Nurse Piper is utilizing her abilities in therapeutic communication when interacting with her clients

admitted in Wating-wating Mental Center.

1. Nurse Piper uses proxemics to distance herself from her patients depending on the activity she is
conducting with them. Which among the following is the distance zone if she is 4 feet from a patient?

1/1

A. Intimate zone

B. Personal zone

C. Social zone

D. Public zone

2. The therapeutic communication interaction is most comfortable when the nurse and client are how
many feet apart?

1/1

A. 3 to 5 feet

B. 3 to 6 feet

C. 4 to 6 feet

D. 4 to 5 feet

3. The following are multiple ways in which nonverbal messages accompany verbal messages. Choose
the exception.

1/1

A. Accent

B. Regulate

C. Substitute

D. Complete
4. If the nurse is using therapeutic communication with broad opening and open-ended questions to
collect information, she is assuming what role?

1/1

A. Non-directive role

B. Guiding role

C. Directive role

D. Client-centered role

Situation

5 of 5 points

Nurse Klaudia has been selected for employment at the Tinoyo Psychiatric Hospital. She is assigned to
the Schizophrenia Ward. The following questions apply.

5. She is observing patients for presence of soft symptoms. She will identify the patient who has:

1/1

A. Meager range of emotional feeling, tone, or mood.

B. False perceptual experiences.

C. Seemingly contradictory beliefs.

D. Impressions that external events have special meaning for the person.

6. Nurse Klaudia knows that the symptoms of a patient with schizophrenia are abated and improved, and
their functional abilities are increased if he is being managed for how many years already?

1/1

A. 16 years

B. 41 years

C. 27 years

D. 18 years
7. Nurse Klaudia is reviewing the biologic theories of schizophrenia. The following are factors thought to
be the causes of this disorder except:

1/1

A. Cytokines

B. Plasma cells

C. Dopamine

D. Serotonin

8. Psychotic behavior observed in countries other than the United States or among particular ethnic
groups has been identified as a “culture-bound” syndrome. Which is an exception?

1/1

A. Bouffée delirante

B. Ghost sickness

C. Qi-gong

D. Zarri

9. A stereotyped repetition of words or phrases that may or may not have meaning to the listener.

1/1

A. Clang Associations

B. Echolalia

C. Perseveration

D. Verbigeration

Situation

5 of 5 points

Nurse Molly is in charge of a group of children and adolescents with disorders. The following questions
apply.
10. Attention deficit/ hyperactivity disorder affects what percentage of school-age children?

1/1

A. 5%

B. 8%

C. 7%

D. 6%

11. Which among the following is not a reason why psychiatric disorders are NOT diagnosed as easily in
children as they are in adults?

1/1

A. They constantly are changing and developing.

B. Children have no sense of a stable, normal self.

C. Behaviors that are normal in a child of one age may indicate problems in a child of another age.

D. Children usually lack the concrete cognitive abilities and verbal skills.

12. Nurse Molly knows that the causes of mental retardation are which among the following. Select all
that apply.

1. Tay-Sachs disease

2. Fragile X syndrome

3. Deprivation of stimulation

4. Trisomy 22

5. Infections

1/1

A. 1, 3, 4, 5

B. 2, 3, 4, 5

C. 1, 2, 3, 5
D. 1, 2, 3, 4

13. An intelligence quotient of 47 indicates which level of mental retardation?

1/1

A. Mild

B. Moderate

C. Severe

D. Profound

14. This disorder involves problems with articulation of sounds that are part of speech:

1/1

A. Stuttering

B. Phonologic disorder

C. Expressive language disorder

D. Lisp disorder

Situation

4 of 5 points

Student Nurse Renz is currently rotating at the ophthalmology unit of Jose Rizal Hospital. He is advised
to study well about the anatomy and physiology of the eye.

15. Which among the following structures maintain the shape of the eye?

1/1

A. Optic nerve

B. Retina

C. Vitreous body

D. Ciliary body
16. Which among the following ocular muscles is not controlled by the oculomotor nerve?

1/1

A. Superior rectus

B. Inferior oblique

C. Medial rectus

D. Superior oblique

17. The use of the Ishihara chart assesses the function of which of the following cranial nerves?

1/1

A. CN II

B. CN IV

C. CN III

D. CN VI

18. Lesion compressing the right optic tract will produce which of the following visual defects?

1/1

A. R eye blindness

B. Left homonymous hemianopsia

C. Bitemporalhemianopsia

D. L eye blindness

19. Lesions affecting the oculomotor nerve will produce the following manifestations, except:

0/1

A. Exophthalmos

B. Paralysis of the medial rectus

D. None is an exception

Situation

2 of 5 points

Angel comes for a consultation with a chief complaint of progressive blurring of vision suggestive of
cataract. She is 70 years old. You assess Angel.

