-

RECALLS 5 NP5

1. Nurse Gemma is aware that Jimot has a history of bipolar I disorder with
hospitalization for a significant manic episode. With this knowledge, the nurse would
draw special concern regarding which category of psych medications?

0/1

a. Atypical antipsychotics

b. Mood stabilizers/antimanics

c. Antianxiety agents (benzodiazepines)

d. SSRI

Correct answer

d. SSRI

2. Nurse Gemma has observed Jimot who is hyperactive and intrusive sitting very
close to Jerlyn, a female patient with his arm around her shoulders. The nurse hears
the male client cracking sexually explicit joke. Nurse Gemma approaches Jimot and
asks him to walk down the hallway. Which of the following statements by the nurse
Gemma should be beneficial to the patient?

1/1
a. “Ayaw ni Jerlyn na nasa tabi mo siya dahil sa pananalita mo”

b. “ Ang pag-sasabi ng mga malalaswang bagay at pag hipo sa iba ay

hindi pinahihintulutan dito”

c. “Kailangan mong maging maingat sa mga sinasabi mo sa ibang

tao” d. “Kinakailangan mo ng pumunta sa iyong kwarto”

3. Another young adult client is diagnosed with bipolar disorder. He has been
religiously taking his medications and has managed the disorder effectively. One
day, the client suddenly becomes manic. The nurse reviews the client’s medication
record. Which among the following medications should the nurse expect to have
contributed to the development of his manic state?

1/1

a. Amitriptyline

b. Prednisone

c. Gabapentin
 d. Buspirone

4. Which of the following drug is often used in conjunction with mood stabilizers
or anti-depressants to treat bipolar disorder?
*

0/1

a. Ziprasidone

b. Aripiprazole

c. Either A or B

d. None of the above

Correct answer

a. Ziprasidone

5. How long would it take for a diagnosis of manic episode or mania be

made? *

0/1

a. 4 weeks

b. 2 weeks
 c. 3 weeks

d. 1 week

Correct answer
d. 1 week

6. Which of following described Bipolar type II?

1/1

a. Recurrent depressive episodes with at least one hypomanic episode.

b. Manic episodes with at least one depressive episode

c. Alternating cycles between periods of mania, normal mood, depression, normal

mood, mania, and so forth.

d. None of the above

Situation

Therapeutic communication is an interpersonal interaction between the nurse and the

client during which the nurse focuses on the client’s specific needs to promote an effective
exchange of information.

7. Client: “I had an accident”

Nurse: “Tell me about your accident”

This is an example of which therapeutic communication

technique? *

1/1

a. Making observations

b. Offering self

c. General lead

d. Reflection

8. “Earlier today you said you were concerned that your son was still upset with you.
When I stopped by your room about an hour ago, you and your son seemed relaxed
and smiling as you spoke to each other. How did things go between the two of
you?” This is an example of which therapeutic communication technique?

0/1

a. Encouraging comparison

b. Consensual validation
 c. Accepting

d. General lead

Correct answer

b. Consensual validation
9. “How does Heart Evangelista make you upset?” is a
non-therapeutic communication technique because it

1/1

a. Gives a literal response

b. Indicates an external source of the emotion

c. Interprets what the client is saying

d. Is just another stereotyped comment

10. what is the best way for the nurse to ask the client to describe her
relationship with Chiz?

1/1

a. “Chiz, who?
 b. “Tell me about Chiz”

c. “Tell me about you and Chiz”

d. “That’s a good Chiz-mis”

11. Which of the following is a concrete message?

1/1

a. “Get this our of here.”

b. “When is she coming home?”

c. “They said it is too early to get in.”

d. “Help me put this pile of books on Jeremy’s desk.”

Situation

Typhoon Egay has recently struck the northern islands of the Philippines leaving
vast damages to the properties.

12. The nurse working at the site of a severe flood sees Janang, standing in
knee-deep water, staring at empty lot. Janang told the nurse, “Masamang
panaginip lang lahat ng ito. Bukas magigising akong nandyan pa ang bahay ko.”
Which of the following crisis intervention strategies are most needed at this time?
Select that apply.
a. Ask the client about any physical injuries she may have.

b. Determine if any of her family are injured or missing.

c. Allow the client to talk about her fears, anger, and other feelings
d. Tell her that groups are being formed at the shelter for flood

survivors e. Refer her to the shelter for dry clothes and food

f. Assess her for risk of suicide and other signs of

decompensation *

0/1

a. abcd

b. bdef

c. adef

d. abcf

Correct answer

d. abcf

13. Nurse Jan is assessing a client who has just experienced a crisis due to
typhoon Egay. Nurse Jan should first assess this client for which of the following
behaviors?

