenomenological experience of the client. This approach includes the following except:
*
1/1
a. Exploring the idea expressed by the person
b. Getting the whole picture of fecal incontinence and its associated factors
c. Focusing interview on fecal incontinence
d. Interviewing and using of questionnaire on client’s responses to his situation

74. The patient also reports multiple lumbar muscle strains, thus is also looking at using alternative
therapies to reduce the pain. The client seeks advice from the nurse as to what type of alterative
therapy would provide the best pain relief. How should the nurse respond?
*
1/1
a. "I have seen many individuals with your type of pain be relieved of pain through the use of acupuncture."
b. "These types of therapies are more than just therapies; they are really a mind over matter type of event or
game."
c. "Some of my other clients swear by magnet therapy to reduce pain as it is very small and very easy to use."
d. "You need to choose the alternative therapy that is right for you based on research that supports the
intervention."

75. Which of the following can the nurse use in protecting the safety of the subjects undergoing the
research study?
 i. Code for Nurses

ii. Nightingale’s pledge

iii. Patient’s Bill of Rights

iv. Human Rights Guidelines

*
1/1
A. 1, 2, 3, 4
B. 1, 3
C 1, 2
D. 3 ONLY

Situation: The diverse Neurologic disorders present a unique challenges of nursing care. The
Nurse must have a clear understanding of the pathologic processes for appropriate nursing
management. Nurse Martha is attending to clients in the ward with Multiple Sclerosis.

76. Which statement by a client with Multiple Sclerosis indicates to Nurse Martha that the client needs
further teaching?
*
0/1
a. “I use a straw to drink liquids.”
b. “I will take a hot bath to help relax my muscles.”
c. “I plan to use an incontinence pad when I go out.”
d. “I may be having a rough time now, but I hope tomorrow will be better.”

77. A recently hospitalized client with Multiple Sclerosis is concerned about generalized weakness
and a fluctuating physical status. What is the priority nursing intervention for this client?
*
0/1
a. encourage bed rest
b. space activities throughout the day
c. teach the limitations imposed by the disease
d. have one of the client’s relatives stay at the bedside

78. Martha is excited to be assigned in a Neuro –Ward after his extensive training. He is preparing to
conduct a Neurologic examination. What nursing intervention is anticipated for a client in the plateau
phase of Guillain-Barre syndrome?
*
0/1
a. providing a straw to stimulate the facial muscles
b. inserting an indwelling catheter to monitor urinary output
c. encouraging aerobic exercises to avoid muscle atrophy
d. administering antibiotic medication to prevent pneumonia

79. Mr. Sam, a 48 year old client carpenter admitted after a spinal cord injury and the Physician
indicates that a client is a Paraplegic. The family asks Nurse Martha what this means. What
explanation should the nurse give to the family?
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a. upper extremities are paralyzed
b. lower extremities are paralyzed
c. one side of the body is paralyzed
d. both lower and upper extremities are paralyzed

80. Which clinical indicator does Nurse Marco identify when assessing a client with hemiplegia?
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a. paresis of both lower extremities
b. paralysis of one side of the body
c. paralysis of both lower extremities
d. paresis of upper and lower extremities

Situation: In the Psychiatric ward nurses are discussing the other factors that caused of
Alzheimer’s disease (AD). And they all agree that it is a degenerative disease of the brain
caused by gradual death and loss of brain cells resulting to progressive and irreversible
Dementia.

81. Which of the following nursing intervention is most helpful in meeting the needs of an older adult
hospitalized with the diagnosis of Dementia of the Alzheimer’s type?
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a. providing a nutritious diet high in carbohydrates and protein
b. simplifying the environment as much as possible while eliminating the need for choices
c. developing a consistent nursing plan with fixed time schedules to provide for emotional needs
d. providing an opportunity for many alternative choices in the daily schedule to stimulate interest

82. The nurse recognizes that Dementia of the Alzheimer’s type is characterized by:
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a. aggressive acting-out behavior
b. periodic remissions and exacerbations
c. hypoxia of selected areas of brain tissue
d. areas of brain destruction called senile plaques

83. A 75-year-old man with the diagnosis of Dementia has been cared for by his wife for 5 years. For
the past 2 years he has not spoken and incontinent of urine and feces. During the last month he has
changed from being placid and easygoing to agitated and aggressive. He is admitted to a Psychiatric
hospital for treatment with Psychopharmacology. Which is the priority nursing care while this client is
in the psychiatric facility?
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a. managing his behavior
b. preventing further deterioration
c. focusing on the needs of the wife
d. establishing on the needs of the wife

84. When attempting to understand the behavior of an older adult diagnosed with Vascular Dementia,
the nurse recognizes that the client is probably:
*
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a. not capable of using any defense mechanisms
b. using one method of defense for every situation
c. making exaggerated use of old, familiar mechanism
d. attempting to develop new defense mechanism to meet the current situation.

