b. Terination of the urethra is in the /entral surface of the 'enis c. efect of the urethra on the dorsal surface of the 'enile shaft d. Penis has 2 urethral o'enings located dorsall( and /entrall( 11@. Surger( is the treatent of choice for L. The nurse understands taht the best tie for surger( is before the child= a. Is )eaned fro dia'ers c. oes to school b. Is toilet trained d. 4alks 11C. Dinda 're'ares a nursing care 'lan for L. Posto'erati/el(< )hich of the follo)ing is a PRI"RIT: nursing diagnosis> a. Risk of infection c. Potential alnutrition b. %lternation of fecal eliination d. %ltered bod( iage 11E. Bill(< 1 (ear old< )as aditted to the unit fro the reco/er( roo 'ost cheilo'last(. Dinda )ould 'lace Bill( in )hich of the follo)ing 'ositions> a. Dateral b. Fo)ler;s c. Su'ine d. Prone 11. 11G. 120. 121. 4hen bill( full( reco/ered fro anestnesia < the doctor ordered clear liquids as tolerated. 4hich of the follo)ing is the %PPR"PRI%T# action of the nurse3 a. %llo) infant to si' fro a cu' b. se s'oon and feed slo)l( and gentl( c. %dinister liquids through a edicine dro''er d. Bottle feed the infant 122. 158* Situatio 19- Nu$(% Ca$/ia i( 4$%4a$i" 'i!%, a 59 %a$ o'. %0' &o$ (u$"%$ &o$ a $%4ai$ a /u'ti4'% t$au/a &$o/ a #a$ a##i.%t 'i!% i( i (%3%$% 4ai' a. #o/&o$t%. 2 t)i( 0i&% a. (i"i&i#at ot)%$(* 12. There e-ist a hierarch( )ho should sign the consent to be legall( /alid if the client is not co'etent. Rank the follo)ing ne-t of kin )ho shall sign the consent for likes surger( 12@. 1. rand'arents fro 'aternal or aternal side 12C. 2. %dult co'etent children 12E. *. Brother or sister 12. . Degitiate s'ouse 12G. @. uardian )hether a''ointed b( court or not a. <@<*<2 and 1 c. <2<1<* and @ b. <*<1<2 and @ d. @<*<<2 and 1 1*0. Degall(< nurse !arina shall assue )hich role during the signing of the consent> a. %d/ocate c. Inter'reter b. 4itness d. !ounsellor 1*1. Dike under)ent e-'lorator( la'aroto( for ulti'le organ in5uries in his abdoen. 4hich doctrine is a''lied )hen the surgeon is held liable )hen there is an incorrect surgical count> a. Res I'sa Doquitor c. octrine of icarious Diabilit( b. !a'tain of the Shi' d. octrine of Inde'endent !ontractor 1*2. uring the surger(< the client )as 'rofusel( bleeding that 'ro'ted the surgeon to /erball( order 6Transfuse all a/ailable blood7. 4hich of the follo)ing o'tions )ould the nurse take so that she )ill not be liable if blood transfusion co'lications occur> a. ocuent as ordered and ha/e the surgeon sign as soon as feasible b. Transfuse the blood )ith the anaesthesiologist c. Send the blood for 'ro'er cross atching and transfuse iediatel( after d. Dea/e the anaesthesiologist to follo) the order 1**. The surgeon is such in hurr( to 6close7because of the deterioting condition of the client. The 'erio'erati/e nurses cannot account for an o'erating s'onge +"S,. 4hich is the &"ST a''ro'riate action of the scrub nurse at this 'oint> a. Aands the suture for closing and tell the surgeon that one "S cannot be accounted for b. The scrub nurse asks the circulating nurse to recheck the s'onges one or ore tie c. The scrub nurse infors the surgeon that one "S cannot be accounted for d. "bligingl( < the scrub nurse hands the suture to close and continue to locate the issing "S 1*. 18* Situatio 1=- Nu$(% A'4)a i( #a$i" &o$ E.0i < %a$ o'. 8 $. .a 4o(t 2o0%' $%(%#tio, NPO 0it) D LR IV 1<<
enta(cin 0 g I 'igg( back in @0 l @ )ater o/er *0 inutes Ranitidine @0 g I in @0 l @ )ater 'iggl( tack in *0 inutes Packed red blood cells +RB!, 2@ol to run for * hours 1*. Ao) an( illieters should Nurse %l'ha docuent as the total intake for the hour shift> a. 1000l c. 1*@0l b. *@0l d. 1*00l 1*G. 4hile reading #d)ins chart< (ou read the laborator( findings as Seru 'otassiu 2.2h #q3D Sodiu 12G #q3D !alciu E.@ g3D 10. The nurse )ould antici'ate 3 're'are )hich of the follo)ing I solutions to be 'rescribed> a. Sodiu chloride 0.@H b. e-trose @H in )ater c. e-trose @H in Dactated Ringers solution d. Noosol 11. 12. 1*. 1. 1@. 1C. 1E. 1. 1G. Nurse %l'ha continued to onitor #d)in )ho has an ongoing I and Packed red blood cells +PRB!, transfusion. The client co'lains of headache< backache and the te'erature began to s'ike. Rank the action of the nurse according to PRI"RIT:= 1@0. 1. Refer to the attending 'h(sician 1@1. 2. %ssess the client 1@2. *. !lose the roller cla' of the PRB! 1@*. . Mee' the /ein o'en )ith NSS @. ocuent obser/ation and inter/ention a. 2<*<<1 and @ b. *<2<1< and @ c. *<<2<1 and @ d. 1<2<*< and @ 1@. Nurse %l'ha identifies risk for )ound co'lications. in case of )ound e/isceration < the I&&#I%T# action of the nurse is to a. Instruct the client to sta( quiet in bed as (ou call for hel' b. %''l( clean abdoinal binder and 'lace the 'illo) on to' of the )ound c. !o/er the )ound )ith sterile gau?e )et )ith sterile NSS d. !all for the surgeon stat 1@@. #d)in has been on NP" since he )as o'erated and asks the nurse )hen he can ha/e food. Nurse %l'ha ost %PPR"PRI%T# res'onse is a. The dietetian )ill ake their rounds in a )hile to assess (ou and other 'osto'erati/e clients b. The surgeon )ill ake their rounds to assess (our readiness to take in (our 'referred diet c. !lear sou' )ill be ser/es as soon as (ou ha/e bo)el sounds d. :ou can ha/e si's of )ater for the ean tie 1@C. 1>* Situatio 5<- Su(a, < %a$( o'. a. 0%i")t( 19<'2(, u.%$0%t #'o'%#(t%#to/ &o$ #)o'%'it)%a(i( a. "a'' (to%(* 19* 1@G. Susan co'lained of incisional )ound 'ain as she reco/ered fro anesthesia . she has n order of eerol E@ g e/er( four hours round the clock for 'ain. The nurses !"RR#!T inter/ention is= a. In5ect eerol E@ g as ordered for 'ain b. Instruct the client to a''l( 'ressure o/er the o'erati/e site c. #ncourage Susan to do dee' breathing 1C0. Because of the fear of )ound ga'ing and 'ain. Susan )as obser/ed su''ressing her cough refle-. The &"ST a''ro'riate nursing inter/ention to inii?e 'ain in e/er( coughing e'isode is to= a. S'lint the o'erati/e site )ith )ide 'laster b. %d/ise the client to turn to sides e/er( *0 inutes c. i/e sedation round the clock to inii?e coughing and 'ain d. Instruct the client to s'lint the incision )ound )ith 'illo) 1C1. 4hich 's(chological nursing inter/ention can (ou offer to inii?e 'osto'erati/e 'ain> a. Sta( )ith the client and offer to cob her hair and 'ut soe ake u' in front of the irror; 34
