RECALLS 3 – NP4

Situation C. Decrease in the level of consciousness

Situation: Sophie is a married female who D. Decrease in the pulse rate.
was admitted to the health psychiatric unit
because of substance abuse. 5. You position the client. Which position
would be MOST appropriate?
1. Which of these initial assessments would
indicate presence of withdrawal? A. Elevate the head to 30 to 45 degrees.
B. Elevate the head to two pillows.
a. Elevated vital signs and nervousness C. Place the client in a Trendelenburg position
b. Drowsiness D. Place the client in left Sim’s position.
c. Hypotension, bradycardia
d. Apathy 6. You assess the client frequently for signs of
increasing intracranial pressure which is
2. Which of these medications will manage ______.
alcohol withdrawal?
CUSHING’S TRIAD – HYPERBRADYBRADY
a. Methadone – MAINTAINANCE OF
ABSTINENCE FROM OPIATES A. Decreasing systolic pressure.
b. Disulfiram – MAINTAINANCE OF ALCOHOL B. Decreasing body temperature.
ABSTINENCE C. Tachycardia
c. Naloxone – MGT FOR OPOID TOXICITY D. Unequal pupil size.
d. Lorazepam - BENZODIAZIPINE
7. You continue to assess the client. Which of
3. Sophie’s spouse comes to you to tell you the following respiratory signs would indicate
that he has to care for Sophie because the increasing intracranial pressure in the brain
patient is in denial of her substance abuse stem?
issues. A nursing diagnosis was made:
Dysfunctional family processes: Alcoholism r/t A. Rapid, shallow respiration.
codependency, as evidenced by the spouse’s B. Asymmetric chest excursion.
rescuing behavior. Which goal would indicate C. Nasal flaring.
an understanding of the current situation and D. Slow, irregular respiration.
the connection between the diagnosis and
outcome. 8. When the client arrives at the ER, which of
the following should you consider a priority
a. Sophie’s spouse admits codependency care?
b. Sophie’s admission of being an alcoholic
c. Raising a considerable amount of funds for A. Replace blood loss.
Sophie’s treatment B. Determine if he has a fracture in the neck.
d. Family achieves improved family dynamics C. Establish an airway.
D. Stop bleeding from the open head wound.
Situation
Situation: You are the nurse in the emergency Situation
room. A 22 year old male is brought in with an Situation: A nurse in the hospital is teaching a
apparent head injury after being involved in a new staff nurse about the guiding principles
serious car accident. He is unconscious on and policies of PhilHealth.
arrival and exhibits signs of increasing 9. Which of the following are not included in
intracranial pressure. the mandate and functions of PhilHealth?
4. You are aware that early indication of
deterioration in the neurologic status of a. Use services now, pay later.
client is a _________. b. Collect and disburse National Health
A. Dilated, fixed pupil. Insurance Fund.
B. Widening or pulse pressure. c. Rich subsidizes the poor. – HEALTHY
SUBDIZES THE SICK
RECALLS 3 – NP4

d. To receive and manage donations. a. Preserve life, respect human rights, and
promote health environment at all times.
10. The following diseases treated at the b. Be equipped with the knowledge of health
outpatient department are covered by resources within the community, and take
PhilHealth except: active roles in primary health care.
c. Actively participate in programs, projects,
a. Cardiac diseases and activities that respond to the problems of
b. Tuberculosis the society.
c. Renal failure d. Project an image that will uplift the nursing
d. Cancer profession at all times.
11. Which of the following PhilHealth benefit 15. The head nurse is starting quality
packages is not included in the case payment improvement in their ward using the Six
scheme? Sigma approach. What is the proper sequence
to follow?
a. Newborn Care Package (NCP)
b. Pneumonia I (Low risk)
i.
c. Outpatient HIV/AIDS Treatment Package
Analyze
d. Asthma
Situation ii.
Situation: Alexis, a head nurse in the OB ward Define
is managing her staff and personnel. She must
be guided by the principles of leadership and iii.
management. The following questions apply: Control