20. Which among the following is not a predisposing factor to cataract formation?

0/1

A. Hyperparathyroidism

B. Radiation exposure

C. Use of miotic agents

D. Down Syndrome

21. You expect Angel to have the following signs and symptoms except:

0/1

A. Gradual loss of vision

B. Decreased color perception

C. Periorbital pain

D. Absent red reflex

22. Angel asks you how cataract develops in the older population. Which among the following
statements explain the pathophysiology of cataract?

1/1

A. Ciliary bodies continuously produce the aqueous humor, increasing the intraocular pressure.

B. There is loss of elasticity of the zonula fibers so the lens is not able to accommodate.
C. Fibrosis and crystal formation occur in the lens, increasing its density and opacity.

D. Trauma causes hemorrhage into the vitreous cavity leading to spontaneous retinal detachment.

23. Angel will undergo phacoemulsification to extract her lens. You are explaining to her the post-
operative manifestations that she should report to the physician. Which among the following is not a
normal occurrence immediately post-surgery?

0/1

A. Mild pruritus surrounding the eye

B. Ocular pain accompanied with nausea

C. Creamy, white, dry, crusty drainage on the eyelids

D. Bloodshot appearance of the affected eye

24. Two weeks after discharge, the patient tells you that her affected sclera appears red and bloodshot
again. This is associated with a decreased vision. She asks you if this is still a normal occurrence. Which
of the following statements is the correct response?

1/1

A. “Please see your ophthalmologist as soon as possible.”

B. “Recurrence of the bloodshot appearance of the affected eye is normal. There is nothing to worry
about.”

C. “That is due to poor compliance to your ophthalmic medications. Continue instill the drops and you
will be okay in a week.”

D. “Stop scratching your eyes. It is your fault that they look like that.”

Situation

5 of 5 points

Nurse Nappi is caring for patients with cognitive disorders. The following questions apply.

25. The following are correct actions by Nurse Nappi when caring for a patient with delirium, except:

1/1
A. Validate client’s anxiety and fears.

B. Encourage daytime napping to promote rest periods.

C. Monitor client’s response to visitors.

D. Allow client to make decisions as much as able.

26. Nurse Nappi asked the patient “Sa’n ka punta?” The patient responded, “To the moon.” The patient
repeated this several more times. “To the moon.” “To the moon.” “To the moon.” The patient is
exhibiting which manifestation?

1/1

A. Echolalia

B. Verbigeration

C. Perseveration

D. Palilalia

27. This is a cognitive disorder and degenerative brain disease that particularly affects the frontal and
temporal lobes.

1/1

A. Pick’s disease

B. Creutzfeldt-Jakob disease

C. Vascular dementia

D. Huntington’s disease

28. A patient with dementia, admitted for 15 years, said “I’m so worried if my cat has already been fed. I
hope he is alright.” Nurse Nappi uses the “going along” technique properly if she said:

1/1

A. “There’s no need to worry; he is just fine.”

C. “You do not have a cat.”

D. “You seem to be worried.”

29. A patient with dementia yelled at the nurse after lunch time. The following are appropriate
responses by Nurse Nappi except:

1/1

A. Leaving the patient and returning after 10 minutes.

B. Say, “You can come with me and watch TV.”

C. Take a walk with the patient at garden.

D. Say, “We have several activities today. What do you want to do?”

Situation

26 of 26 points

The following questions involve the knowledge of psychopharmacology.