1/1

a. Effective problem solving

b. Level of anxiety
c. Attention Span

d. Help-seeking

14. Which of the following typify a situational crisis?

0/1

a. Natural catastrophe

b. Death of a loved one

c. menarche

d. Marriage

Correct answer

b. Death of a loved one

15. The nurse should be aware that which of the following is the priority
assessment for crisis?

1/1
a. Defense mechanism of the person

b. Financial stability

c. Perception of the patient to the crisis along with the presence of support system
and coping mechanism

d. None of the above

16. A 16-year-old who is being seen by the crisis nurse after making several
superficial cuts on her wrist states that all her friends are siding with her
ex-boyfriend and won’t talk to her anymore. She says she knows that the relationship
is over, but “If I can’t have him, no one else will.” Which of the following client
problems takes the highest priority?

1/1

a. Risk for other-directed violence

 b. Situational low self-esteem

c. Risk for suicide

d. Risk-prone health behavior

Situation

The nurse is preparing a client with schizophrenia who has a history of command
hallucinations for discharge by providing instructions on interventions for
managing hallucinations and anxiety.
17. Which statement in response to these instructions suggests to the nurse that
the client has a need for additional information?

1/1

a. “My medication will help my anxious feelings.”

b. “I’ll go to support group and talk about what I am feeling.”

c. “When I have command hallucinations, I’ll call a friend for help.”

d. “I need to get enough sleep and eat well to help prevent feeling anxious.”

18. Which of the following group of symptoms are considered positive

symptoms? *
0/1

a. Hallucination, Delusions, and Apathy

b. Asociality, Catatonia, and Flat affect

c. Inattention, avolition, and apathy

d. Perseveration, hallucination, and bizarre behavior

Correct answer
d. Perseveration, hallucination, and bizarre behavior

19. Neurochemical studies have consistently demonstrated alterations in the

neurotransmitter systems of the brain in people with schizophrenia. Which of
the following neurotransmitter is not implicated by several studies to have been
associated with schizophrenia?

0/1

a. GABA

b. Dopamine

c. Serotonin

d. Norepinephrine

Correct answer
 a. GABA

20. The primary medical treatment for schizophrenia is psychopharmacology.

The firs-generation antipsychotics target which manifestation of schizophrenia?

1/1
a. Hallucinations

b. Avolition

c. Alogia

d. Alopecia

21. One of the side effects of antipsychotic medication is neuroleptic

malignant syndrome. What should be the nursing intervention should this
occur?

1/1

a. Stop all antipsychotic medications; notify the physician

b. Administer medications as ordered

 c. Assess for effectiveness

d. None of the above

Situation

Nurse John is aware that he has a crucial role in managing clients with
anxiety-related disorders.

22. The client reports becoming involved with legislation that promotes gun safety
after the death of the child by accidental shooting. Which defense mechanism is
the client exhibiting?
*

1/1

a. Denial

b. Sublimation

c. Identification

d. Intellectualization

23. The client reports becoming physically ill with frequent crying episodes, intense
feelings of worthlessness, and loss of appetite on the anniversary of the death of
the client’s spouse. The client reports that this has occurred for the last 5 years-
What should be the nurse’s focus when counseling the client?

*
1/1

a. Anticipatory grief

b. Uncomplicated grief

c. Delayed grief reaction

d. Distorted grief reaction

24. The client is being discharged after hospitalization for a suicide attempt.
Which question asked by the nurse assesses the learned prevention and future
coping strategies of the client?

1/1

a. “How did you try to kill yourself?”

b. “Why did you think life wasn’t worth living?”

c. “What skills can you utilize if you experience problems again?”

d. “Do you have the phone number of the suicide prevention center?”

25. The nurse is caring for the client with a major depressive disorder. Which
nursing problem should be priority?

1/1
 a. Powerlessness

b. Attempted suicide

c. Anticipatory grieving

d. Disturbed sleep pattern

26. The nurse is interviewing the client at a mental health clinic who recently
attempted suicide and continues to report active suicidal ideation. Which
care setting is most appropriate for this client?

1/1

a. An acute care hospital unit

b. An inpatient mental health unit

c. An outpatient mental health clinic

d. A community detoxification center

Situation

The recently discharged veteran who served in active combat reports symptoms of
recurring intrusive thoughts, insomnia, and hyper vigilance.

27. Which question would be most helpful in establishing a

diagnosis? *

0/1

a. “Do you find yourself falling asleep while working?”

b. “Are you also having nightmares when you do sleep?"

c. “Your hair seems thin. Are you also pulling at your hair?”

d. “Have you ever been diagnosed with obsessive compulsive

disorder?” Correct answer

b. “Are you also having nightmares when you do sleep?"