b. %llo) client to con/erse )ith other clients regarding their e-'erience in co'ing 'ost o'erati/e 'ain c. Instruct client and significant others to a/oid talking about 'ain )ithin the hearing distance of the client d. Restrict /isitors that can aggra/ate noise and destruction of rest 1C2. "ne cause of 'ost o'erati/e 'ain is incision )ound containation. Aence< nurses and other ebers of the health tea are e-'ected to do chea' and effecti/e infection 're/ention easures such as a. No touch technique b. !hange glo/es in bet)een 'atient c. Aand )ashing bet)een client d. se alcohol s)ab if hand )ashing is not 'erissible 1C*. Post o'erati/e 'ain kee's surgical clients in bd. &ost surgical clients like Susan are encouraged to abulate= a. %s soon as indicated b. 4ithin C to hours surger( c. Bet)een 10 to 12 hours after surger( d. "n the second 'osto'erati/e da( 1C. 1C@. 1CC. 1CE. 1C.
1+=* A1 PASSERS TRAINING, RESEARCH, REVIEW AND DEVELOPMENT COMPANY 1><* PRE-;OARD EXAMINATION 1>1* 1E2. NURSING PRACTICE IV-!are of !lients )ith Ph(siologic and Ps(chosocial %lteration 1E*. 1E. 1>* GENERAL INSTRUCTIONS: 1EC. 1. This test booklet contains 100 test questions. 1EE. 2. Read INSTR!TI"NS T" #$%&IN##S 'rinted on (our ans)er sheet. 1E. *. Shade onl( one +1, bo- for each question on (our ans)er sheets. T)o or ore bo-es shaded )ill in/alidate (our ans)er. 1EG. . %"I #R%SR#S. 10. 191* INSTRUCTIONS: 12. 1. etach one +1, ans)er sheet fro the botto of (our #-ainee I3%ns)er Sheet Set. 1*. 2. 4rite the sub5ect title 6Nursing Practice I7 on the bo- 'ro/ided. 1. *. Shade Set Bo- 6%7 on (our ans)er sheet if (our test booklet is Set %8 Set Bo- 6B7 if (our test booklet is Set B. 1@. 999999999999999999999999999999999999999999999999999999999999999999999999999999999 999999999
1C. 19>* Situatio 1-ua#)ito, $(* o'., )a( i.io4at)i# %4)$iti# (.$o/%* H% )a( "%%$a'i@%. %.%/a 0it) a 4u&& &a#%, .i(t%.%. a2.o/% a. %.%/atou( '%"(* ;'oo. 4$%((u$% i( o$/a'* ;'oo. t%(t( ()o0 )4oa'2u/i%/ia* 1. The nurse is a)are that generali?ed edea is due to h('oalbuineia )hich lead 'riaril( to )hich of the follo)ing> a. Increased secretion of antidiuretic horone b. Reduced intra/ascular /olue c. ecreased 'lasa osotic 'ressure d. Stiulation of the rennin anglotensin s(ste 2. The nurse closel( onitors the urine out'ut of the 'atient. 4hich of the follo)ing characteristics of a urine sa'le )ill the nurse e-'ect> a. Fruit( odor c. rine is froth( b. Increase aount d. Blood in urine *. The attending 'h(sician of Luanchito 'rescribed renal bio's(. 4hen the nurse 'lans for the nursing care of Luanchito after the bio's(< )hich of the follo)ing )ill be a PRI"RIT: inter/ention to 're/ent bleeding> a. "bser/e for abdoinal 'ain and c. Place on co'lete bed rest tenderness d. !losel( )atch urine out'ut b. &onitor /ital signs . !ortecostiroid thera'( )as 'rescribed. 4hich of the follo)ing is the &"ST rele/ant nursing inter/ention to address co'lications of the thera'(> 35
a. 4eigh dail( to onitor fluid balance c. &aintain on a salt restricted diet b. !losel( onitor for changes in bod( d. "ffer sall frequent eals te'erature @. 4hen the nurse 're'ares her health instruction for the other of Luanchito< )hich of the follo)ing side effects of the drug )ill the nurse include in her 'lan> C. 1. iuresis E. 2. Airsutis . *. %bdoinal distention G. . Doss of a''etite 10. @. Rounding of the face a. *<<@ c. 1<2<@ b. 2<*<@ d. 1<2<* e. &* Situatio 5- a( ED u$(% ou ()ou'. a'0a( 2% $%a. to a !i. o& %/%$"%# (ituatio 11. Peter < a *0 (earold factor( )orker< is brought to the eergenc( de'artent )ith ulti'le lacerations and tissue a/ulsion of the right hand after catching the hand in a 'roduce con/e(or belt. 4hen asked about the tetanus iuni?ation < he sa(s< 6I;/e ne/er had an( /accinations7< :ou )ill antici'ate adinistration of= a. Tetanus to-oid b. Iunoglobulin and tetanu-di'htheria to-oid c. Iunoglobulin d. Iunoglobulin< tetanus di'htheria to-oid< and 'ertussis /accine 12. Paul is brought to the # b( his co )orker after suffering fro a'utation of a left iddle finger. %s his nurse )hich of the follo)ing should (ou %"I to do> a. Placing the )ra''ed finger in a 'lastic bag b. !leansing the stu' area )ith noral saline c. 4ra''ing the a'utated finger in sterile gau?e oistened )ith saline d. Placing the a'utated finger directl( on ice 1*. Losh< a E (ear old child is brought to the # b( his other co'laining of ar 'ain after falling off a s)ing at alcohol. %fter assessing Losh;s 'ain on a scale of 110< )hat )ill be (our PRI"RIT: acti/it(> a. %ssue that Losh is too (oung to /erbali?e ho) uch 'ain he is e-'eriencing b. "btain further inforation about his 'ain using age a''ro'riate tool c. i/e Losh a narcotic 'ain edication d. %sk his to )ait in the )aiting roo to find out if Losh gets better )ithout his other 1. uring the 'riar( assessent of Bernie< )ho has sustained ulti'le traua< (ou obser/e taht his right 'edal 'ulses are absent and the leg is s)ollen. :our PRI"RIT: action is to a. Initiate isotonic fluid infusion through t)o large bore I lines b. Finish the air)a(< breathing< circulation < disabilit( sur/e( c. Send blood to the laborator( for a co'lete blood count +!B!, d. %ssess further for a cause of the decreased circulation 1@. %nthon(< 20 (ears old college student < unconscious < is aditted to the # about @ inutes after ingesting a''ro-iatel( *0 dia?e'a +aliu, tablets. The 'h(sician 'rescribes gastric la/age. %s a nurse < (our FIRST action )hen i'leenting the order is to a. Insert large bore nasogastric tube b. Position %nthon( on his side c. %ssist the 'h(sician to intubate %nthon( d. Pre'are a @0 l s(ringe )ith saline e. &* Situatio 8- A'i#ia a %0' )i$%. (ta&& u$(% i( a((i"%. to a 4ati%t .ia"o(%. 