30. The following are drugs used to treat extrapyramidal side effects except:

1/1

A. Propranolol (Inderal)

B. Diazepam (Valium)

C. Procyclidine (Kemadrin)

D. Trihexyphenidyl (Cogentin)

31. AIMS is used to screen for extrapyramidal side effects of antipsychotics. What does AIMS mean?

1/1

A. Abnormal Involuntary Movement Scale

B. Acute Involuntary Movement Screening

D. Abnormal Involuntary Motion Screening

32. Which among the following drugs has the highest potential to cause hypotension?

1/1

A. Chlorpromazine (Thorazine)

B. Trifluoperazine (Trilafon)

C. Risperidone (Risperdol)

D. Haloperidol (Haldol)

33. Which among the following drugs has the highest potential to cause sedation?

1/1

A. Olanzapine (Zyprexia)

B. Fluphenazine (Prolixin)

C. Risperidone (Risperdol)

D. Perphenazine (Etrafon)

34. Psychotropic medications often are tapered. This is because of potential problems with rebound,
which refers to:

1/1

A. Temporary return of symptoms

B. Recurrence of the original symptoms

C. New symptoms resulting from discontinuation of the drug

D. Affinity to the use of the drug

35. The typical antipsychotic drugs are potent antagonists of the following dopamine receptors, except:
1/1

A. D1

B. D2

C. D3

D. D4

36. Haldol and Prolixin are available in depot injection, a time-release form of medication for
maintenance therapy. The vehicle for these injections is:

1/1

A. Coconut oil

B. Sesame oil

C. Palm seed oil

D. Canola oil

37. Acute dystonic reactions can be painful and frightening for the client. Immediate treatment can be
achieved with:

1/1

A. Acetylcholine blocking drugs

B. Acetylcholinesterase inhibitor drugs

C. Inotropic drugs

D. Antidopaminergic drugs

38. Akathisia can be treated by all of the following aside from:

1/1

A. A change in antipsychotic medication

B. Beta adrenergic blocker

D. Benzodiazepine

39. Neuroleptic malignant syndrome (NMS) is not characterized by:

1/1

A. An idiosyncratic reaction to major tranquilizer drugs.

B. Major symptoms are rigidity, high fever, unstable blood pressure and elevated levels of creatinine
phosphokinase (CPK) enzyme.

C. Clients usually are confused and often mute.

D. Most often occurs in the first 2 weeks of therapy.

40. Antipsychotic drugs are also known to have an effect to prolactin levels. Which among the following
is not an expected manifestation?

1/1

A. Breast tenderness in men

B. Diminished libido

C. Weight loss

D. Menstrual irregularities

41. The following may lengthen the QT interval leading to potentially life-threatening cardiac
dysrhythmias or cardiac arrest except:

1/1

A. Perphenazine

B. Droperidol

C. Thioridazine

D. Mesoridazine
42. Which among the following drugs can potentially lead to agranulocytosis?

1/1

A. Clozapine

B. Tranylcypromine

C. Phenelzine

D. Isocarboxazid

43. Drugs that may cause potentially fatal interactions with MAOIs include the following except:

1/1

A. Dextromethorphan

B. Buspirone

C. Meperidine

D. Minoxidil

44. Dialysis may be indicated if lithium levels exceed:

1/1

A. 1.5 mEq/L

B. 2.0 mEq/L

C. 2.5 mEq/L

D. 3.0 mEq/L

45. This can be described as the effect seen when minor seizure activity seems to build up into more
frequent and severe seizures.

1/1

A. Snowball effect
B. Domino sequence

C. Kindling process

D. Chain reaction

46. This can cause aplastic anemia and agranulocytosis at a rate five to eight times greater than the
general population.