12. The nurse entered a patient’s room to iv.

perform tepid sponge bath. The patient Measure
refused the attempt but the nurse responded,
“I need to bathe you or else I will have to tie
v.
you down.” The nurse has committed what
Improve
tort?
a. ii, i, iii, iv, v
a. Assault - THREATENING
b. iv, ii, iii, i, v
b. Battery
c. ii, iv, i, v, iii
c. False imprisonment
d. iv, ii, i, v, iii.
d. Invasion of privacy
16. ISBAR is a verbal communication tool that
13. During a meeting with the staff, the head
provides structured, orderly approach in
nurse involves the group in decision making
providing accurate, relevant information in
regarding the scheduling of ward classes. The
emergent patient situations and handoffs.
group was divided into two decisions. What
Which of the following is not part of ISBAR?
must the head nurse do?
INTRODUCTION, SITUATION, BACKGROUND,
ASSESSMENT, RECOMMENDATION
a. Agree on a 60-40% rule.
b. The head nurse takes over and decides for
a. Situation
the group.
b. Background
c. Come up with a majority vote.
c. Analysis
d. Ask the two groups to meet halfway.
d. Recommendation
14. According to RA 9173, the following are
Situation
the guidelines to be observed by registered
Situation: A nurse in Fifth Avenue Hospital is
nurses, except:
caring for an HIV-positive patient.
RECALLS 3 – NP4

17. The patient is prescribed with Zidovudine b. Health teaching on nutritious food that
(Retrovir). What should the nurse instruct the must be consumed.
patient to do? c. Ask the patient to consume the serving of
food from the dietary department.
a. “Take the medication only with food.” d. Allowing the patient to have small meals
b. “Lie down after taking capsules.” evenly spread throughout the day
c. “Instruct that with proper usage, it can cure
the disease.” 22. Which of the following suggestions should
d. “Take the drug at specified intervals.” a nurse make to a known poly substance-
abusing woman who is 18 weeks pregnant?
18. What is the major problem the nurse
should be cautious of when taking care of a a. “If you cannot stop taking drugs, you might
patient taking Zidovudine? consider terminating the pregnancy.”
- S/E: SEVERE ANEMIA, NEUTROPENIA b. “You should stop using all drugs
immediately before your baby develops birth
a. The details of the prescription defects.”
b. Drug-drug interactions c. “If you enter a drug treatment program
c. The side effects in taking the drug now, your baby will be born healthy.”
d. Patient education d. ”It may not be possible for you to stop
drugs completely, but you should consider
19. Which among the following laboratory limiting the drugs you use during pregnancy.”
findings is the MOST significant in an HIV-
positive patient? 23. What drug is given to maintain abstinence
from opiates?
a. Decreased CD4+ / T-helper cell count
b. Decreased RBCs a. Disulfiram (Antabuse)
c. Increased AST/ALT b. Methadone (Dolophine)
d. Decreased WBCs c. Lorazepam (Ativan)
d. Naloxone (Narcan)
CD4 COUNT – AMOUNT OF CD4 CELLS IN THE
BLOOD. THE HIGHER THE BETTER
VIRAL LOAD: AMOUNT OF HIV IN THE BLOOD. Situation
THE LOWER THE BETTER. Situation: Sophie is a married female who was
admitted to the health psychiatric unit
20. Headache, impaired cognition, and loss of because of substance abuse.
vision are early manifestations of which of
the following? 24. Sophie has completed one week of
treatment for her alcohol dependency. She
a. Acquired immunodeficiency syndrome exclaims, “I will not resort to alcohol drinking
(AIDS) now, but there seems nothing left for me.”
b. Severe Combined Immunodeficiency (SCID) How would you best respond?
c. Systemic inflammatory response syndrome
(SIRS) a. “I am here whenever you needed me. I’m
d. Multi-acquired agranulocytosis-induced your nurse.”
modulation syndrome (MAAMS) b. “You still have your family who is always
there for you.”
21. The nurse came up with the nursing c. “I will give you this prescribed medication
problem “Imbalanced Nutrition: Less than to help you with the withdrawal.”
body requirements”. Her intervention for this d. “What did your addiction mean to you
would focus on: emotionally?”
a. Encourage to drink water frequently. 25. Sophie was admitted to the facility to treat
her alcohol treatment. This was insisted by
RECALLS 3 – NP4