28. The nurse is caring for a victim of sexual assault brought to the ED by a
roommate. How should the nurse respond when the client begins to angrily
insist upon reporting the details of the assault?

1/1

sk the roommate to sit with the client until the examination can be resumed. b.

Redirect the client to the physical tasks related to securing any existing evidence. c.

Encourage the client to use deep breathing techniques to regain emotional control. d.

Listen quietly as the client expresses the anger and rage currently being experienced
29. The young adult after being robbed is attending counseling sessions to
address anxiety issues. What is the nurse’s best response when the client asks,
“When will things get better for me?”

*
0/1

a. “These types of crises are self-limiting, and usually things are better in 4 to 6 weeks.”

b. “Try not to worry; it is best for you to think about the future and not focus on the

past.”

c. “Being assaulted is traumatic; in time the anxiety will lessen, and you’ll feel more
in control.”

d. “By using the skills you’re learning, the goal for you is to feel better or be back to
normal in about 6 weeks.”

Correct answer

d. “By using the skills you’re learning, the goal for you is to feel better or be back to
normal in about 6 weeks.”

30. The client presents to the ED reporting that he was sexually assaulted by
several men he met at a local bar. Which action should the nurse plan to include
when preparing to assess the client?

*
0/1

a. Ask the client if he had been drinking alcohol excessively.

b. Call the male nurse on duty to assume the care of this client.

c. Do the interview in the same way as for other sexual assaults.

d. Ask whether the client resisted any of the sexual advancements.

Correct answer

c. Do the interview in the same way as for other sexual assaults.

31. The 10—year-old who was sexually abused by a family member experiences
flashbacks of a disagreement with that adult and the resulting sexual assault.
Which suggestion should the nurse make to the parents in order to help minimize
this reaction?

0/1

a. Have the child avoid arguments with adults until this reaction is unlearned. b.

Ask the HCP to prescribe a medication to minimize the child’s aggressiveness. c.

Adults in your family should learn to recognize and diffuse arguments effectively.

d. You and your child should regularly discuss bad memories to decrease their
effect. Correct answer

d. You and your child should regularly discuss bad memories to decrease their effect.

Situations

The Philippines is home to many destructive typhoons.

32. The client’s home was destroyed by a major flood. The client is attending a
support group and says, “I will rebuild my home as good as new and be back in it in
a few months.” What should be the nurse’s initial response?

0/1

a. “That’s a very ambitious plan to undertake at this time.”

b. “I’m proud of your resiliency and willingness to start over.”

c. “Have you given thought to what may happen if it floods again?”

d. “Can you tell me how many months you think rebuilding will take?”

Correct answer

d. “Can you tell me how many months you think rebuilding will take?”

33. The client is being treated after surviving a major hurricane that took the lives
of many neighbors. Which statement by the client provides the nurse with the [best
evidence that therapy has been successful?

*
1/1

a. “Therapy has been a very good thing for me since the hurricane ruined

things.” b. “I’m ready and able to move on with my life in spite of all that has

happened.”

c. “Nothing can happen to me that is worse than what I’ve been through already.”

d. “I’ve learned a lot about myself since agreeing to attend crisis therapy

sessions.”

34. The nurse in the ED is assessing the client who was injured in a car accident.
The nurse considers that the client may have psychogenic amnesia when the client
is unable to recall any personal information. Which statement that reflects the
nurse’s critical thinking about psychogenic amnesia is correct?

0/1

a. Psycho genie amnesia is a long—lasting condition.

b. Psychogenic amnesia is seen more often in men than women.

c. Psycho genie amnesia is categorized with memory loss and dementia.

d. Psycho genie amnesia symptoms include wandering and

disorientation. Correct answer

d. Psycho genie amnesia symptoms include wandering and disorientation.

35. Which among the following options correctly describe

debriefing? *

1/1

a. Participants are asked about their emotional reactions to the incident, what
symptoms they may be experiencing and other psychological medications.

b. Is a process by which the person receives education about recognition of

stress reactions and management strategies for handling stress.

c. Either A or B

d. None of the above

36. The 10—year-old who was sexually abused by a family member experiences
flashbacks of a disagreement with that adult and the resulting sexual assault.
Which suggestion should the nurse make to the parents in order to help minimize
this reaction?

1/1
 a. Have the child avoid arguments with adults until this reaction is unlearned. b. Ask

the HCP to prescribe a medication to minimize the child’s aggressiveness. c. Adults

in your family should learn to recognize and diffuse arguments effectively. d. You

and your child should regularly discuss bad memories to decrease their effect.

Situation
The client is hospitalized after sustaining a head injury and a fractured wrist from a fall.
The client admits to drinking alcohol in moderation several times per week.