1/1

A. Carbamazepine

B. Lamotrigine

C. Lithium

D. Valproic acid

47. Which among the following is true about benzodiazepines and GABA?

1/1

A. GABA-receptor channels selectively admit the cation sodium into neurons.

B. Activation of GABA receptors hyperpolarizes neurons.

C. Benzodiazepines is a non-competitive affecter.

D. Benzodiazepines inhibit the actions of the amino acid GABA

48. Which among the following benzodiazepines have the shortest half-life?

1/1

A. Triazolam

B. Alprazolam

C. Chlordiazepoxide

D. Lorazepam
49. A supply of methylphenidate for how many days, if taken by a child, can be fatal.

1/1

A. 5 days

B. 7 days

C. 8 days

D. 10 days

50. Which among the following anxiolytics has the slowest onset?

1/1

A. Chlorazepate

B. Clonazepam

C. Buspirone

D. Oxazepam

51. Which among the following is false about the mechanism of action of lithium?

1/1

A. Produces its effects within neuronal synapses.

B. Regulates reuptake of serotonin, norepinephrine, acetylcholine, and dopamine.

C. Reduces the release of norepinephrine.

D. Acts directly on G proteins and cyclic adenosine monophosphates and phosphatidylinositol.

52. The patient taking MAOI should avoid the following foods aside from:

1/1

A. Beef bourguignon

B. Steak Diane
C. Curds and whey

D. Stilton

53. Which among the following is false about taking antidepressant medications?

1/1

A. SSRIs are taken first thing in the morning.

B. Fluoxetine most often causes sedation.

C. If the client forgets a dose of an SSRI, he or she can take it up to 8 hours after the missed dose.

D. Tricyclic compounds are taken at night.

54. Which among the following antidepressants has the highest risk of potentiating seizures?

1/1

A. Bupropion

B. Imipramine

C. Isocarboxazid

D. Escitalopram

55. The following are preferred drugs of choice for potentially suicidal or highly impulsive patients
except:

1/1

A. Paroxetine

B. Trazodone

C. Amitriptyline

D. Citalopram

Situation
9 of 20 points

Student Nurse Lexi is reviewing the theories and foundations of neurosciences in preparation for her
upcoming clinical exposure. The following questions apply.

56. Higher levels of which of these are associated with a reduced Parkinson's disease risk?

0/1

A. Zinc

B. Urate

C. Copper

D. Iron

57. Which is recommended for the initial treatment of early Parkinson's disease?

0/1

A. Monoamine oxidase type B inhibitors

B. Physical therapy

C. Levodopa

D. Dopamine agonists

58. For patients with early Parkinson's disease, dopamine agonists have shown greater risk than
levodopa for which adverse effect?

0/1

A. Memory loss

B. Diabetes

C. Dyskinesia

D. Impulse control disorder

1/1

A. Arm swing while walking is unaffected in Parkinson's disease

B. Arm swing on one side of the body is normal but reduced on the other side

C. Arm swing is reduced on both sides of the body, but more so on one side

D. Arm swing is reduced on both sides of the body to an equal degree

60. Dysphagia is present in which stage of Parkinson's disease?

0/1

A. Only early-stage Parkinson's disease

B. Only mid-stage Parkinson's disease

C. Only advanced-stage Parkinson's disease

D. Every stage of Parkinson's disease

61. As an acute treatment for migraine, triptans __________.

1/1

A. Are first-line treatment in patients who have allodynia

B. Are not associated with medication overuse risk

C. Are not associated with serotonin syndrome risk in any patient group

D. None of the above

62. Aura occurs in approximately _____ of cases of migraine attack.

0/1

A. 25%

B. 50%
C. 75%

D. 80%

63. Which type of aura occurs most frequently in migraine attacks?

1/1

A. Language

B. Motor

C. Sensory

D. Visual

64. Scintillating scotoma is a rare symptom of visual aura in migraine.

0/1

A. True

B. False

C. Both a and b

D. Neither a nor b

65. The headache that occurs during migraine attack:

1/1

A. Increases in intensity over a course of hours

B. Is bilateral in nearly all cases

C. Is usually throbbing in sensation

D. A and B

E. A and C
66. Which of the following statements is/are TRUE regarding the prevalence of migraine by patient age
and sex?

0/1

A. Before puberty, migraine has similarly prevalence between either sex

B. The peak prevalence of migraine among female patients is between 50 and 60 years of age

C. Both A and B

D. Neither A nor B

67. During migraine attack, __________ has been found to be greater among female patients compared
to among male patients.

0/1

A. Duration of headache

B. Severity of headache

C. Sensory hypersensitivity

D. A and B

E. A, B, and C

68. Which of the following statements is most accurate regarding motor symptoms in hemiplegic
migraine?

1/1

A. These motor symptoms manifest without any other aura symptoms

B. Motor symptoms are usually more prominent in the lower extremities

C. Associated motor weakness is unilateral

D. Babinski sign is negative in neurologic exam

69. During migraine aura, patients typically experience a regional drop in blood flow to which of the
following sites?
1/1

