Nursing Practice V

NURSING PRACTICE VV- Care of Clients with physiologic and Psychosocial Alterations (Part C). SITUATIONAL Situation 1 – Jimmy developed this goal for hospitalization. “To get a handle on my nervousness.” nervousness.” The nurse is going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead. He realized he needed help. 1. The nurse recognized that Jimmy had conceptualized his problem and t he next priority goal in the care plan is: A.help

the client find meaning in his experience B.help the client to plan alternatives present problem C.help the client cope with the present D.help the client to communicate

2. The nurse is guided that Jimmy is aware of his concerns of the “here and now” when he crossed out which item from this “list of what to know”.

A.anxiety

laden unconscious conflicts idea of the range of mild to severe anxiety anxiety C.early signs of anxiety D.physiologic indices of anxiety B.subjective

3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that that complete disruption of the ability to perceive perceive occurs in: A.panic

state of anxiety B.severe anxiety C.moderate anxiety D.mild anxiety 4. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT: EXCEPT: agreeing ing A.agree

to contact the staff when he is anxious B.becoming aware of the conscious feeling C.assessing need for medication and medicating himself D.writing out a list of behaviors that he identified as anxious 5. The nurse notes effectiveness of interventions in using subjective and objective data in the: A.initial

plans or orders

B.database C.problem

list D.progress notes

Situation 2 – A research study was undertaken in order to identify and analyze a disabled boy’s coping reaction pattern during stress.

Titles you can't find anywhere else

Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.









6. This study which is an in depth study of one boy is a: A.case

study

B.longitudinal

study C.cross-sectional study D.evaluative study 7. The process recording was the principal principal tool for data collection. Which of the following is NOT a part of a process recording? recording? A.Non

verbal narrative account interpretation B.Analysis and interpretation C.Audio-visual recording D.Verbal narrative account 8. Which of these does NOT happen in a descriptive study? A.Exploration

of relationship between two or more phenomena. B.Explanation of relationship between two or more phenomena. C.Investigation of a phenomenon in real life context. D.Manipulation of variable 9. The investigator also provided the nursing care of the subject. The investigator is referred to as a/an: A.Participant-observer B.Observer

researcher

C.Caregiver D.Advocate

10. To ensure reliability of the study, the investigator’s analysis and interpretations were: A.subjected

to statistical treatment with a list of coping behaviors C.subjected to an inter-observer agreement D.scored and compared standard criteria B.correlated correlated

Situation 3 – During the morning endorsement, the outgoing nurse informed the nursing staff that Regina, 35 years old, was given Flurazepam (Dalmane) 15mg at 10:00pm because she had trouble going to sleep. Before approaching Regina, the nurse read the observation of the night nurse. 11. Which of the following approaches approaches of the nurse validates the data gathered? gathered? A.“I

learned that you were up till ten last night, tell me what happened









12. Regina is a high school teacher. Which of these information LEAST communicate attention and care for her needs for information about her medicine? A.Guided

by a medication teaching plan, go over with her the purpose, indications and special instructions, about the medication and provide her a checklist B.Provide a drug literature. C.Have an informal conversation about the medication and its effects D.Ask her what time she would like to watch the informative video about the medication. 13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina to: A.face

emerging problems realistically B.conceptualize her problem C.cope with her present problem D.perceive her participation in an experience !4. Which of these responses indicate that Regina needs further discussion regarding special instructions? A.“I

have to take this medicine judiciously” know I will stop taking the medicine when there is advice from the doctor for me to discontinue.” reactions I have.” C.“I will inform you and the doctor any untoward reactions D.“I like taking this sleeping pill. It solves my problem of insomnia. I wish I can take it for life.” B.“I

15. Regina commits to herself that she understood and will observe all the medicine precautions by: A.affixing her signature to the teaching plan that she has understood the nurse B.committing what she learned to her memory C.verbally agreeing with the nurse D.relying on her husband to remember the precautions precautions

Situation 4 – The nurse-patient relationship is a modality through which the nurse meets the client’s needs. 16. The nurse’s most unique tool in working with the emotionally ill client is his/her A.theoretical

knowledge personality make up B. C.emotional reactions D.communication skills 17. The psychiatric nurse who is alert to both the physical and emotional needs of









There D. There

is a basic similarity among all human beings.