37. Which assessment finding should the nurse associate with early
alcohol withdrawal?

0/1

a. Agitation

b. Somnolence

c. Slightly elevated BP

d. Delirium tremens (DTs)

Correct answer

c. Slightly elevated BP
38. The nurse is caring for the client who is 2 days postadmission to a medical
unit and has a long history of heavy alcohol abuse. The nurse should monitor for
which acute complications related to alcohol abuse? Select all that apply

a. Seizures

b. Pancreatitis
c. GI bleeding

d. Exophthalmos

e. Delirium tremens

1/1

a. edcb

b. abcd

c. abce

d. bcde

39. The female client tells the nurse, “I usually have a few drinks after work, but I
always limit it to three. I’m not risking becoming addicted, am I?” What is the
nurse’s best response?
*

0/1

a. “There is no harm in social drinking as long as you know your limits and you are
not driving while intoxicated.”

b. “As long as you don’t have any social problems associated with your use of alcohol,
you do not need to be concerned.”
c. “If you are concerned about the frequency and the number of drinks consumed, then
you might be developing a dependency.”

d. “Three drinks a day or seven drinks in a week is high-risk drinking for women. You
seem concerned that you might have an alcohol dependency.”

Correct answer

d. “Three drinks a day or seven drinks in a week is high-risk drinking for women. You
seem concerned that you might have an alcohol dependency.”

40. The nurse is preparing to administer thiamine (vitamin B,) to the client receiving
treatment for alcohol dependence. Which statement best describes the rationale
for the use of thiamine?

0/1

a. Thiamine improves the absorption of other essential vitamins and folic acid. b.
 Thiamine helps to reverse the malnutrition often associated with alcohol abuse.

c. Thiamine reduces the risk of seizures occurring during withdrawal from

alcohol.

d. Thiamine prevents neuropathy and confusion associated with chronic alcohol

use. Correct answer

d. Thiamine prevents neuropathy and confusion associated with chronic alcohol use.
41. The hospitalized client has a history of weekly moderate alcohol use.
Which symptoms assessed by the nurse indicate that the client may be
experiencing alcohol withdrawal? Select all that apply.

a. Agitation

b. Hypotension

c. Tachycardia

d. Hallucinations

e. Tongue tremor

0/1

a. bcde

b. abcd
 c. abcde

d. acde

Correct answer

d. acde

Situation

Nurse Mira is assigned to care for a patient with Parkinson’s Disease.

42. Nurse Mira has admitted a patient with PD with a fever and patchy infiltrates in
the lung fields on the chest x-ray. Which clinical manifestations of PD would
explain these assessment data?

0/1

a. Maskliek facies and shuffling gait.

b. Difficulty swallowing and immobility.

c. Pill rolling of fingers and flat affect

d. Lack of arm swing and bradykinesia

Correct answer

b. Difficulty swallowing and immobility.

43. The client diagnosed with PD is being discharged on carbidopa/levodopa
(Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale
for combining these medication?

0/1

a. There will be fewer side effects with this combination than with carbidopa alone.
b. Dopamine D requires the presence of both of these medications to work.

c. Carbidopa makes more levodopa available to the brain.

d. Carbidopa crosses the BBB to treat Parkinson’s disease.

Correct answer

c. Carbidopa makes more levodopa available to the brain.

44. Which is a common cognitive problem associated with Parkinson’s

disease? *

1/1

a. Emotional lability

b. Depression
 c. Memory deficits

d. Paranoia

45. A new medication regimen is prescribed for a client with Parkinson’s disease.
At which time should the nurse make certain that the medication is taken?

*
0/1

a. At bedtime

b. All at one time

c. Two hours before mealtime

d. At the time scheduled

Correct answer

d. At the time scheduled

46. The nurse has asked the nursing assistant to ambulate a client with Parkinson’s
disease. The nurse observes the nursing assistant pulling on the client’s arms to
get the client to walk forward. The nurse should:

*
1/1

a. Praise the nursing assistant as this is appropriate.

b. Explain how to overcome a freezing gait by telling the client to march in place.

c. Assist the NA with getting the client back in bed.

d. Give the client a muscle relaxant as studies have proved that this is effective in
this situation.

Situation
The male client is sitting in the chair and his entire body is rigid with his arms and legs
contracting and relaxing. The client is not aware of what is going on and is making
guttural sounds.

47. Which action should the nurse implement first?

1/1

a. Push aside any furniture

b. Place the client on his side

c. Assess the client’s v/s

d. Ease the client to the floor

48. The client who just had a three minute seizure has no apparent injuries and
is oriented to name, place, and time but is lethargic and just wants to sleep.
Which intervention should the nurse implement?