the spouse. During interview, Sophie tells you, 29. Use of touch as part of nursing care for
“I may drink everyday but my habit is geriatric clients is generally considered as
controlled and non-destructive.” You therapeutic. Which of the following is true
recognize this as denial of the current about use of touch?
situation. How would you best respond?
a. It is calming for the elderly patient.
a. “What have been the negative b. Most elderly patients get angry when
consequences of your drinking?” touched.
b. “You are not telling the truth, I suppose.” c. Its effect is based on the individual
c. “Is it okay if I will ask your spouse to preferences.
observe and note your pattern of drinking?” d. Patient’s face is touched to communicate
d. “How much do you drink to say that it’s empathy most effectively.
controlled?”
30. Time travel is________:
26. Sophie’s spouse comes to you to tell you
that he has to care for Sophie because the a. To remember the pain when the pain
patient is in denial of her substance abuse subsides
issues. A nursing diagnosis was made: b. Through deep meditative techniques and
Dysfunctional family processes: Alcoholism r/t imaginations, divert using your mind thinking
codependency, as evidenced by the spouse’s place you've never been into.
rescuing behavior. Which goal would indicate c. Through hypnosis as well, you can
an understanding of the current situation and absolutely go back into your past and heal
the connection between the diagnosis and things.
outcome? d. Ability that allows humans to be constantly
aware of the past and the future and not only
for recollection of past personal experiences
a. Sophie’s spouse admits codependency
b. Sophie’s admission of being an alcoholic Situation
c. Raising a considerable amount of funds for Situation: Nurse Dede is a nurse for several
Sophie’s treatment clients in the National Center for Mental
d. Family achieves improved family dynamics Health. The following questions apply:

27. Which of these medications will manage 31. A patient has just attempted to commit
alcohol withdrawal? suicide by hanging. To prevent the patient
from attempting this again, which of the
a. Methadone following is appropriate for the nurse to do?
b. Disulfiram
c. Naloxone a. Ask a nurse to watch the patient constantly.
d. Lorazepam b. Take him to seclusion room.
c. Ask the peer to safeguard client
28. Which of these initial assessments would d. Remove one’s clothing to make sure no
indicate presence of withdrawal? other items are with the patient.

a. Elevated vital signs and nervousness 32. A client with a diagnosis of antisocial
b. Drowsiness personality disorder was given a 2-hour pass
c. Hypotension, bradycardia to leave the hospital. The client returned to
d. Apathy the unit 15 minutes past curfew and did not
sign in. The next day, this behavior is brought
Situation up in a group meeting. The client says, "It's all
Situation: A nurse is attempting other the nurse's fault. The nurse was right there
biobehavioral nursing interventions when and did not remind me to sign in." What is the
taking care of her patients. best response by the nurse?
RECALLS 3 – NP4

a. “I'm sorry. I should have reminded you to 37. One of the violent acts is sexual violence.
sign in." Which of the following does NOT constitute
b. “It is not my fault that you forgot to sign sexual violence?
in."
c. “It is your responsibility to sign in when you a. Sexual Abuse
return from a pass." b. Incest
d. “You were late coming back from your pass. c. Economic abuse
Is that why you did not sign in?" d. Drug-facilitated sexual assault
33. A patient is experiencing acute dystonic 38. Women and their children are protected
reaction. All of the following PRN medications against violence under this law:
are prescribed. Which of the following
medication should the nurse administer? a. R. A. 7610
- THERE’S MUSCLE SPASM b. R.A. 8353
c. R.A. 7160
b. Chlorpromazine hydrochloride (Thorazine) d. R.A. 9262 - VAWC
c. Lorazepam (Ativan)
d. Diphenhydramine Hydrochloride (Benadryl) Situation:
e. Alprazolam (Xanax) Situation: Dylan is a 21-year old Volleyball
varsity player in a leading university. He was
Situation admitted for eye trauma after a Volleyball
Situation: You are an advocate for women's game.
rights. You were invited as a resource speaker
on "Violence against women and their 39. Dylan has a bluish discoloration in his right
children." the following questions relate to eye. This condition is caused by:
this.
a. skin irritation
34. Which of the following should be the b. the impact of the blow
focus of care for client who are suspected to c. tissue swelling around the eye
be abused, maltreated or neglected? d. rupture of a blood vessel in the conjunctiva
– BLACK EYE
a. Proper documentation
b. Immediate treatment of any injury 40. A potential result of blunt eye trauma is
c. Verbalization of feelings bleeding into the anterior chamber if the eye.
d. Preservation of evidence This condition is termed of:

35. Which of the following is the most a. Chemosis

common clinical manifestation of a child b. Hyphema
neglect? c. conjunctival hemorrhage
d. ecchymosis
a. Malnutrition and dehydration
b. Cough and colds 41. Which of the following is the PRIORITY
c. Frequent urinary tract infection nursing diagnosis for a patient with eye
d. Crying incessantly trauma?