0it) Dia2%ti# J%toa#i.o(i( 0it) U$o(%4(i( i t)% It%(i3% Ca$% Uit "* 1C. Ph(sician 'rescribed that !a'illar( blood glucose +!B, be onitored e/er( 1 hour. %licia issed to check the 'atient;s ca'illar( blood glucose at 1000A. 4hich of the follo)ing decisions of %licia regarding docuentation of hourl( !B is &"ST a''ro'riate> a. Sign the s'ace of the data to indicate !B reading not done b. State reason for not ha/ing taken the !B reading c. ocuent 'er hos'ital 'rotocol d. Dea/e the s'ace that corres'onds to 1000A blank 1E. %licia )as taught on electronic record kee'ing and becae a)are that the follo)ing are the benefits of electronic record kee'ing #$!#PT= a. Pre/ents ta'ering )ith a 'atients record b. Pass)ord secures accessing the s(ste c. #liinates 'roble of illegible hand)riting d. Increases tie required for docuenting 1. To aintain confidentialit( of 'atients record. %licia recoended )hich of the follo)ing 'ractices needs i'ro/eent> 36
a. Screen /isible to 'assersb( c. %ccess code are not shared b( the b. !o'uter log off autoaticall( )hen nurses not in use d. Printouts are retrie/ed iediatel( 1G. %licia looked for a anual )hich could facilitate her orientation regarding docuentation the anual is not a/ailable. This obser/ation reflects anageent inadequac( in )hich of the follo)ing> a. !ontrolling b. Planning c. irecting d. "rgani?ing 20. Standards of docuentation require that a s(ste is in 'lace regarding correcti/e actions related to errors in charting. 4hich of the follo)ing obser/ations in the 'atients record indicates taht the standard is i'leentation> a. 'dated inforation )ith notation arked as late entr( b. !orrection of the erroneous entr( )ritten abo/e c. !orrected inforation )ritten in the ne-t a/ailable s'ace d. % straight line dra)n across a 'hrase in the nurses notes< dated 'h(sicians initialled 21. 22. 2*. 2. 2@. 2C. 2E. 2. 5=* Situatio - Dio/%.%(, a + %a$ o'. &a$/%$, 0a( a./itt%. i t)% E/%$"%# D%4a$t/%t EDB 2%#au(% o& )%/at%/%(i( a##o/4ai%. 2 )%/ato#)%@ia* Dio/%.%( i( a a'#o)o'i# a. i( u.%$ t$%at/%t &o$ #i$$)o(i( o& t)% 'i3%$* Hi( a2.o/% i( %'a$"%. a. )i( 'o0%$ %6t$%/iti%( a$% %.%/atou(* A./itti" 4)(i#ia( iitia' .ia"o(i( i( $u4tu$%. %(o4)a"%a' 3a$i#%(* *0. %ssessent re/eals signs and s('tos of earl( co'ensator( heorrhagic shock. If (ou )ere the nurse )ho aditted. ioedes< )hich of the follo)ing )ill (ou consider as the co'ensator( echanis res'onsible for the increased heart rate and res'irator( rate> a. Stiulation of the s('athetic ner/ous s(ste b. Increase in si?e of the /ascular bed to 'eri'heral /asodilation c. Rennin angiotensin res'onse d. Release of adrenocorticotro'ic horone fro the h('othalaus *1. To restore heod(naic stabilit( on the client< )hich of the follo)ing )ill the nurse e-'ect to be done FIRST> a. Insertion of central arterial and /enous catheters b. #ndosco'ic ligation of ru'ture /arices c. Blood transfusion of blood re'laceent d. %dinistration of /asoacti/e and inotro'ic drugs *2. Aeod(naics easureent re/ealed stable /ital signs and increased cardiac out'ut. The 'h(sician ordered treatent of the eso'hageal /arices. 4hich of the follo)ing 'rocedures )ill the nurse e-'ect to be done> a. ''er endosco'( c. #-'lorator( la'aroto( b. Intrahe'atic 'ortal s(steic shunt d. !oagulation thera'( **. In the intensi/e care unit nursing orders required all nurses to assess regularl( for earl( anifestations of 'ortal s(steic ence'halo'ath(. 4hich of the follo)ing )ill the nurse note during her obser/ation> a. "ccurrence of estere-is b. e/elo'ent of disorientation and incoherence c. Signs and s('tos of increased intracranial 'ressure d. Presence of 'a'illedea *. Seru aonia le/el of the client reained to be ele/ated. The follo)ing a( be considered b( the nurse to be true regarding this obser/ation e-ce't> a. %onia is fored as 'roteins and aino acids are broken do)n b( intestinal bacteria b. %onia accuulates in the blood due to inabilit( of the kidne( to e-crete aonia c. ue to bleeding< blood in the intestinal tract is digested as 'rotein< thereb( increasing seru aonia d. Since li/er function is destro(ed < aonia can no longer to be con/erted to less to-ic for. *@. 8+* Situatio - T)% .%#'ii" '%3%' o& 4ati%t (ati(&a#tio $%'at%. to u$(i" (%$3i#% 4%$ (u$3% $%(u't( a( 0%'' a( i#$%a(%. i#i.%#%( o& )o(4ita' a#?ui$%. i&%#tio .u$i" t)% 4a(t + /ot)( #au(%. t)% u$(i" (%$3i#% .i3i(io to 4u() t)% u$(i" uit( to %64'o$% ?ua'it i/4$o3%/%t 4$o%#t(* *E. The Intensi/e !are nit +I!, Jualit( I'ro/eent tea decided to gather data to deterine 'robable causes of central line infection aong the I! 'atients< if (ou )ere the eber of the qualit( 37