1/1

a. Perform a complete neurological assessment

b. Awaken the client every 30 minutes

c. Turn the client to the side and allow the client to sleep
d. Interview the client to find out what caused the seizure

49. The nurse is teaching the client who is scheduled For an outpatient EEG.
Which instruction should the nurse include?

1/1

a. Remove all hairpins before coming in for the EEG test.

b. Avoid eating or drinking at least 6 hours prior to the test.

c. Some hair will be removed with a razor to place electrodes.

 d. Have blood drawn for a glucose level 2 hours before the test.

50. The nurse in the ED documents that the newly admitted client is “postictal
upon transfer." What did the nurse observe?

1/1

a. Yellowing of the skin due to a liver condition

b. Drowsy or confused state following a seizure

c. Severe itching of the eyes from an allergic reaction

d. Abnormal sensations including tingling of the skin

51. The nurse asks the male client with epilepsy if he has auras with his seizures.
The client says, “I don’t know what you mean. What are auras?” Which statement
by the nurse would be the best response?

1/1

a. “Some people have a warning that the seizure is about to start.”

b. “Auras occur when you are physically and psychologically

 exhausted.” c. “You’re concerned that you do not have auras before

your seizures?” d. “Auras fight for her friend in the bar.”

Situation

A nurse is caring for several patients who are suffering from meningitis.

52. The wife of the client diagnosed with septic meningitis asks the nurse, “I am
so scared. What is meningitis?” Which statement would be the most appropriate
response by the nurse?

1/1
a. “There is bleeding into his brain causing irritation of the meninges.” b. “A virus

has infected the brain and meninges, causing inflammation.” c. “This is a

bacterial infection of the tissues that cover the brain and spinal cord.”

d. “This is an inflammation of the brain parenchyma caused by a mosquito bite.”

53. The client is at risk for septic emboli after being diagnosed with
meningococcal meningitis. Which action by the nurse directly addresses this risk?

0/1

a. Monitoring vital signs and oxygen saturation levels hourly

 b. Planning to give meningocoeeal polysaccharide vaccine

c. Assessing neurological function with the Glasgow Coma Scale

q2h d. Completing a thorough vascular assessment of all extremities

q2h Correct answer

d. Completing a thorough vascular assessment of all extremities q2h

54. The nurse is assessing the client with a tentative diagnosis of meningitis.
Which findings should the nurse associate with meningitis? Select all that apply.
I. Nuchal rigidity

II. Severe headache

III. Pill-rolling tremor

IV. Photophobia

V. Lethargy

1/1

a. I, II, III

b. I, III, IV, and V

 c. I and III only

d. I, II, IV and V

55. The nurse is assessing the client diagnosed with meningococcal

meningitis. Which assessment data would warrant notifying the HCP?

0/1

a. Purpuric lesions on the face

b. Complaints of light hurting the eyes

c. Dull, aching, frontal headache

d. Not remembering the day of the week

Correct answer

a. Purpuric lesions on the face

56. Which type of precautions should the nurse implement for the client
diagnosed with septic meningitis?

0/1
 a. Standard precautions

b. Airborne precautions

c. Contact precautions

d. Droplet precautions

Correct answer

d. Droplet precautions

Situation
The Mariano Marcos Memorial Hospital and Medical Center just opened its new
Performance Improvement Department. Mr. Greg is appointed as the Quality Control
Officer. He commits himself to his new role and plans his strategies to realize the goals
and objectives of the department.

57. Which of the following is a primary task that they should perform to have
an effective control system?

1/1

a. Make an interpretation about strengths and weaknesses

b. Identify the values of the department

c. Identify structure, process, outcome standards & criteria

 d. Measure actual performances

58. Ms. Valencia develops the standards to be followed. Among the

following standards, which is considered as a structure standard?

1/1

a. The patients verbalized satisfaction of the nursing care received

b. Rotation of duty will be done every four weeks for all patient care personnel.
c. All patients shall have their weights taken recorded

d. Patients shall answer the evaluation form before discharge

59. When she presents the nursing procedures to be followed, she refers to
what type of standards?

1/1

a. Process

b. Outcome

c. Structure

d. Criteria
60. The following are basic steps in the controlling process of the department.
Which of the following is NOT included?

1/1

a. Measure actual performance

b. Set nursing standards and criteria

c. Compare results of performance to standards and objectives

d. Identify possible courses of action

61. Which of the following statements refers to criteria?

1/1

a. Agreed on level of nursing care

b. Characteristics used to measure the level of nursing care

c. Step-by-step guidelines

d. Statement which guide the group in decision making and problem

solving Situation

Using Maslow's need theory, Airway, Breathing and Circulation are the physiological needs
vital to life. The nurse's knowledge and ability to identify and immediately intervene to
meet these needs is important to save lives.