18. One way to increase objectivity in dealing with one’s fears and anxieties is through the process of: A.observation B.intervention C.validation D.collaboration

19. All of the following responses are non therapeutic. Which is the MOST direct violation of the concept, congruence of behavior? A.Responding Responding

in a punitive manner to the client. the client as a unique human being C. Tolerating Tolerating all behavior in the client. D.Communicating ambivalent messages messages to the client. B.Rejecting

20. The mentally ill person responds positively to the nurse who is warm and caring. This is a demonstration of the nurse’s role as: A.counselor B.mother

surrogate

C.therapist D.socializing agent

Situation 5 – The nurse engages the client in a nurse-patient interaction. 21. The best time to inform the client about terminating the nurse-patient nurse-patient relationship relationship is: A.when

the client asks how long the relationship would be B.during the working phase C.towards the end of the relationship D.at the start of the relationship 22. The client says, “I want to tell you something but can you promise that you will keep this a secret?” A therapeutic response of the nurse is: A.“Yes,

our interaction is confidential provided the information you tell me is not detrimental to your safety.” B.“Of course yes, this is just between you and me. Promise!” C.“Yes, it is my principle to uphold my client’s rights.” D.“Yes, you have the right to invoke confidentiality of our interaction.” 23. When the nurse respects the client’s self-disclosure, this is a gauge for the nurse’s: A.trustworthiness









be: A.“The

best time to talk is during the nurse-client interaction interaction time. I am committed to have this time available for us while you are at the hospital and ends after your discharge.” B.“Yes, If you keep it confidential, this is part of privileged communication.” C.“I am committed for your care.” D.“I am sorry, though I would want to, it is against hospital policy.” 25. The client has not been visited by relatives for months. He gives a telephone number and requests the nurse to call. An appropriate action of the nurse would be: A.Inform

the attending physician about the request of the client. B.Assist the client to bring his concern to the attention of the social worker. C.“Here (gives her mobile phone). You may call this number now”. D.Ask the client what is the purpose of contacting his relatives. Situation 6 – Camila, 25 years old, was reported to be gradually withdrawing withdrawing and isolating herself from friends and family members. She became neglectful of her personal hygiene. She was observed to be talking irrelevantly and incoherently. She was diagnosed as schizophrenia disorder. 26. The past history of Camila would most probably reveal that her premorbid personality is: A.schizoid B.extrovert C.ambivert D.cycloid

27. Camila refuses to relate with to others because she: A.is

irritable superior of others C.anticipates rejection D.is depressed B.feels

28. Which of the following disturbances in interpersonal relationships relationships MOST often predispose to the development of schizophrenia? A.Lack

of participation in peer groups B.Faulty family atmosphere and interaction C.Extreme rebellion towards authority figures D.Solo parenting 29. Camila’s indifference toward the environment is a compensatory behavior to overcome:









30. Schizophrenia is a/an: A.anxiety

disorder B.neurosis C.psychosis D.personality disorder Situation 7 – Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder than usual. She would prefer to be alone and take her meals by herself, minimize receiving visitors at home and no longer bothers to answer telephone calls because because of deterioration of hearing. She was brought by her daughter to the Geriatric clinic for assessment and treatment. 31. The nurse counsels Salome’s daughter that Salome’s becoming very loud and tendency to become aggressive is a/an: A.beginning

indifference indifference to the world around her to maintain authoritative role overcompensation tion for hearing loss C.overcompensa D.behavior indicative of unresolved repressed repressed conflict of the past B.attempt