i'ro/eent tea< )hich of the follo)ing data )ill (ou consider as &"ST a''ro'riate to (ield the ost 'robable cause of central line infection> a. Nurses notes on hourl( assessent of the sites of central line b. Perfored central line care inter/entions as obser/ed c. ail( e/er( shift re'ort of central line care easures fro bedside nurses d. Incidence of central line infection as re'orted b( infection control nurse *. The highest incidence of fall aong the hos'itali?ed 'atient is in the edical unit. The edical units qualit( i'ro/eent tea has identified the 'robable causes of the incidences of fall aong their hos'itali?ed 'atients. 4ith the data anal(?ed and findings organi?ed . )hich of the follo)ing should the qualit( i'ro/eent tea do first> a. I'leent 're/ention easures identified to be effecti/e b. Pro'ose a list of nursing actions intended to identif( fall risks and 're/enti/e easures c. o a 'ilot stud( of the fall 're/ention easures to a sall grou' of 'atients d. Brainstor for a 'lan for an a''ro'riate action for change *G. %nother grou' of qualit( i'ro/eent tea in the I! conducted a 'ro5ect of /entilator associated 'neuonia incidences aong I! 'atients. If (ou are a eber of this tea. 4hich of the follo)ing easures )ill (ou consider as the &"ST a''ro'riate to be i'leented in collaboration )ith the res'irator( thera'ist> a. Perfor regularl( assessent of the clients readiness to be e-tubated b. !onsider orotracheal as a 'referred route of endotrachealintubation c. &aintain head ele/ation at *0@ degress d. Suction endotracheal tube as 'rescribed in the anual of 'rocedures 0. 1. 2. *. Noise le/el in the I! has al)a(s been a co'laint in the 'atient satisfaction sur/e(. 4hich of the follo)ing tools can be recoended to the qualit( i'ro/eent tea as ost a''ro'riate to deterine le/el of noise in the I!> a. Juestionnaire )ith clients and 'atients as res'ondents b. "bser/ation checklist c. &easureent de/ice d. Inter/ie) schedule for )ith nurses < clients and relati/es as inter/ie)ees . uring a grou' discussion < 'robable factors res'onsible for urinar( tract infection incidences aong hos'itali?ed clients in the edical unit )ere being e-'lored < )hich of the follo)ing )ill (ou consider as the grou' of data )ould D#%ST hel'ful> @. 1. iaeter and length of Fole( catheter C. 2. Dength of tie Fole( catheter has been ke't ind)elling E. *. %ge and se- of client . . ail( 'h(sical acti/ities of the client G. @. Rele/ant data regarding need for continuing ind)elling catheter a. 1<2< c. 1<2<* b. *<<@ d. 2<*< e. &* Situatio 9- Ji!o, 9 %a$( o'., )a( t0o #)%(t tu2%( #o%#t%. to a .i(4o(a2'% 0at%$ (%'%. .$aia"% ((t%/ 2%#au(% o& #)%(t iu$i%( &$o/ a 3%)i#u'a$ a##i.%t* @0. The nurse obser/ed that the drainage fro the chest tubes ha/e not increased fro the 're/ios shift re'ort. 4hich of the follo)ing is the PRI"RIT: action of the nurse> a. !heck the chest tube for kinks c. ocuent obser/ation in the chart b. %ssess for breath sounds d. !hange 'osition of the 'atient @1. Frequent assessent of the closed drainage s(ste is i'ortant to ensure a''ro'riate functioning. The nurse obser/es that )ater le/el fluctuates )ith res'irator( effort. The nurse considers this as a sign of a. Tra''ed air c. Patent tubes b. %n inefficient s(ste d. %ir leaks @2. The nurse )orks )ith a nursing aide. 4hich of the follo)ing is a !"RR#!T action of the nurse> The nurse directed the nursing aide to= a. %l)a(s check that cla' is a/ailable at the bedside b. "bser/e regularl( the aount and color of drainage fro chest tubes c. Re'ort signs of 'atients discoforts at the site of the chest tubes d. Turn the 'atient regularl( and aintain connections of the tubes @*. 4hile the nurse )as turning the 'atient during bed bath. "ne of the chest tubes )as 'ulled out fro its site. 4hich of the follo)ing )ill the nurse do FIRST> a. Reinsert the chest tube b. isconnect chest tube fro drainage s(ste c. !o/er )ound site occlusi/el( d. !la' the chest tube 38
@. To deterine if chest tubes are in 'lace and 'neuothora- is corrected. 4hich of the follo)ing )ill the nurse e-'ect the 'h(sician to order> a. Tidal /olue easureent c. !hest radiogra'h b. %rterial blood gas anal(sis d. Thoracentesis @@. If (ou are a eber of a research tea< )hich of the follo)ing )ill (ou consider as the research stud( inde'endent /ariable )hen (ou forulate the research 'roble> a. Incidence of infection b. Relationshi' of endotracheal suctioning and incidence of infection c. e'endence of clients on echanical /entilation d. Frequenc( of endotracheal suctioning @C. ata regarding the stud( de'endent /ariable )ill be collected b( the research tea through )hich of the follo)ing> a. Self re'ort technique c. Pro5ecti/e techniques b. In /itro easures d. %/ailable data in the 'atient;s chart @E. The research tea is full( a)are that easureent of /ariables is a /er( i'ortant consideration in obtaining qualit( data in the stud(. 4hich of the follo)ing stateents )ill (ou acce't as TR#> a. Reliabilit( qualit( of an instruent is inde'endent of its /alidit( b. %n instruent can be /alid )ithout being reliable c. % easuring de/ice )hich is unreliable can be /alid d. Aigh reliabilit( of an instruent 'ro/ides no e/idence of its /alidit( @. Taking into consideration of the content of the )ritten infored consent. 4hich of the follo)ing reflects the research tea;s recognition of the 'artici'ant;s right to 'ri/ac(> a. Right to )ithdra) and )ithhold c. oluntar( consent inforation d. Potential benefits and risks b. !onfidentialit( 'ledge