36. The health worker's main concern when a. Impaired visual acuity
abused, maltreatment or neglect is suspected b. Risk for eye injury: ocular
should be: c. Risk for eye injury: visual
d. Impaired tissue integrity: ocular
a. Verbalization of feelings
b. Airway 42. When teaching Dylan in relation to eye
c. Reporting to the legal authorities injuries, which of the following would be your
d. Safety and welfare of the client focus?
RECALLS 3 – NP4

a. Instillation of eye drops 46. Keith spends most of the day lying in bed
b. Prompt treatment of the injury with the sheet pulled over his head. Which of
c. Prevention and first aid measures the following approaches by Nurse Bong is
d. Use of protective devices most therapeutic?
a. Wait for the client to begin the
43. Another cause of eye trauma is a chemical conversation.
burn. Which of the following measures would b. Initiate contact with the client frequently.
you advise when it happens in the home? c. Sit outside the client’s room.
d. Question the client until he responds.
a. Apply eye drops to the affected side
b. Take the victim to the nearest hospital 47. Neuroleptic malignant syndrome (NMS) is
solution potentially lethal complication of treatment
c. Irrigate the affected eye with normal saline with antipsychotic drugs. Which of the
d. Irrigate the affected eye with tap water – following manifestations should the nurse
RUNNING WATER. IF IN HOSP. SALINE WATER recognize as an early sign of neuroleptic
malignant syndrome?
Situation
Situation: You are a nurse in the psychiatric a. Difficulty swallowing
ward caring for several patients. b. Delirium
44. A patient express many physical c. Muscle stiffness
complaints during the first two weeks on the d. Respiratory depression
alcohol rehabilitation unit. The result of the 48. The nurse provides information to a
physical examinations have been negative. depressed patient and his family about
The patient frequently approaches staff electroconvulsive therapy (ECT). Which of the
members to request for medication for her following statements would the nurse include
discomfort. Based on the patient’s members in the teaching?
to request for medication for her discomfort.
Based on the patient’s behavior, which of the a. “The patient will have a minimal muscle
following interpretations is correct? twitching during the treatment.”
b. The patient must be in restraints following
a. The patient is trying to make the staff feel the treatments.”
guilty. c. “The patient will remain awake and alert
b. The patient is attempting to relieve the during the treatment.”
anxiety. d. “The patient must remain flat on his back
c. The patient is experiencing organic pain for one hour after treatment.”
from alcohol withdrawal.
d. The patient is using a more mature way of Situation
meeting her needs than alcohol. Situation: You are a staff nurse in the
Orthopedic Unit of the Department of
45. The client exhibits a flat affect, Surgery of the Hospital trying to do research
psychomotor retardation, and depressed studies.
mood. The nurse attempts to engage the
client in an interaction but the client does not 49. You are assisting in a research study on
respond to the nurse. Which response by the assessing patient's reactions to the use of new
nurse is most appropriate? dressing material. A medical student
questions the credibility of the nursing
a. “I’ll sit here with you for 15 minutes.” research. Your response would be:
b. “I’ll come back a little bit later to talk.”
c. “I’ll find someone else for you to talk with.” a. To keep quiet
d. “I’ll get you something to read.” b. "Nursing research is essential for the
development of nursing science"
RECALLS 3 – NP4