85. The Nurse develops a nursing diagnosis of self care deficit for an older client with Dementia.
Which of the following is the most appropriate goal for this client?
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a. The client will be admitted to a long care facility to have activities of daily living needs met
b. The client will function at the highest level of independence possible
c. The client will complete all activities of daily living independently within one (1) hour time frame
d. The Nursing staff will attend to all the client’s activities of daily living needs during the hospitalization

Situation: In a Nursing Practice you are directly involved in conducting a comprehensive

physical assessment especially to older clients with sensory limitations.

86. When formulating nursing care plans for older adults, Nurse Beb should include special measures
to accommodate for age-related sensory losses such as:
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A. difficulty in swallowing
B. increased sensitivity to heat
C. diminished sensation of pain
D. heightened response to stimuli

87. The client with head injury is having problems with several sensory functions. Nurse Beb should
understand that the structure that acts as a relay center for sensory impulses is the:
*
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A. thalamus
B. cerebellum
C. hypothalamus
D. medulla oblongata

88. After a brain attack a client remains unresponsive to sensory stimulation. Nurse Trisia
understands general sensations such as heat, cold, pain, and touch are registered in the:
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A. frontal lobe
B. parietal lobe
C. occipital lobe
D. temporal lobe

89. The novice nurse who is administering a beta blocker asks the Senior Staff Nurse about its effect
on the Autonomic Nervous System. When formulating a response the nurse should understand which
common misconception about the Autonomic Nervous System?
*
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A. both sympathetic and parasympathetic impulses continually affect most visceral effectors
B. the autonomic nervous systems is regulated by impulses from the hypothalamus and other parts of the brain
C. sympathetic impulses stimulate while parasympathetic impulses inhibit the functioning of any visceral
effector
D. visceral effectors (e.g., cardiac muscle, smooth muscle, glandular epithelial tissue) receive impulses only via
autonomic neurons

90. Visual Acuity declines with age. Presbyopia is a progressive decline in:
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A. Distinguishing between blues and greens and among pastel shades
B. Ability to see in darkness
C. The ability of the eyes to accommodate for close detailed work
D. Adaptation to abrupt changes from dark areas to light areas
Situation: The fundamental assumption of theory of life cycle theories is that development
occurs in successive stages. The different life cycle theories try to explain personality
development as well as development of Psychiatric disorders. The following questions refer to
this situation.

91. The nurse understands that Freud’s phallic stage of psychosexual development, which compares
with Erikson’s psychosocial phase of initiative versus guilt, is seen best at:
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A. adolescent
B. 6 to 12 years
C. 3 to 51/2 years
D. birth to 1 year

92. A 3 year old boy was brought to a Pediatric clinic for an indifferent behavior. About a month after
their toddler is diagnosed as moderately retarded, the parents discuss the toddler’s future, reflecting
specifically on plans for their child’s independent functioning. The nurse recognizes that the parents:
*
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A. Are using denial
B. Accept the child’s diagnoses
C. Are using intellectualization
D. Accept their child’s limitation

93. The nurse understands that problems with dependence versus independence develop during the
stage of growth and development known as:
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A. Infancy
B. School age
C. Toddlerhood
D. Preschool age

94. When planning to teach about the stages of growth and development, what stage does the nurse
indicate as basically concerned with role identification?
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A. Oral stage
B. Genital stage
C. Oedipal stage
D. Latency stage
95. The nurse utilizes play when interacting with children based on the understanding that play for the
preschool-age child is necessary for the emotional development of:
*
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A. Projection
B. Introjection
C. Competition
D. Independence

Situation: Shamira, a Psychiatric Nurse responds in a variety setting to different clients with
Personality disorders.

96. Strict toilet and too early training to a toddler child will cause problems in personality development
because at this age a child is learning to:
*
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A. Satisfy own needs
B. Identify own needs
C. Satisfy parents’ needs
D. Live up to society’s expectations

97. The Psychiatrist orders “Restraints PRN” for a client who has a history of violent behavior. Nurse
Shamira should:
*
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A. Utilize the restraint order if the client begins to act-out
B. Ask the psychiatrist to clarify the type of restraint order
C. Ensure that the entire staff is aware of the restraint order
D. Recognize that PRN orders for restraints are unacceptable

98. A client on the Psychiatric unit asks Nurse Shamira about Psychiatric Advances Directives (PAD).
The nurse explains that these advances directives:
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A. Make the appointment of a surrogate decision maker unnecessary
B. Permit the client to dictate what treatments will be given during future hospitalization
C. Eliminate the need for involuntary admissions when the client is a threat to self or others
D. Allow the client, while having the capacity, to consent or refuse potential psychiatric treatments in the event
of a future incapacitating mental health crisis
99. As Depression begins to lift, a client is asked to join a small discussion group that meets every
evening on the unit. The client is reluctant to join because, “I have nothing to talk about.” What is the
best response by the nurse?
*
1/1
A. “Maybe tomorrow you will feel more like talking.”
B. “Could you start off by talking about your family?”
C. “A person like you has a great deal to offer the group.”
D. “You feel you will not be accepted unless you have something to say?”

100. The nurse encourages a client to join a self-helping group after being discharged from a Mental
health facility. The purpose of having people work in a group is to provide:
*
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a. support
b. confrontation
c. psychotheraphy
self-awarness