62. Which of these clients has a problem with the transport of oxygen from the
lungs to the tissues?

1/1
a. Carol with a tumor in the brain

b. Theresa with anemia

c. Sonny Boy with a fracture in the femur

d. Brigette with diarrhea

63. Laboratory tests are prescribed for the client who has a smooth and reddened
tongue and ulcers at the corners of the mouth. Which result would the nurse find
if the client has iron-deficiency anemia?

1/1

a. Low hemoglobin and hematocrit

 b. Elevated red blood cells (RBCs)

c. Prolonged prothrombin time (PT)

d. Elevated white blood cells (WBCs)

64. The nurse is teaching the client who is a strict vegetarian how to decrease
the risk of developing megaloblastic anemia. Which information should the
nurse provide?

*
1/1

a. Undergo an annual Schilling test.

b. Increase intake of foods high in iron.

c. Supplement the diet with vitamin B12

d. Have a hemoglobin level drawn monthly.

65. The nurse assesses that the client with hemolytic anemia has weakness, fatigue,
malaise, and skin and mucous membrane pallor. Which finding should the nurse
also associate with hemolytic anemia?

1/1
 a. Scleral jaundice

b. A smooth, red tongue

c. A craving for ice to chew

d. A poor intake of fresh vegetables

66. The client is being admitted with folic acid deficiency anemia. Which would
be the most appropriate referral?
*

0/1

a. Alcoholics anonymous

b. Leukemia society of the PH

c. A hematologist

d. A social worker

Correct answer

a. Alcoholics anonymous

Situation

The nurse's understanding of ethico-legal responsibilities will guide his/her nursing practice.
67. The principles that -govern right and proper conducts of a person regarding
life, biology and the health professions is referred to as:

1/1

a. Morality

b. Religion

c. Values

d. Bioethics
68. The purpose of having nurses' code of ethics is:

0/1

a. Delineate the scope and areas of nursing practice

b. Identify nursing action recommended for specific healthcare situations

c. To help the public understand professional conduct, expected of nurses

Correct answer

c. To help the public understand professional conduct, expected of nurses

69. You inform the patient about his rights which include the following

EXCEPT: *

1/1

a. Right to expect reasonable continuity of care

b. Right to consent to or decline to participate in research studies or

experiments c. Right to obtain information about another patient

d. Right to expect that the records about his care will be treated as confidential

70. The principle states that a person has unconditional worth and has the
capacity to determine his own destiny.

1/1

a. Bioethics

b. Justice

c. Fidelity

d. Autonomy
71. Standards of nursing practice serve as guide for:

1/1

a. Nursing practice in the different fields of nursing

b. Proper nursing approaches and techniques

c. Safe nursing care and management

d. Evaluation of nursing cared rendered

Situation

You are taking care of Mrs. Gil, 65 years old, who is terminally ill with ovarian cancer stage IV.

72. When caring for a dying client you will perform which of the following

activities? *

1/1

a. Encourage the client to reach optimal health

b. Assist client perform activities of daily living

c. Assist the client towards a peaceful death

 d. Motivate client to gain independence

73. The client prepares for eventual death and discusses with the nurse and her
family how she would like her funeral to look like and what dress she will use.
This client is in the stage of:

1/1

a. Acceptance
b. Resolution

c. Denial

d. bargaining

74. The spouse of a client dying from lung cancer states, “ I don’t understand
this death rattle. She has not had anything to drink in days. Where is the fluid
coming from? Which is the hospice care nurse’s best response?

1/1

a. “The body produces about two teaspoons of fluid every minute on its own.”
 b. “Are you sure someone is not putting ice chips in her mouth?”

c. “There is no reason for this, but it does happen from time to time.” d. “I

can administer a patch to her skin to dry up the secretions if you wish.”

75. The hospice care nurse is conducting a spiritual care assessment.

Which statement is the scientific rationale for this intervention?

1/1

a. The client will ask all of his or her spiritual questions and get answers.
b. The nurse is able to explain to the client how death will affect the

spirit. c. Spirituality provides a sense of meaning and purpose for many

clients.

d. The nurse is the expert when assisting the client with spiritual matters.

76. The client who is terminally ill called the significant others to the room and
said good-bye, then dismissed them and now lies quietly and refuses to eat. The
nurse understands the client is in what stage of the grieving process?