c. "Doing research is one of the competencies a. Passivity

of professional nurses" b. Inattention
d. "Nursing practice is based on research c. Hyperactivity
findings" d. impulsivity
50. Which of the following research methods 54. His teacher has observed Luke to have
has for its purpose to describe social difficulty waiting for his tutor often batting
processes present within human into conversations and blurts out answers
interactions? without waiting for questions to be finished.
These are manifestations of_________.
a. Phenomenology – LIVED EXPERIENCES
b. Grounded theory a. Hyperactivity – FIDGETING, EXCESSIVE
c. Participatory action research – TAPPING SHOES
NAKIKIHALOBILA SA PARTICIPANTS b. Inattention
d. Case study – IN DEPTH STUDY c. passivity
d. impulsivity – MOVES CONSTANT
51. In a clinical question, "Is breastfeeding
more effective in increasing the birth weight Situation
of preterm infant than adding corn oil to the Situation: Lily is a 7-year old, Grade one kid,
infant formula?" what is the intervention of who is diagnosed with Attention Deficit/
interest? Hyperactive Disorder (AD/HD).
- PICO: Population. Intervention (NEW
TREATMENT YOU WANT TO PROVE - CAN BE DIAGNOSED AROUND SCHOOL AGE
EFFECTIVE), COMPARISON OR PRESCHOOLER
(EXISTING/TRADITIONAL TREATMENT), 55. Manifestations of ADHD are usually
OUTCOME identified in what situation or event? When a
child is
a. Breastfeeding
b. Increasing the birth weight - OUTCOME a. At home, by parents
c. Preterm infant - POPULATION b. With peers, during play
d. Adding corn oil to the infant formula - c. Enrolled in the education system
COMPARISON d. Is brought to a well-baby clinic
52. In a research question, "What is the 56. The school nurse reports that Lily
relationship between wound healing and frequently exhibits the following behavioral
nutrition among elderly patient with hip manifestations of ADHD, except:
surgery?" which one is the dependent
variable? a. Interrupt others and can't take turns
- PIRD: Population, Independent Variable, b. Moody and bad-tempered behavior
Relationship, Dependent Variable c. Easily distracted and forgetful
a. Elderly patient - POPULATION d. Incorrect and messy work
b. Wound healing
c. hip surgery 57. Lily tells the nurse, "I don't have friends
d. Nutrition – INDEPENDENT VARIABLE because I'm stupid." Which of the following
nursing diagnosis would the nurse identify for
Situation him?
Situation: Luke is an 11-year old Grade IV
pupil in a private school was diagnosed to a. Ineffective coping
have an attention-deficit hyperactivity b. Anxiety
disorder (ADHD). c. withdrawal syndrome
53. Which of the following is NOT a MAIN d. low self esteem
characteristic of ADHD?
RECALLS 3 – NP4

58. The nurse expects Lily to have impaired 61. The MAIN objective of crisis intervention is
social interaction as the child exhibits to_____________
excessive talking, short attention span, and - CRISIS – Sudden event in one’s life that
low frustration tolerance. Which of the disturbs homeostasis during which coping
following nursing interventions is NOT useful mechanisms cannot resolve the problem
in his case?
a. Make the person realize his/her mistakes
a. Call Tommy's name and establish eye b. Ensure patient’s safety
contact c. Return the person to the root of the crisis to
b. Give instructions to the child slowly using identify the cause
simple language d. Eliminate the stressor
c. Provide positive feedback for completion of
each task 62. Which of the following is NOT an
d. Give complex tasks at the same time assumption in the concept of crisis?