@G. C0. C1. The research tea decided to conduct the stud( for * onths. tili?ing the 'ros'ecti/e a''roach. 4hich of the follo)ing )ill the research a''ro'riatel( do> a. Partici'ants )ill be assigned to the e-'eriental and control grou' and incidence of infection in t)o grou's )ill be co'ared b. uring the 'eriod of * onths< those /entilator assisted 'atients )ho de/elo'ed infection )ill be included in the stud( c. "n the last da( of the * rd onth charts of 'artici'ants be re/ie)ed and data collected regarding frequenc( of endotracheal suction and incidence of infection d. Fro da( one to the last of the * rd onth< data regarding frequenc( of endotracheal suctioning and incidence of infection )ill be collected C2. +8* Situatio 9- A += %a$ o'. &%/a'% 4ati%t 0a( a./itt%. i t)% E/%$"%# D%4a$t/%t ERB 3ia a a/2u'a#% &$o/ a %a$2 $%(tau$at* Pati%t 0a( .$o0( a. 0a( ua2'% to i.%ti& )%$(%'&* ;'oo. 4$%((u$% 0a( 1<=<* Ta#)#a$.ia a. $%(4i$atio ()a''o0 0it) a $at% o& 8</iut%* Co/4aio o& t)% 4ati%t #'ai/%. t)at 0)i'% 'au")i", t)% 4ati%t "ot #)o!%. 0it) a 4i%#% o& 4o$! /%at a. 0a( ua2'% to 2$%at)% &o$ ?uit% (o/% ti/% uti' (o/%.a (u##%((&u'' "ot it out o& )%$ t)$oat* C. Ph(sicians aditting diagnosis is acute res'irator( acidosis. If (ou )ere the # nurse )ho aditted the client. 4hich of the follo)ing )ill (ou e-'ect> a. % noral 'A and a Pa!"2 greater than @ Ag b. % 'A ore than E.*@ and a Pa!"2 lo)er than @ Ag c. % 'A less than E.*@ and a Pa!"2 greater than @ Ag d. % 'A less than E.*@ and a Pa!"2 of @Ag C@. The initial arterial blood gases results of the client re/ealed a noral bicarbonate le/el )hich of the follo)ing stateents )ill the nurse acce'ts as TR# that )ould e-'lain this s'ecific finding> a. Seru bicarbonate )ill reain unchanged onl( the e-cretion rate of acids b. The kidne(s can odif( onl( the e-cretion rate of acids c. The co'ensator( res'onse of the kidne(s occurs onl( o/er hours to da(s d. % change in seru bicarbonate is noted onl( in cases of res'irator( acidosis CC. :ou are understands that the alternation in the ental status of the client is 'riaril( due to the acute effects of )hich of the follo)ing> a. A('er/entilation c. Tach('nea b. A('erca'nia d. A('o-eia CE. Related to te'orar( air)a( obstruction< the aditting nurse identified. 6I'aired gas e-change8 as a 'riorit( nursing diagnosis. 4hich of the follo)ing inter/entions )ill (ou consider to be the &"ST a''ro'riate to deterine if noral gas e-change has been regained> a. %dinister 'rescribed bronchodilator b. &aintain on o-(gen inhalation as ordered c. Place on Fo)ler;s 'osition as tolerated d. &onitor arterial blood gases redra)n e/er( 2 hours 39
C. The client is closel( obser/ed for signs of d(srrh(thia. If (ou )ere the nurse at the bedside< )hich of the follo)ing )a/es in the cardiac onitor )ill (ou consider as the )a/e that re'resents the contraction of the /entricles> a. JT inter/al c. PR inter/al b. JRS co'led. ST segent e. &* Situatio =- Lito, 8 %a$( o'. i( HIV 4o(iti3%* A(i.% &$o/ &ati"u%* Lito )a( o ot)%$ #o/4'ait( CG. The result of the #n?(elinked iunosol/ent %ssa( Test +#DIS%, )as 'ositi/e. The nurse understands that this is attest to deterine the 'resence of a. AI antibod( c. AI antigen antibod( res'onse b. %cti/el( re'licating AI d. Increased ! cell count E0. 4hich of the follo)ing is N"T a 'riaril( tool for %IS 'recention> a. #ducation c. Iuni?ation b. !ounselling d. Beha/ior odification E1. 4hich of the follo)ing is an %PPR"PRI%T# ad/ice of the nurse for Dito> a. o not engage in un'rotecti/e se-ual acti/it( b. Infor all health care 'ersonnel c. Infor all se-ual 'artners of his health status d. o not becoe 'regnant E2. Fro the list of nursing diagnosis 're'ared b( the nurse for Dito. 4hich of the follo)ing is a PRI"RIT: nursing diagnosis> a. Risk for i'aired skin integrit( b. Risk for in5ur( c. Ineffecti/e co'ing d. Ineffecti/e se-ualit( 'attern E*. E. E@. 4hen the nurse interacts )ith the clients< )hich of the follo)ing 'recautionar( easures should she obser/e to 're/ent containation> a. %/oid touching bod( fluids c. &aintain a * feet distance fro the b. 4ear glo/es 'atient d. 4ear ask and go)n e. &* Situatio 1<- L%o )a( 2%% .ia"o(%. 0it) E. Sta"% $%a' Di(%a(%* T)% 4)(i#ia 4$%(#$i2%. .i%ta$ t%a#)i" a. out4ati%t )%/o.ia'(i( t)$%% ti/%( a 0%%! EC. Deon asks the nurse to tell hi the 'ur'ose of the treatent. )hich of the follo)ing is the &"ST a''ro'riate res'onse of the nurse3 a. Aeodial(sis reo/es e-cess fluids and )aste 'roducts and restores electrol(te balance b. Aeodial(sis uses the 'rinci'les of diffusion and ultrafiltration to reo/e electrol(tes c. Blood is 'u'ed through a sei'ereable ca'illar( in a heodial(?er d. Aeodial(sis is one of se/eral renal re'laceent thera'( EE. %n intra/enous fistula has been created. Posto'erati/el(< )hich of the follo)ing )ill the nurse include as a PRI"RIT: nursing inter/ention to 'roote circulation> a. %uscultate for bruit e/er( hours c. "bser/e finger ti's for c(anosis b. #le/ate the affected ar d. Mee' dressing intact E. 4hich of the follo)ing 're dial(sis care is done b( the nurse to be able to deterine effecti/eness of treatent )ith regards to e-cess fluid /olue> a. %ssess integuentar( status c. Aa/e 'atient e't( bladder 'rior to b. %ssess /ascular site treatent d. Record )eight and /ital signs EG. Nutrition thera'( of Deon includes control of 'rotein. ietar( 'rescri'tion states that leon is allo)ed 0. gra of 'rotein 'er kg 'er da(. If Deon )eighs 120lbs< ho) uch is his dail( 'rotein allo)ance> a. @E.G g c. 1.Eg b. *.Cg d. GCg 0. Deon clais he lo/es to eat raisins. The nurse instructs the 'atient to a/oid this food because it is rich in )hich of the follo)ing> a. Sodiu c. &agnesiu b. Potassiu d. Phos'horous e. &* Situatio 11- A$%' , 9 %a$( o'., 4o(t tota' t)$o.%#to/ 0it) /o.i&i%. %#! .i((%#tio .u% to 4a4i''a$ #a$#io/a o& t)% t)$oi. "'a. 0it) '/4) o.% /%ta(ta(i( 0a( a./itt%. &o$ $a.ioa#ti3% io.i% t)%$a4* 1. Prior to adission< the client under)ent a scan )ith a test aount of radioacti/e iodine. If (ou )ere the nurse )ho aditted the client< )hich of the follo)ing )ill (ou consider as the reason for this inter/ention> a. To deterine the e-istence of kno)n distant etastatic tuor b. To easure si?e of reaining th(roid tissue c. To e-'lore the o'erati/e site for baseline data 40
2.