A. An occipital lobe

B. A temporal lobe

C. A and B

D. Neither A nor B.

70. Of the following substances, consumption of __________ has the strongest evidence of being able to
trigger migraine.

1/1

A. Chocolate

B. Monosodium glutamate

C. Red wine

D. Sea foods

71. Early-onset Alzheimer’s disease (EOAD) is defined as Alzheimer’s disease occurring before age:

1/1

A. 45

B. 55

C. 65

D. 75

72. Which of the following conditions is associated with seizures that are unprovoked, rather than
provoked?

1/1

A. Electrolyte disorder

B. Epilepsy
C. Infectious processes

D. Vascular anomalies

73. Which pathologic sign and symptom points to early AD rather than normal aging?

0/1

A. Struggling to find the right word

B. Cerebral atrophy

C. Oxidative stress

D. Forgetting recently learned information or events

74. Which statement is accurate regarding neuropsychiatric symptoms of AD?

0/1

A. They can precede the clinical onset of the disease

B. They occur episodically

C. They cannot predict disease progression

D. Their presence reflects a more severe form of disease

75. Which symptom is characteristic of mild Alzheimer’s disease?

0/1

A. Shortened attention span

B. Muscle twitches

C. Difficulty with language

D. Mood and personality changes

Situation

2 of 5 points
Student Nurse Lexi is reviewing the theories and foundations of psychiatric nursing in preparation for
her upcoming clinical exposure. The following questions apply.

76. Which among following are part of the general criteria to diagnose mental disorders according to the
American Psychiatric Association (APA)? Select all that apply.

1. Dissatisfaction with one’s accomplishments.

2. Ineffective or non-satisfying relationships.

3. Deviant behavior indicates a mental disorder.

4. Lack of cultural growth.

5. Behavior is sanctioned by society.

6. Dissatisfaction with one’s place in the world.

1/1

A. 2, 4, 6

B. 1, 3, 5

C. 3, 4, 5

D. 1, 2, 6

77. The following are factors contributing to mental illness, except:

0/1

A. Individual

B. Social

C. Emotional

D. Interpersonal

78. The period of scientific study and treatment of mental disorders began with the following persons
except:

1/1

A. Sigmund Freud
B. Emil Kraepelin

C. Eugene Bleuler

D. Morris Schwartz

79. The American Psychiatric Association describes a mental disorder as the following, except:

0/1

A. A clinically significant behavioral syndrome

B. Significant loss of control

C. Increased risk of suffering death

D. Associated with disability

80. The revolving door effect pertains to which of the following?

0/1

A. A deliberate shift from institutional care in state hospitals to community facilities.

B. Opening of institutions as safe havens offering protection for the mentally ill.

C. Development of alternative community services.

D. People with severe and persistent mental illnesses have shorter hospital stay.

Situation

3 of 3 points

Nurse Stella is caring for a group of patients with sensorineural problems. The following questions
apply.

81. A patient is about to undergo Amsler grid test. Nurse Stella should know that this test:

1/1

A. Visualizes the angle of the anterior chamber to identify abnormalities in appearance and
measurements.
B. Consists of a geometric grid of identical squares with a central fixation.

C. Evaluates clinically significant macular edema.

D. Detects and documents retinal lesions.

82. The indirect theory on how increased IOP damages the optic nerve in glaucoma is uniquely
characterized by:

1/1

A. High IOP damaging the retinal layer as it passes through the optic nerve head.

B. High IOP compressing the microcirculation in the optic nerve head.

C. High IOP resulting in cell injury and death.

D. High IOP causing mechanical trauma to the optic nerve head.

83. This condition is characterized by a conical protuberance of the cornea with progressive thinning on
protrusion and irregular astigmatism.

1/1

A. Keratoconus

B. Bullous keratopathy

C. Corneal dystrophy

D. Keratoastigmatism

SITUATION

2 of 7 points

Nurse Jade So, an experienced triage nurse at Hottiana Medical Hospital, begins her shift in the busy
emergency department. As the triage nurse, Jade is responsible for assessing incoming patients and
determining the priority of their care based on the severity of their conditions.

84. A 35-year-old pit crew worker was rushed to the emergency room after sustaining a workplace injury
during a high-pressure race event. The patient reported sudden, intense pain in the upper thigh and
groin area, describing it as tearing, snapping, and accompanied by muscle spasms. Upon examination,
the affected leg showed significant swelling and bruising, and the patient was unable to move the leg or
bear weight. A recent X-ray revealed an avulsion fracture. Based on Jade So’s knowledge and experience,
which degree of strain does the manifestations fall?