Situation a. Crisis is acute and resolved within a short

Situation: Nurse Claire wants to improve in period of time
her care for patient Phil, who is an alcoholic. b. All individuals experience a crisis
She asks help from her Head Nurse Gloria. c. Crisis is a growth-retarding factor to the
emotional development of a person
59. Claire goes to Phil’s bedside to greet him. d. Specific identifiable events precipitate a
Gloria corrects Claire of her greeting which is crisis
NOT appropriate to Phil? (-)
63. Which of the following nursing
a. "Hi, Phil! so you got drunk last night" interventions is the most appropriate for a
b. "Hi, Phil! I heard you enjoyed yourself last client who is in the early state of crisis?
night"
c. "Hi, Phil! I heard you had a drinking spree a. Encourage client to express feeling and
last night" emotions related to crisis
d. "Hi, Phil! How was your drinking affair last b. Require client to be actively involved in
night" establishing goals
c. Encourage client to begin the development
60. Phil turned his back away from Nurse of insight
Claire, saying "It's none of your business, you d. Ask client to evaluate the situation
ugly duckling." The appropriate response of
Nurse Claire would be: 64. A crisis that is acute but temporary and
due to external source is__________.
a. "What you said hurt me, you alcoholic!"
b. "You beast, you are as ugly as I am" a. Developmental
c. "You really are a drunkard" b. Transitional
d. "I don't think you mean what you have just c. Traumatic – RAPE, TRAUMATIC CRIMES
said, do you?" d. Dispositional
Situation Situation
Situation: You are a staff nurse in a Situation: Alex is a staff nurse in a psychiatric
government hospital being transferred to the ward of Hospital Cabo. The following
Psychiatric Unit. You were required to equip questions apply:
yourself by attending the enhancement
program on Crisis Intervention. To assess 65. Obsessive-compulsive disorder is
your knowledge and skills on the subject you characterized by recurrent, unwanted
were given a pre-test. thoughts which lead to ritualistic and
repetitive behaviors in an attempt to
RECALLS 3 – NP4

neutralize anxiety. Which of the following 69. Which of the following actions should a
medications are appropriate for OCD? nurse take when making the first contact with
a paranoid patient?
a. Tacrine (Cognex)
b. Bupropion (Wellbutrin) a. Introduce self and avoid touching the
c. Haloperidol (Haldol) patient
d. Clomipramine (Anafranil) b. Avoid eye contact and shake hands with the
patient.
66. Which of the following sets of symptoms c. Close the door to the interview room and
is characteristic of generalized anxiety remain standing
disorder? d. Wait for the patient to initiate
communication
a. Uncontrollable worrying, significant distress
or impaired social functioning for at least 6 70. The outcome that would be most
months. appropriate for the patient who has a
b. Intense fear and helplessness within 1 diagnosis of agoraphobia would be that the
month after exposure to traumatic event that patient will:
lasts 2 days to 4 weeks. – ACUTE STRESS
DISORDER a. Go shopping in town
c. Re-experiencing of an extremely traumatic b. handle money without wearing gloves
event and numbing of responsiveness within 3 c. Touch the neighbor’s dog
months to years after the event. - PTSD d. Bathe only once a day
d. Significant anxiety provoked by a specific
feared object or situation. – SPECIFIC ANXIETY Situation
Situation: Cameron is a new staff nurse in a
67. A schizophrenic patient says to a nurse, psychiatric ward reviewing the guidelines on
“You are wearing a pretty red dress. Tomatoes ethical principles.
are red. Vegetables make you healthy. I am
not healthy.” A nurse should recognize that 71. Which of the following long term goals is
these statements are an example of appropriate for this client?
ECHOPRAXIA – REPITITION OF ACTIONS
PALILALIA – REPITITION OF OWN WORDS a. Become appropriately interdependent with
others
a. Echolalia – REPITITION OF WORDS FROM b. Become involved in activities that foster
OTHERS social relationships
b. Neologisms – CREATION OF NEW WORDS c. Verbalized a realistic view of self
c. Confabulation – CREATION OF FALSE d. Take steps to address disorganized thinking
MEMORIES 72. The client makes an inappropriate and
d. Looseness of association unreasonable report to you. Which of the
68. A male patient’s yearly laboratory following principles of good communication
screening reveals an elevated serum prostate- skill is important for you to use?
specific antigen (PSA) level. To which of the
following nursing diagnosis should a nurse a. Use nonverbal communication to address
give priority for this patient? the issue
b. Use logic to address the client’s concerns
a. Defensive coping c. Tell the client that you do not share this
b. Hopelessness interpretation
c. Anxiety d. Confront the client about the stated
d. Social Isolation misperception
RECALLS 3 – NP4