32. A nursing diagnosis for Salome is: A.sensory deprivation B.social

isolation C.cognitive impairment impairment D.ego despair 33. The nurse will assist Salome and her daughter to plan a goal which is for Salome to: A.adjust

to the loss of sensory and perceptual function in conversation and other social situations C.accept the steady loss of hearing that occurs with aging D.increase her self-esteem to maintain her authoritative role B.participate

34. The daughter understood, the following ways to assist Salome meet her needs and avoiding which of the following: A.Using

short simple sentences B.Speaking distinctly and slowly C.Speaking at eye level and having the client’s attention D.Allowing her to take her meals alone 35. Salome was fitted a hearing aid. She understood the proper use and wear of this device when she says that the battery should be functional, the device is turned on and adjusted to a:











worried and feeling as if something dreadful is going to happen. She fears being alone in places and situations where she thinks that no one might come to rescue her just in case something happens to her. her. 36. Cecilia is demonstrating: A.acrophobia B.claustrophobia C.agoraphobia D.xenophobia

37. Cecilia’s problem is that she always sees and thinks negative things hence she is always fearful. Phobia is a symptom described as: A.organic B.psychosomatic C.psychotic D.neurotic

38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her: A.communication B.cognition C.observation D.perception

39. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions. reactions. Which of the following should the nurse implement? A.assist

her in recognizing irrational beliefs and thoughts B.help find meaning in her behavior C.provide positive reinforcement for acceptable behavior D.Administer anxiolytic drug 40. After discharge, which of these behaviors indicate a positive result of being able to overcome her phobia? A.She

reads a book in the public library She drives alone along the long expressway.









42. The nurse must see to it that the written consent of mentally ill patients must be taken from: A.Doctor B.Social

worker C.Parents or legal guardian D.Law enforcement authorities 43. In an extreme situation and when no other resident or intern is available, should a nurse receive telephone orders, the order has to be correctly correctly written and signed by the physician within: A.24

hours hours C.48 hours D.12 hours B.36

44. The following are SOAP (Subjective – Objective – Analysis – Plan) statements on a problem: Anxiety about diagnosis. What is the objective data? A.Relate Relate

patient’s feelings to physician; initiate and encourage her to verbalize her fears; give emotional support by spending more time with patient; continue to make necessary explanations regarding diagnostic tests. B.Has periods of crying; frequently verbalizes fear of what diagnostic tests will reveal C.Anxiety due to unknown D.“I’m so worried about what else they’ll find wrong with me.” 45. Nursing care plans provide very meaningful data for the patient profile and initial plan because the focus is on the: t he: A.Summary of chronological notations made by individual health team members B.Identification of patient’s responses to medical diagnoses and treatment C.Patient’s Patient’s responses to health and illness as a total person in interaction with the environment D.Step by step procedures for the management of common problems









C.learning D.placebo

as a form of treatment

48. To help Marie who bed wets at night practice acceptable and appropriate behavior, it is important for the parents to be co nsistent with the following approaches EXCEPT: EXCEPT: A.discipline

with a kind attitude B.matter of fact in handling the behavior C.sympathize for the child D.be loving yet firm 49. A therapeutic verbal approach that communicates strong disapproval is: A.“You

are supposed to get up and go in the toilet when you feel you have to go and did not. The next time you bed wet, I’ll tell your friends and hang your sheets out the window for them to see.” B.“You are supposed to get up and go in the toilet when you feel you have to go and did not. I expect you to from now on without fail.” C.“If you bed wet, you will change your bed linen and wash the sheets.” D.“If you don’t make an effort to control your bedwetting, I’d be upset and disappointed.” 50. During your conference, the parent inquires inquires how to motivate Marie to be dry in the morning. Your response which is an immediate intervention would be: A.Give

a star each time she wakes up dry and every set of five stars, give a

prize. Tokens make her materialistic at an early age. Give praise and hugs B. Tokens occasionally. C.What does your child want that you can give every time he/she wakes up dry in the morning? D.Promise him/her a long awaited vacation after school is over. Situation 11 – The nurse is often met with the following situations when clients become angry and hostile. 51. To maintain a therapeutic eye contact and body posture while interacting with angry and aggressive individual, the nurse should:









A.“When

asked about his relationship with his father, client became anxious.” B.“When asked about his relationship with his father, client clenched his jaw/teeth, made a fist and turned away from the nurse.” C.“When asked about his relationship with his father, client was resistant to respond” D.“When asked about his relationship with his father, his anger was suppressed” 54. To encourage thought, which of the following approaches is NOT therapeutic? A.“Why

do you feel angry?” B.“When do you usually feel angry?” C.“How do you usually express anger?” D.What situations provoke you to be angry?” 55. A patient grabs and about to throw it. The nurse best responds saying. A.“Stop!

Put that chair down.” b e silly.” B.“Don’t be C.“Stop! The security will be here in a minute.” D.“Calm down.” Situation 12 – Nursing care for the elderly 56. In planning care for a patient with Parkinson’s Parkinson’s disease, which of these nursing diagnoses should have priority? A.potential

for injury B.altered altered nutritional state C.ineffective coping D.altered mood state 57. A healthy adaptation to aging is primarily related related to an individual’s… A.Number

of accomplishments B.Ability to avoid interpersonal conflict C.Physical health throughout life Personality lity development in his life span D.Persona









60. An elderly who has lots of regrets, regrets, unhappy and miserable is experiencing: experiencing: A.Crisis B.Despair C.Loss D.Ambivalence

Situation 13 – Graciela 1½ year old is admitted to the hospital from the emergency room with a fracture of the left femur due to a fall down a flight of stairs. Graciela is placed on Bryant’s traction. 61. While on Bryant’s traction, which of these observations of Graciela and her traction apparatus would indicate a decrease in the effectiveness of her traction? A.Graciela’s

buttocks are resting on the bed. B. The traction weights are hanging 10 inches above the floor. C.Graciela’s legs are suspended at a 90 degree angle to her trunk. D. The The traction ropes move freely through the pulley. 62. The nurse notes that the fall might also cause a possible head injury. She will be observed for signs of increased intracranial pressure which include: A.Narrowing

of the pulse pressure

B.Vomiting C.Periorbital

edema D.A positive Kernig’s sign 63. Graciela is assessed to have no head injury. The Bryant’s traction is removed. A plaster of Paris hip spica is applied. Which of these finding is a concern of immediate attention that must be reported to the physician immediately? A.Graciela

is scratching the cast over her abdomen. B. The The toes of Graciela’s Graciela’s left foot blanch when the nurse applies pressure on them. Graciela’s cast is still damp. C.Graciela’s The nurse is unable to insert a finger under the edge of Graciela’s cast on D. The her left foot.











D.Autonomy

Situation 14 – Jolina is an 18 year old beginning college student. Her mother observed that she is having problems relating relating with her friends. She is undecided about her future. She has lost insight, lost interest interest in anything and complained of constant tiredness. 66. Jolina is put on antidepressant antidepressant drugs. These drugs act on the brain chemistry, therefore therefore they would be useful in which type of depression? A.exogenous

depression B.neurotic depression C.endogenous depress depression ion D.psychotic depression depression 67. This is a tricyclic antidepressant antidepressant drug: A.Venlafaxine

(Effexor) B.Flouxetine (Prozac) C.Sertraline (Zoloft) D.Imipramine (Tofranil) 68. After one week of antidepressant medication, Jolina still manifests depression. The nurse evaluates this as: A.Unusual

because action of antidepressant antidepressant drug is immediate. B.Unexpected because therapeutic effectiveness takes within a few days. C.Expected because therapeutic effectiveness takes 2-4 weeks.