0/1

A. First degree

B. Second degree

C. Third degree

D. Fourth degree

85. Nurse Jade So quickly initiated first aid measures to prevent further complications while awaiting
definitive treatment. The following are not the primary actions Nurse Jade So likely take in this situation,
except:

0/1

A. Intermittent application of cold packs for 25 minutes.

B. Mobilization by a splint in order for the joint to not lose its stability.

C. Monitor circulation, motion, and sensation at frequent intervals.

D. Intermittent application of hot packs for 25 minutes.

86. Pain is the initial manifestation of progressing neurovascular compromise. In the case of the pit crew
worker, Nurse Jade So recognizes the critical importance of identifying the type of pain indicative of
compartment syndrome. Which of the following classifications of pain best characterizes compartment
syndrome?

1/1

A. Pain on passive motion

B. Sudden increase in pain

C. Intense itching sensation

D. Absence of pain
87. As Nurse Jade So completed her treatment of the pit crew worker, she was immediately called to
assess another patient who had just arrived in the emergency room. A 17-year-old male soccer player
named Jason, presented with a knee injury sustained during a soccer match. Jason described that while
he was running, another player collided with him, striking the medial side of his knee while his foot was
firmly planted on the ground. Jason reported a sudden onset of sharp pain and instability in his knee
immediately following the impact. Nurse Jade So knows that the patient likely has experienced what
injury?

0/1

A. Lateral collateral ligament injury

B. Medial collateral ligament injury

C. Anterior cruciate ligament injury

D. Posterior cruciate ligament injury

88. Due to the severity of the knee injury, Jason requires the assistance of crutches. Which of the
following should Nurse Jade So not consider when instructing Jason on the use of crutches?

0/1

A. Instruct the client to look down and outward when ambulating and to place the crutches 6 to 10
inches (25.5 cm) diagonally in front of the foot.

B. The distance between the axillae and the arm pieces on the crutches should be 2 to 3 finger widths in
the axilla space.

C. Stand on the affected side when assisting the client on ambulation.

D. Instruct the client to stop ambulation if numbness or tingling in the hands or arms occurs.

89. Jason needs to be on partial weight bearing on the affected leg which requires him to have strength
and balance. A three-point gait should be used as recommended. When teaching Jason about the system
in this kind of gait, which instruction should Nurse Jade So say?

0/1

A. the crutch on the affected side and the unaffected foot are advanced at the same time.

B. when both crutches are advanced together, then both legs are lifted and placed down on a spot
behind the crutches.
C. the right crutch is advanced, then the left foot, then the left crutch, and then the right foot.

D. both crutches and the foot of the affected extremity are advanced together, followed by the foot of
the unaffected extremity.

90. Jason expressed his frustrations as he is having difficulty figuring out how to sit with crutches. What
steps would Nurse Jade So advise Jason to follow to sit down safely and comfortably with crutches?

I. Place the unaffected leg against the front of the chair.

II. Move the crutches to the affected side, and grasp the arm of the chair with the hand on the
unaffected side.

III. Flex the knee of the unaffected leg to lower self into the chair while placing the affected leg
straight out in front.

1/1

A. I,II,III

B. I,III,II

C. II,I,III

D. III, II, I

SITUATION

2 of 5 points

Newly registered nurse Brigiding is undergoing his training and refresher program at Divine Medical
Center before starting his assignment in the medical-surgical ward. This program is designed to ensure
Brigiding is well-prepared with essential skills and knowledge related to hospital procedures and core
nursing concepts.

91. On his first day, Brigiding was introduced to gastrointestinal intubation, an important procedure that
can be seen in the medical-surgical ward. Nurse Educator Sarah explained that gastrointestinal
intubation is typically performed for various clinical situations, including:

I. Decompression of the stomach

II. Flushing of the stomach and removing ingested toxins or other harmful materials

III. Diagnosing GI disorders

IV. Administering tube feedings, fluids, and medications

V. Compressing a bleeding site

0/1

A. I, II, IV, V, VI

B. I, II, IV, V,

C. I, II, III, IV, VI

D. I, II, III, IV, V, VI

92. Nurse Brigiding asked Nurse Sarah about a specific type of gastric tube that is radiopaque, made of
clear plastic, and has a double lumen. Which of the following tubes is Brigiding referring to?