73. You noticed that the client has impaired a. Verbal consent by the patient is sufficient
social skills. Which of the following short-term b. Another patient is needed to witness the
goals is MOST appropriate for the client? consent form
c. Permission is granted by the patient when
a. Address positive and negative feelings he signed the hospital’s admission form
about self d. Failure to obtain the patient’s written
b. Obtain feedback from other people consent can result to a lawsuit
c. Identify personal feeling that hinder social
interactions 78. A male psychiatric nurse receives a call
d. Discuss anxiety-provoking situations asking whether a certain person has been a
patient in the facility. How should the nurse
74. The client discusses current problems with respond? Nurse_______________.
the nurse. Which of the following
interventions should have priority in the a. States that he is unable to give any
nursing care plans. Have the information to the caller
client____________. b. Asks the caller why the information is being
sought
a. Discuss the use of defense mechanisms c. Suggests to the caller to speak to Mr X’s
b. Look at the source of frustration doctor
c. Clarify his thoughts and beliefs about an d. States that Mr X has been at the facility but
event gives no further information
d. Focus on the ways to interact with the
others 79. The nurse learns that a patient was
admitted involuntarily on the shift. What
75. What other traits is expected from a client assumption can the nurse make about the
with paranoid personality disorder. The client: patient?

a. Avoids responsibility for health care actions a. For the first 48 hours, he can be given
b. Is afraid another person will inflict harm medication despite his objections
c. Cannot follow limits set on behavior b. He can leave the ward upon demand
d. Depends on others to make important c. At the time of admission, he was considered
decisions to be an imminent danger to himself or to
others
76. When the nurse is told by the patient that d. He has agreed to accept the treatment and
she consented to ECT out of fear of being participate fully in care planning
abandoned by her husband, what nursing
action is required? 80. The intervention by a psychiatric nurse
that implements the ethical principle of
a. Explain that consenting to ECT will make autonomy is when the nurse______________.
her husband happy
b. Reassure the patient that her decision is a. Stays with the client who is demonstrating
sound high level of anxiety
c. Document the patient’s statement b. Intervenes when a self-mutilating client
d. Reprimand the husband for coercing his attempts to slash wrist
wife c. Explores alternative solutions with the
client, where client later chooses one
77. A patient is about to receive alternative
electroconvulsive therapy (ECT) when the d. Suggest that two clients who are fighting be
nurse sees that the patient has not signed a restricted to the unit
consent for treatment. Which of the following
facts should determine the action of the Situation
nurse?
RECALLS 3 – NP4

Situation: As a professional nurse you take 2. He is competent to make a choice

into consideration the ethico-moral
principles in providing nursing care. 3. He has the freedom to make a choice
81. Nurse Bong is planning care with Keith.
4. He can understand the consequences
The client believes in “mal ojo” (the evil eye),
and uses treatment by a root healer. The
a. 1, 2, 3
nurse should do which of the following?
b. 1, 2, 4
TRANSCULTURAL THEORY: MADELEINE
c. 1, 2, 3, 4
LEININGER
d. 1, 3, 4
a. Avoid talking to the client about the root 85. Mrs. Cruz needs to undergo a hip surgery.
healer. She refused to have it done even after the
b. Explain to the client that Western medicine attending surgeon has explained the
has a scientific, not mystical, basis. procedure thoroughly. Which ethical principle
c. Explain that such beliefs are superstitious applies in this situation?
and should be forgotten. a. Autonomy
d. Involve the root healer in a consultation b. Justice
with the client, physician and nurse. c. Non-maleficence
d. Beneficence
82. A nurse caring for a patient from a
different culture notices that the patient did 86. Your patient is having difficulty making
not eat the food on the meal tray. Which of decision to undergo hip surgery. Which of the
the following comments by the nurse following nursing actions BEST describes your
demonstrate an understanding of cultural advocacy roles as a nurse?
diversity?
a. Protect patient’s autonomy and
a. “What foods do you eat at home?” independence
b. “You need to eat to keep up your strength” b. Communicate patient’s needs to the
c. “You will lose weight if you do not eat.” interdisciplinary team
d. “Why didn’t you tell me you don’t like c. Advise the client to undergo surgery
hospital food?’ because it is best for her
d. Actively support patient’s decision
83. Another requirement of informed consent
is voluntariness. It means, freedom of choice 87. You released information over the phone
without the following conditions, to a caller who identified himself as the
EXCEPT__________. brother of your patient. You found out later
that the brother was out of town. Which of
a. Force the following rights did you violate?
b. Fraud
c. Consequences a. Right to privacy
d. Deceit b. Right to continuity of care
c. Right to confidentiality
84. Informed consent is one of the patient’s
d. Right to respectful care
bill of rights. One of its requirements is the
capacity of the patient to give it. Which of the Situation
following elements is/are related to this Situation: You are a nurse caring for patients
capacity? (SELECT ALL THAT APPLY). who are victims of child abuse. The following
questions apply:
88. A nurse is planning a community
1. Patient is an adult education presentation on domestic violence.
RECALLS 3 – NP4