*
0/1

a. Denial

b. Anger

c. Bargaining

d. Acceptance

Correct answer

d. Acceptance

Situation

Nursing research is considered essential to the achievement of high-quality patient care

and outcomes.
77. Which of the following is a method of non-probability

sampling? *

0/1

a. Cluster sampling

b. Snowball sampling

c. Simple random sampling

d. stratified random sampling

Correct answer

c. Simple random sampling

78. The data on the family’s number of children is appropriate for what level
of measurement?

0/1

a. Interval

b. Ordinal

c. Ratio
d. Nominal

Correct answer

c. Ratio

79. A nurse researcher wants to study the response of patients who suffer
from dysrhythmia to pacemaker. The appropriate research design would be?

0/1
 a. Experimental research design

b. Descriptive-correlational

c. Comparative descriptive

d. Correlational

Correct answer

a. Experimental research design

80. Which of the following are qualitative data sources?

1/1
a. Interview and observation.

b. Primary sources and secondary sources

c. Books and journals

d. Questionnaires and survey

81. All of the following are advantages of using questionnaires

EXCEPT: *

0/1

a. Easy to test data for reliability and validity

b. Facilitates data gathering

c. Less time consuming than interview and observation

d. Respondents may provide socially acceptable answers

Correct answer

d. Respondents may provide socially acceptable answers

Untitled Title

Situation

Nurse Jenny arrives at the site of a one-car motor-vehicle accident and stops to render
aid. The driver of the car is unconscious.
82. After stabilizing the client’s cervical spine, which action should the nurse
take next?

1/1

a. Carefully remove the driver from the car.

b. Assess the client’s pupil for reaction.

c. Assess the client’s airway.

 d. Attempt to wake the client up by shaking him.

83. In assessing the client with T12 SCI, which clinical manifestations would
the nurse expect to find to support the diagnosis of spinal shock?

1/1

a. No reflex activity below the waist

b. Inability to move upper extremities

c. Complaints of a pounding headache

d. Hypotension and bradycardia

84. The client with a C6 SCI is admitted to the emergency department complaining
of a sever pounding headache and has BP of 180/110. Which intervention should the
emergency department nurse implement?

0/1

a. Keep the client flat in bed

b. Dim the lights in the room

 c. Assess for bladder distention

d. Administer a narcotic analgesic.

Correct answer

c. Assess for bladder distention

85. The nurse assesses the client, who was injured in a diving accident 2 hours
earlier. The client is breathing independently but has no movement or muscle
tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical
vertebra. The nurse should plan interventions for which problem?

1/1

a. Complete spinal cord transection

b. Spinal shock

c. An upper motor neuron injury

d. Quadriplegia

86. Spinal precautions are ordered for the client. Who sustained a neck injury
during an MVA. The client has yet to be cleared that there is no cervical fracture.
Which action is the nurse’s priority when receiving the client in the ED?

*
0/1

a. Assessing the client using the Glasgow Coma Scale (GCS)

b. Assessing the level of sensation in the client‘s extremities

c. Checking that the cervical collar was correctly placed by EMS

d. Applying antiembolism hose to the client‘s lower Extremities

Correct answer

c. Checking that the cervical collar was correctly placed by EMS

Situation

Nurse Oni is caring for patients with Multiple Sclerosis.

87. Nurse Oni should conduct a focused assessment with client with
multiple sclerosis for risk of which of the following?

I. Dehydration

II. Falls

III. Seizures

IV. Skin breakdown

V. Fatigue

*
0/1

a. II, III, IV, V

b. I, II, III, IV

c. II, IV, V

d. I and II

Correct answer

c. II, IV, V

88. Which of the following is not a typical clinical manifestation of MS?

*

1/1

a. Double vision

b. Sudden bursts of energy

c. Weakness in the extremities

d. Muscle tremors

89. Nurse Oni should know that the primary reason why she find it difficult
to evaluate the effectiveness of the drugs the client has used for 15 years
is?

0/1

a. The client exhibits intolerance to many drugs.

b. The client experiences spontaneous remissions from time to

time. c. The client requires multiple drugs simultaneously.

d. The client endures long periods of exacerbation before the illness responds to
a particular drug.

Correct answer

b. The client experiences spontaneous remissions from time to time.

90. The client with MS tells the nurse about extreme fatigue. Which assessment
findings should the nurse identify as contributing to the client's fatigue? Select
all that apply.

I. Hemoglobin 9.5 g/dL and hematocrit is 31.8%

II. Taking baclofen 15 mg 3 times per day

III. Working 4 to 8 hours per week in the family business

IV. Stopped taking amitriptyline 8 weeks earlier

V. Presence of a cardiac murmur at the tricuspid valve.

VI. Bilateral leg weakness noted when walking in room

0/1

a. I, II, III

b. I, II, III, IV

c. I, II, IV, V, VI

d. I, II, III, IV, V

Correct answer
c. I, II, IV, V, VI

91. The home-care nurse is counseling the client who has MS. The client is
experiencing weakness, ataxia, intermittent adductor spasms of the hips, and
occasional incontinence from loss of bladder sensation. Which self-care
measures should the nurse recommend? Select all that apply.