*.
.
@. C. E. . G. G0.
d. To ark the site )here the radioacti/e iodine )ill be adinistered In the nursing care 'lan 're'ared for the client< )hich of the follo)ing nursing inter/entions is D#%ST rele/ant to ensure a safe en/ironent once treatent has started> a. tili?e 'referabl( onl( dis'osable ites for 'atients 'ersonal use b. Pro/ide hand saniti?ers in the corridor outside the clients roo c. is'ose a''ro'riatel( garbage bags arked radioacti/e d. Aa/e all frequentl( handled ites in the roo co/ered )ith absorbent aterial %s the nurse assigned to the client< (ou understand that after radioacti/e iodine has been adinistered< e-cess iodine not absorbed b( the th(roid tissue< )ill lea/e the bod( PRI&%RID: through )hich of the follo)ing> a. S)eat c. Feces b. rine d. Sali/a To ensure effecti/eness of the radioacti/e iodine thera'(< (ou e-'ect the 'h(sician )ill 'rescribe lo) iodine diet during )hich of the follo)ing> a. a( of adinistration of the radioacti/e iodine until da( of discharge b. T)o )eeks before< during and until 2 da(s after the treatent c. The da( before the scan until the first da( after the treatent d. 'on adission in the hos'ital until a )eek after the treatent 4hen 'lanning discharge< )hich of the follo)ing instructions )ill (ou consider for reduction of radioacti/e e-'osure to others> 1. se 'ri/ate toilet facilities and flush 2* ties after use 2. 4ash eating utensils se'aratel( fro others *. rink noral intake of fluids . Bathe dail( and )ash hands frequentl( @. Sta( in isolation at hoe t)o )eeks after the treatent a. %ll e-ce't * c. 2< and @ b. 2<* and @ d. 1<2 and
e. &* "* )* Situatio 15- Mau%', %a$( o'. i( 4o(iti3% &o$ ;a#t%$ia' M%i"iti( G1. Fro the histor( obtained fro the other< )hich of the follo)ing could be the 'ossible ethod b( )hich the infection )as transitted to the 'atient> a. rinking )ater in the counit( )as containated b. !ontact )ith res'irator( secretions of an infected 'erson c. Aand of caregi/er )as containated )ith fecal discharges d. #ating utensils of the child )ere containated G2. The 'h(sician 'rescribed lubar ta'. 4hen the nurse reads the laborator( results< )hich of the follo)ing reflects 'ositi/e results indicati/e of Bacterial eningitis> a. ecreased )hite blood cells< decreased 'roteins< high glucose b. Noral )hite blood cells count < increased 'roteins< high glucose c. Increased )hite blood cells< increased 'roteins< lo) glucose d. Increased )hite blood cells< decreased 'roteins< lo) glucose G*. %ssessent findings re/eal 'ositi/e Brud?inski;s sign. 4hen the nurse fle-ed the !hilds neck for)ard. 4hich of the follo)ing beha/ior indicated a 'ositi/e Brud?inski;s sign> a. Ai' fle-ed and knee e-tended c. Deg e-tended )ith resistance b. Mnee e-tended and ankle fle-ed d. Ai'< knee and ankle fle-ed G. In the nursing care 'lan 're'ared b( the nurse< Pain related to eningeal irritation= is a 'riorit( nursing diagnosis. 4hich of the follo)ing should the nurse a/oid to do to 're/ent 'ain )hen 'ositioning the 'atient> a. #-tend leg c. A('ere-tend the neck b. Fle- the neck for)ard d. Fle- the hi' G@. Ineffecti/e tissue 'erfusion related to increased intracranial 'ressure7 is another nursing diagnosis forulated b( the nurse. 4hich of the follo)ing assessent data s'ecific to e(e changes )ould t he nurse inter'ret as noral intracranial 'ressure> a. Positi/e sunset e(e signs c. Positi/e n(stagus b. Positi/e strabisus d. Positi/e dolls e(e reflee. &* Situatio 18- You a$% a((i"%. i t)% N%4)$o'o" Wa$.* O% o& ou$ 4ati%t( i( Ca$'o( 0it) a a./itti" i/4$%((io o& $i")t $%a' #a'#u'i* ;a(%. o )i( )i(to$, Ca$'o( 0a( 2$ou")t to t)% ED 2 )i( &$i%. 0)% )% %64%$i%#%. (%3%$% %6#$u#iati" $i")t &'u! 4ai, au(%a a. 3o/iti"* T)i( 0a( $%'i%3%. 0)% t)% .o#to$ "a3% )i/ ;u(#o4a* T)% .o#to$ o$.%$%. (%3%$a' .ia"o(ti# 0o$!( u4: Ji.% u$ia$ ;'a..%$ a. it$a3%ou( P%"$a4) JU;-IVPB a. u't$a(ou.* ;'oo. #)%/i(t$ a. 5 )ou$ u$i% #o''%#tio to /%a(u$% #a'#iu/, u$i# a#i., #$%atii%, (o.iu/, 4H a. tota' 3o'u/% 0%$%, 'i!%0i(% o$.%$%.* GC. %s a nurse of !arlos )ho is for MBIP< )hich of the follo)ing )ill (ou include in (our teachi ng 'lan> a. 1. 4hat is an intra/enous '(elogra'h( +IP, 41
b. 2. Ao) should I 're'are for this 'rocedure> c. *. Ao) is the 'rocedure 'erfored> d. . 4hat )ill e-'erience during and after the 'rocedure> e. * and g. 1 and 2 f. %ll of the abo/e h. %ll e-ce't * GE. "ne of the 'h(sicians orders in 2 hour urine test. 4hat instruction )ill (ou gi/e !arlos if the collection )ill start toorro) at E=00 %& +a( 1, and end at E=00 % the follo)ing da( +da( 2,> a. iscard (our first urine sa'le at E=00 %& toorro) then start urine collection until E=00 %& da( 2 b. Start urine collection at e-actl( E=00 %& toorro) u' to da( 2 but discard the last urine at E=00 %& of da( 2 c. iscard (our first urine sa'le toorro) at E=00%& and (our last urine sa'le collection on a( 2 at E=00%& and collect all urine sa'les bet)een those ties d. Start urine sa'le collection at e-actl( E=00 %& toorro) G. The diagnostic e-aination confired the 'resence of renal calculi. % dietar( edication and fail( histor( of renal stone )as 'art of the assessent that )as done in order to a. %/oid taking drugs that could ha/e contributed to stone foration b. Identif( the factors 'redis'osing !arlos to foration of stone c. Prescribe the t('e of diet that is needed to 're/ent recurrence d. Identif( )hat t('e of stone )as fored GG. To facilitate s'ontaneous 'assage of stone and dilute the urine < the follo)ing can be ad/ised for !arlos #$!