Which of the following factors should a nurse c. Bantay Bata 163

include? d. Nearest child protection agency

a. Instructions on harmonious living with 93. The family of a dependent psychiatric

spouse patient accuses Nurse Pau of negligence of
b. The telephone number of the local safe her nursing responsibilities. Nurse Pau uses
house the patient’s chart to:
c. Ways to include the extended family
d. Assertiveness training a. Show that she is not the nurse in charge
when negligence happened.
89. If child abuse is suspected in a family, b. Serve as an evidence of Nurse Pau’s care
which of the following approaches would a given to the client at the time of the event in
nurse take when beginning to interview the question
child? c. Prove the patient’s psychiatric illness and
a. Speaking to the child by using specific, that his accusations are not based on reality.
anatomically-correct terminology d. Bring it to the court for Nurse Pau’s defense
b. Expressing concern to the child that from patient’s statements
something like this could have happened
c. Assuring the child that any information 94. Computerized patient records may be
given will be kept confidential used as legal documents. To maintain the
d. Providing a private place to talk the child legal standards in computer records, which of
about the incident the following should be observed?

90. Which of the following is a characteristic a. Only the nurse involved in the care can see
of a sexual abuser? the patient records.
b. The nurse can get permission from the
a. Only males can be sexual abusers. head nurse if a record has to be altered.
b. A sexual abuser is usually a stranger to the c. Once the data has been input, further
victim. changes will not be allowed.
c. He was most likely sexually abused as a d. The nurse counterchecks the computer
child. input of another nurse if it is valid and
d. He comes from a low-income family. appropriate.
91. The following are signs that child abuse is 95. A student nurse asks why ink is imperative
most likely present in a pediatric client except: in documentation. This is because:
(-)
a. Changes will be easily-noticed, and the
a. Abrasions on knees due to a bicycle crash as documents are permanent.
reported by the mother. b. It looks more formal and readable
b. Child was brought to the clinic for burn compared to pencil.
injury that happened 4 days ago. c. Use of ink is according to the guidelines and
c. Mother tells that the bruises were due to policies by the hospital.
home accident. The next day she tells that it’s d. The other members of the health care team
due to a fight with a neighbor. can understand the records better.
d. Recurrent urinary tract infections
96. The nurse is handling a psychiatric patient.
92. A nurse found out that her patient in a During one of their interactions, the patient
medical ward was raped by her grandfather. told the nurse, “I am mad.” How would the
She appropriately reports this assessment to nurse document this?
which of the following agencies/departments?
a. Looks fierce and hostile
a. PNP b. Clenched fists, ready to attack
b. DSWD c. Loud and belligerent, frown on face
RECALLS 3 – NP4

d. Face looks angry, yet fearful

97. A psychiatric patient tells you, “I feel so

depressed.” Which of these behavioral
manifestations would be the best
documentation for the said cue?

a. Feels sad and alone, his heart is full of

sorrow and pain
b. Cries when alone, avoids eye contact, with
drooping posture
c. Doesn’t cooperate with the nurse, not
having fun in going to group activities
d. Looking for the presence of nurse,
interested in nurse-patient interaction
98. A nurse would assess a patient who
experiences prolonged vomiting for signs of

a. Hypovolemic shock
b. Metabolic acidosis – SHOULD BE ALKALOSIS
c. Water intoxication
d. Potassium excess - HYPOKALEMIA
99. A nurse observes a colleague performing a
assessment of a child who has a head injury
by using the Glasgow coma scale. Which of
the following assessments, if performed by
the colleague, indicates the colleague needs
instructions regarding the use of this scale?

a. Motor responses
b. Deep tendon reflex
c. Verbal ability
d. Eye opening
100. You have a newly admitted patient with
bulging fontanels, setting-sun eyes, and
lethargy. Which of the following doctor’s
order would you question? An order of:

a. Arterial blood draw

b. Magnetic resonance imaging
c. Computerized tomography scan
d. Lumbar puncture