1/1

A. Sengstaken–Blakemore tube

B. Salem Sump

C. Levin Tube

D. Moss Tube

93. Brigiding further inquired about the steps to take when a patient is worried about leakage of gastric
contents from the aforementioned gastric tube. Which statement from Nurse Sarah should Brigiding
follow to prevent reflux of gastric contents from escaping?

0/1

A. Prime the tubing with 30 mL of normal saline.

B. Keep the vent lumen above the patients waist.

C. Maintain the patient in a high Fowlers position.

D. Have the patient pin the tube to the thigh

94. During the discussion, Nurse Educator Sarah explained that after a nasogastric tube is inserted,
certain assessment findings are particularly concerning. She emphasized that which specific assessment
finding should be regarded as the most alarming and prompt immediate attention?
0/1

A. The patient reports that the tube is irritating nose and throat feels sore.

B. Gastric contents have a coffee-ground appearance.

C. The patient demonstrates coughing and cannot speak clearly.

D. Gastric fluid is bright red and has small clots.

95. At the end of the training session, Nurse Sarah verified Nurse Brigiding’s learning and asked, "What
question would you, as the RN, not ask the other staff nurse who is assigned to perform an enteral
feeding for a patient with a small-bore feeding tube?"

1/1

A. “Have you evaluated the nutritional status of the patient?”

B. “Is the patient tolerating the supine position after feedings?”

C. “Have you had any problems checking the residual?”

D. “Is the patient developing any problems related to the feedings?”

SITUATION

2 of 5 points

Nurse Jennie walked into the hospital room, her eyes meeting those of her patient, Perlas. Perlas, a
vibrant woman in her late forties, had been admitted a week ago and diagnosed with advanced gastric
cancer. The disease had progressed silently, revealing itself only when it was too late for conventional
treatments. Due to the severity of Perlas' condition and her compromised gastrointestinal function,
the healthcare team decided to initiate parenteral nutrition.

96. During Perlas' hospitalization, her daughter who turns out to be a nurse, engaged in discussions
about supportive treatments. She raised questions about parenteral nutrition and total nutritional
admixture. She asked what advantages are associated with choosing TNA over PN. The following are
incorrect explanations, except?

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A. “TNA can be mixed by a certified registered nurse.”

B. “TNA can be administered over 8 hours, while PN requires 24-hour administration.”

D. “TNA does not require the use of a micron filter.”

97. The physician is about to initiate the procedure when the daughter of Perlas intruded. She
questioned the need for insertion of a central venous catheter, expressing a preference for a normal IV.
Jennie should know that peripheral administration of high-concentration formulas is contraindicated
because of the risk for what complication?

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A. Chemical phlebitis

B. Hyperglycemia

C. Dumping syndrome

D. Line sepsis

98. Anticipating potential questions due to the demeanor of Perlas’ daughter , Jennie reviewed her
knowledge of various types of central venous access devices. If asked, what details will she include?

I. percutaneous (Nontunneled) central catheters

II. peripherally inserted central catheters (PICCs)

III. surgically placed (or tunneled) catheters

IV. implanted vascular access ports femoral central catheters

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A. I,II,IV,V

B. I,II,III,V

C. I,II,III,IV

D. I,II,III,IV,V

99. Nurse Jennie is finally starting total parenteral nutrition for Perlas. Unfortunately, she has developed
complications. To prevent such things, Jennie should not begin therapy performing the following actions,
except?

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A. Adjusting the administration rate every 2 hours in response to serum electrolyte levels.

B. Elevating the infusion rate during mealtimes to emulate the body's natural circadian rhythm.

C. Commencing the infusion gradually while monitoring the patient's fluid and glucose tolerance.

D. Beginning with an accelerated infusion rate to promptly address the patient's nutritional
requirements.

100. As Jennie prepares Perlas for discharge home with parenteral nutrition, what essential components
should be included in an effective home care education program?

I. Preparing the patient to identify and address potential problems

II. Educating the patient and family on rigorous sterile procedures

III. Demonstrating the setup process for the infusion

IV. Instructing the patient on the proper technique for flushing the line with sterile water

V. Guiding the patient on when it is appropriate to leave the access site uncovered.

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A. I,II,III

B. I,II,III V

C. I, III,IV

D. I,II,III,IV,V