#PT= a. Diit fluid intake to 1.@ liters 'er da( to a/oid o/erload b. #-aine all urine out'ut for 'resence of stone c. Proote sufficient fluid intake to aintain a urine out'ut of * liters3da( d. Record intake and out'ut and dail( )eight to assess fluid status and renal function 100. 101. 102. 10*. Stone assa( )as done follo)ing its s'ontaneous 'assage. The result re/ealed uric acid stone. Prior to his discharge< (ou ade a teaching 'lan for !arlos on ho) he can 're/ent kidne( stone foration. The follo)ing )ere included in (our 'lan #$!#PT= a. Take %llo'urinol +(lo'ri, that is 'rescribed b( the doctor to reduce seru uric acid le/els and urinar( uric acid e-cretion b. %/oid food high risk like shellfish< ancho/ies< ushroo and organ eal c. uring the )aking hours drink fluids e/er( 12 hours and at bedtie take 2 glasses of )ater to 're/ent urine fro being too concentrated d. #ncourage acti/ities leading to sudden increases in te'erature to facilitate e-cretion of uric acid through s)eating 10. 1<* Situatio 1-EMERGENCY-T$ia"% to &a#i'itat% #a$% o& #'i%t( i t)% %/%$"%# $oo/, 3a$iou( /aa"%/%t (t$at%"i%( )a3% 2%% .%3i(%. to a..$%(( t)% (u$3i3a' %%.( o& 4ati%t(* A( a ER u$(% ou ()ou'. 2% %?ui44%. 0it) !o0'%."%, (!i''( a. attitu.% to #o4% 0it) u%64%#t%. 4$o2'%/(: 10C. :ou are assigned as the triage nurse in the #R . Four 'atients in5ured in a /ehicular accident )ere brought to the #ergenc( Roo at the sae tie. To )ho )ill (ou assign the AIA#ST 'riorit( a. &arissa < )ith acillofacial in5ur( and gurgling res'iration b. Rebecca < )ith se/ere head in5ur( but )ith no 'erce'tible blood 'ressure c. Rose< )ith lubar s'inal cord in5ur( )ith lo)er e-treit( 'aral(sis d. !harlene< onths 'regnant )ith 'reature labor contraction 10E. Reund< )as sides)i'ed b( a otor c(cle )hile he )as )aiting for a bus. Ais head hit the concrete 'a/eent. %ccording to a )itness Reund )as unconscious for a )hile but regained his consciousness as if nothing ha''ened. Ao)e/er< after a )hile he co'lained of se/ere headache and asked to be brought to the nearest #ergenc( Roo. :ou are the nurse in the #ergenc( Roo. If increased intracranial 'ressure is sus'ected< )hat )ould be the sign> a. In/oluntar( 'osturing c. Pa'illar( as(etr( b. Irregular breathing 'attern d. %lteration in le/el of consciousness 10. :ou are caring for Reund )ho sustained ulti'le in5uries follo)ing an autoobile accident. :our initial assessent re/ealed that he is oriented to 'erson and 'lace but is rather confused as to tie. Ae co'lains of se/ere headache and dro)siness. Ais 'u'ils are both equal and reacti/e to light. :our critical nursing inter/ention )ould be= a. Pre/ent unnecessar( o/eent b. Pre'are to adinister &annitol c. Mee' Reund alert and res'onsi/e d. &onitor for signs of increased intracranial 'ressure 42
10G. Berne is aditted into the eergenc( roo follo)ing an assault )here she )as beaten in the face and head. Based on Berne;s histor(< )hich of the follo)ing inter/entions should be fored first> a. Insert an oral or naso'har(ngeal c. Insert an intra/enous catheter air)a( d. "btain arterial blood gases b. i/e 100H o-(gen b( ask 110. &arlou losses consciousness< (ou should 're'are for )hich of the follo)ing FIRST> a. #ndotracheal intubation or surgical air)a( 'laceent b. !T scan on the head c. Place a nasogastric tube d. Place a second I line 111. 115* Situatio 1- Lu#i''a i( a E/%$"%# D%4a$t/%t u$(% 0o$!i" .u$i" t)% /o$i" ()i&t* A %0' ()o#!* W)i#) o& t)% &o''o0i" i(t$u#tio( o& Lu#i''a to t)% %0' )i$%. u$(% i( LEAST it%.%. to o2tai .ata $%"a$.i" )4o3o'%/i# ()o#!K 11*. % 1 (ear old /icti of gunshot )ound is being assessed closel( for signs of h('o/oleic shock. 4hich of the follo)ing instructions of Ducilla to ne)l( hired nurse is D#%ST intended to obtain data regarding h('o/oleic shock> a. Talk to the 'atient b. Note skin color of the 'atient c. Re'ort to e changes in /ital signs d. &aintain 'ressure on the )ound 11. The ne)l( hired nurse obser/ed Ducilla 'erfor assessent on a @0 (ear old feale )ho sustained 'artial and full thickness burns on both lo)er e-treities due to fire. 4hich of the follo)ing questions asked b( Ducila )ill the ne)l( hired nurse consider as an atte't to deterine full thickness burns> a. !an (ou o/e both e-treities> b. Ao) long )ere (our e-treities e-'osed to the flaes> c. o (ou co/er (our e-treities )ith an( aterial like a blanket> d. o (ou e-'erience 'ain> 11@. 11C. 11E. 11. Ducilla adinistered as 'rescribed< anti/eno and tetanus to-oid to a client aditted )ith histor( of snakebite. If (ou )ere the ne)l( hired nurse. 