D.Discusses

personal concerns with group members

72. Which of the following questions illustrates the group role of encourager? A.What

were you saying? B.Who wants to respond next? next ? C.Where do you go from here? D.Why haven’t we heard from you? 73. The goal of remotivation therapy is to facilitate: A.Insight B.Productivity C.Socialization D.Intimacy

74. The treatment of the family as a unit is based on the belief that the family: A.is

a social system and all the members are interrelated components of that system B.as a unit of society needs the opportunity to change its own destiny C.who has therapy together will tend to remain together D.is “contaminated” by the presence of deviant member and all members need treatment. 75. The working phase in a therapy group is usually characterized characterized by which of the following?









to read patterns, cut out fabric and use a sewing machine to make simple outfits that will help her earn in the future. What type of therapy is this? A.Recreational

therapy

B.Art

therapy therapy D.Educational therapy C.Vocational

79. In a residential residential treatment home for adolescent girls, the clients were becoming increasingly tense and upset because of shortening of their recreation time. To de-escalate possible possible anger and aggression aggression among the clients it is BEST to play: A.religious

music B.relaxation music C.dance music D.rock music 80. The parents of special children who are behaviorally disturbed need mental health education. Which of these topics would the school nurse consider as priority for their parent’s class? A.Drug

education abuse C.Effective parenting D.Sex education B.Child

Situation 17 – Nurses in all practice areas are likely to come in contact with clients suffering from acute or chronic drug abuse.









A.teach

skills to recognize and respond to health threatening threatening situations B.increase the client’s awareness of unsatisfactory protective behaviors C.implement behavior modification D.promote homeostasis and minimize the client’s withdrawal symptoms 85. Commonly known as “shabu” is: A.Cannabis

Sativa acid diethylamide C.Methylenedioxy Methylenedioxy methamphetamine D.Methamphetamine hydrochlor hydrochloride ide B.Lysergic

Situation 18 – It is common that clients ask the nurse personal questions. 86. Anticipation of personal questions is given adequate attention during which phase of the nurse patient relationship? A.Orientation phase B.Working

phase C.Pre-interaction phase D. Termination Termination phase 87. If the client asks for the nurse’s telephone number, which of these responses is NOT appropriate? appropriate? A. “It is confidential I just don’t give it to anyone.” B. “What would you do with my number if I give it to you?” C. “If I say No to your request, what are your thoughts about it?”









Situation 19 – Ricky is a 12 year old boy with Down’s syndrome. He stands 5’ ½” and weighs 100 lbs. he is slim and walks sluggishly with a limp. He wears a neck brace as a support for his neck. X-ray of cervical spine showed “subluxation of C1 in relation to C2 with cord compression”. compression”. He attends a school for a special education. 91. The classroom teacher consults the school nurse for guidance on how to take care of Ricky while inside of the classroom. The nurse considers as priority, Ricky’s: A.Physiological

needs B.Need for self esteem C.Needs for safety and security D.Needs for belonging 92. Ricky’s mother visited the school nurse. She asked, “What should I do when Ricky fondles his genitalia?” An appropriate appropriate response of the nurse is for the mother to: A.Divert

Ricky’s attention and engage him in satisfying activities Ricky that it is wrong to keep fondling his genitalia C.Ignore Ricky’s behavior because he will outgrow it later D.Engage him in computer TV games that engage his hands B. Tell Tell

93. The nurse had one on one health education sessions with Ricky’s mother. The mother understood that for her son to learn to cope and be independent, she should constantly provide activities for Ricky to be able to: A.socialize

with people











C.church D.family

97. A drug dependent utilizes this defense mechanism and enables him to forget shame and pain. A.repression B.rationalization C.projection D.sublimation

98. This drug produces mirthfulness, fantasies, fantasies, flight of ideas, loss of train of thought, distortion of size, distance and time, and “bloodshot eyes” due to dilated pupils. A.Opiates B.LSD C.Marijuana

Nursing Practice V

Recommend Documents