I. “Adductor spasms can be relieved by taking a hot bath."

II. “If a muscle is in spasm, stretch and hold it, and then relax.”

III. “Rest first and then walk as able using a walker for
support.“ IV. “When walking, keep feet close together, legs

slightly bent.”

V. “Set an alarm to remind you to void 30 minutes After fluid intake."

0/1

a. II, III, V

b. II, III, IV

c. II, III, I

d. II, III

Correct answer
a. II, III, V

Situation

Nurse Carla is caring for a patient with Guillain-Barré.

92. The client diagnosed with Guillain-Barré syndrome is scheduled to receive

plasmapheresis treatments. The client’s spouse asks the nurse about the purpose
of plasmapheresis. Which explanation is correct?

0/1
 a. “Plasmapheresis removes excess fluid from the bloodstream.”

b. “Plasmapheresis will increase the protein levels in the blood.”

c. “Plasmapheresis removes circulating antibodies from the blood.”

d. “Plasmapheresis infuses lipoproteins to restore the myelin sheath.”

Correct answer

c. “Plasmapheresis removes circulating antibodies from the blood.”

93. The nurse is caring for the client experiencing Guillain-Barré syndrome (GBS). It
is most important for the nurse to monitor the client for which complication?

*
0/1

a. Autonomic dysreflexia

b. Septic emboli

c. Cardiac dysrhythmias

d. Respiratory failure

Correct answer

d. Respiratory failure
94. Nurse Carla learns that the pathophysiology of Guillain-Barré syndrome
includes segmental demyelination. The nurse should understand that this causes
what?

0/1

a. Delayed afferent nerve impulses

b. Paralysis of affected muscles

c. Paresthesia in upper extremities

d. Slowed nerve impulse transmission

Correct answer

d. Slowed nerve impulse transmission

95. Which assessment finding is most indicative of Guillain-Barré syndrome

(GBS)? *

0/1

A. Pupillary dilation

B. Expressive aphasia
 C. Loss of bowel and bladder control

D. A sudden onset of muscle weakness and pain

Correct answer

D. A sudden onset of muscle weakness and pain

96. Which laboratory result is consistent with the diagnosis of

Guillain-Barré syndrome (GBS)?

0/1

A. Positive rheumatoid factor

B. Decreased serum albumin

C. Decreased erythrocyte sedimentation rate

D. Increased protein in the cerebrospinal fluid

Correct answer

D. Increased protein in the cerebrospinal fluid

Situation

Nurse Mira works as a nurse in a rehabilitation center for individuals who abuse a
certain substance.
97.The spouse of the client who is currently in inpatient treatment for substance
abuse tells the nurse, “We’ve done this so many times. I don’t think my spouse is
ever going to change. Do you think it’s time for me to get a divorce?” Which response
by the nurse is most helpful?

0/1

a. “You don’t think your spouse is ever going to change?”

b. “Sounds like you’re feeling discouraged in your marriage.”

c. “Your spouse will likely continue to use and need treatment again.”

d. “That’s your decision; I can’t tell you whether you should get a

divorce.” Correct answer

b. “Sounds like you’re feeling discouraged in your marriage.”

98. The nurse is in the working phase of a relationship with the client being
treated for substance abuse. Which intervention would be appropriate during this
phase of treatment?

0/1

a. Assessing the client’s readiness to change substance-abusing behavior

 b. Evaluating the effectiveness of the client’s newly adapted coping skills c.

Confronting the client’s denial that substances have negatively impacted daily life d.

Determining the extent to which substances have impaired the client’s functioning

Correct answer

c. Confronting the client’s denial that substances have negatively impacted daily life

99. The nurse is assessing the college student who presents with generalized
fatigue, dry mouth, tachycardia, and an increased appetite. Which additional
finding from the client’s history and physical exam should alert the nurse to
explore possible marijuana abuse?

0/1

a. Paranoia
b. Flashbacks

c. Gastric disturbances

d. Conjunctival infection

Correct answer

d. Conjunctival infection
100. The client states, “I don’t see any problem with smoking a little weed. It
isn’t addictive.” Which response by the nurse is most accurate?

1/1

a. “Marijuana is a natural chemical that has many therapeutic uses, but it is still illegal
to use.”

b. “Marijuana is not addictive. The danger is that. it often leads to abuse of more
illicit drugs.”

c. “Marijuana has effects similar to alcohol, hallucinogens, and sedatives that

are addictive.”

d. “There are no withdrawal symptoms, so it is controversial whether marijuana

is addictive.”