4hich of the follo)ing stateents )ill (ou consider IN!"RR#!T> a. Tetanus to-oid enhances effect of anti/eno b. %ount of anti/eno is de'endent on the se/erit( of reaction than )eight of the client c. !o'lications induced a( be 're/ented b( tetanus to-oid d. %nti/eno is an antidote for snakebite 11G. Ducilla instructed the ne)l( hired nurse to infor the client )ith congesti/e heart failure to a/oid alsal/a t('e aneu/ers. The ne)l( hired nurse understands that these include the follo)ing #$!#PT= a. 4alking to and fro the bathroo c. &o/ing fro su'ine to lateral 'osition b. !oughing and straining d. etting out of bed to a )heelchair 120. 4hen a''raising the 'erforance of the ne)l( hired nurse during the shift< )hich of the follo)ing beha/iours )ill Ducille consider as reflecti/e of a res'onsibilit( to i'ro/e e/aluation abilit(> a. Seeks clarifications regarding de/iations fro standard 'rocedures b. "rgani?es reference aterials on edication 'rescri'tions c. Juestions a''ro'riatel( data obtained fro the client d. %sks for su'er/ision of 'erforance of a ne) 'rocedure 121. 155* Situatio 1+- H%$/iio, >< %a$( o'., 0a( a./itt%. &o$ o4%$ati3% $%4ai$ o& a2.o/ia' ao$ti# a%u$(/* 12*. The nurse )ho aditted that 'atient recogni?es that the de/elo'ent of abdoinal aortic aneur(s in the 'atient could be associated 'riaril( )ith )hich of the follo)ing data obtained through nursing histor(. a. Ae sto''ed soking )hen he )as C@ (ears old b. Patient is under treatent for h('erli'ideia c. Patient is E0 (ears old d. Prolonged histor( of h('ertension 12. 4hen the nurse e-aines the 'atient;s abdoen< )hich of the follo)ing )ill she e-'ect u'on 'al'ation> a. Pulsating ass on the id and u''er abdoen b. Bruit o/er a ass in the abdoen c. Rebound tenderness on the id abdoen d. Rigid board like abdoen 43
12@. Preo'erati/el(< the 'riorit( nursing diagnosis in the nursing care 'lan is 6Risk for ineffecti/e tissue 'erfusion related to aneur(s ru'ture resulting to heorrhage.74hich of the follo)ing inter/entions is ost a''ro'riate to 're/ent ru'ture> a. %''l( cold co'ress on the abdoen c. &aintain co'lete bed rest )ith legs b. Place 'atient on a Fo)ler;s 'osition flat on bed d. Relie/e 'ain iediatel( 12C. Posto'erati/el(< the nursing orders include onitoring 'atient closel( for signs of graft leakage. 4hich of the follo)ing signs of graft leakage )ill the nurse consider to be related to renal 'erfusion> a. ecreasing hourl( urinar( out'ut c. Increasing 'el/ic and groin 'ain b. Increased abdoinal 'ain d. #cch(osis of scrotu 12E. Second da( 'osto'erati/el(< the 'atient co'lained of absence of sensation in the lo)er e-treities. Recogni?ing anifestations of co'lications< the nurse attributes the co'laint to )hich of the follo)ing> a. #ffect of anesthasia c. #lectrol(te ibalance b. S'inal cord ischeia d. %rterial occlusion e. &* Situatio 1>- Vi#to$ia, t)% (ta&& u$(% i( 4$%4a$i" a t%a#)i" 4'a &o$ M$(* Sato( a > %a$ o'. 0)o i( $%#o3%$i" &$o/ a %4i(o.% o& A#ut% ;$o#)iti( 0)i#) %6a#%$2at%. )%$ .ia2%t%(* M$(* Sato( i( )a$. o& )%a$i" a. a$t)$iti# 2ut a'%$t a. o$i%t%.* "* 12. In de/elo'ing the teaching 'lan for &rs. Santos< )hich of the follo)ing ste's is done after ictoria has identified the learning needs of her client> a. eterine content c. Set learning outcoes b. Set 'riorities for teaching d. "rgani?e the learning e-'eriences 12G. 4hich of the follo)ing beha/ioural ob5ecti/es is &"ST a''ro'riate before &rs. Santos is e-'ected to self adinister edications 'rescribed b( the 'h(sician> a. 4rite the naes of the drugs c. Select the 'rescribed edications b. Identif( all the edications d. "rgani?e the edications 1*0. 1*1. 1*2. 1**. 1*. 1*@. uring assessent< )hich of the follo)ing is best for ictoria to do to be able to deterine the learning st(le 'referred b( &rs. Santos> %sk &rs. Santos= a. The things she usuall( do d. 4ho )ill be interested to learn )ith b. Ao) she learned best in the 'ast her c. For changes she is )illing to do 1*C. This of the follo)ing )ill be &"ST effecti/e )hen ictoria uses the one on one 6discussion ethod of teaching> a. Frequentl( re'hrase stateents to facilitate understanding b. se 'rinted aterials )ith all ca'ital letters for eas( reading c. %llo) &rs. Santos to recoend a schedule of drug adinistration d. Diit to /erbal instructions 1*E. uring the discussion< ictoria asked &rs. Santos to re'eat )hat she 5ust taught &rs. Santos did not res'ond. 4hich of the follo)ing is B#ST for ictoria to sa(> a. %re there things )hich I did not sa( clearl( b. &rs. Santos< did (ou hear )hat I ask (ou> c. id (ou understand )hat I ha/e 5ust taught (ou> d. I asked (ou to re'eat )hat I ha/e 5ust said< &rs. Santos> 1*. 18=* Situatio 19- You a$% a((i"%. i t)% Ca#%$ I(titut% a. #a$i" &o$ 4ati%t( 0it) 3a$i" t4%( o& #a#%$* 1<* 11. Aector< nonAodgkin;s l('hoa< de/elo's a 'latelet count of 10<0003ul during cheothera'(. Base on these findings< an a''ro'riate nursing inter/ention is to= a. #ncourage fluids to *000l3da( c. !heck the te'erature q hr b. !heck all stools for accult blood d. Pro/ide oral h(giene q 2 hr 12. Fannie< a 2C (ear old teacher )ith stage II Aodgkins l('hoa asks (ou 6Ao) long do I ha/e to li/e> :our B#ST res'onse is= a. &ost 'atients )ith (our stage Aodgkin;s disease are treated successfull( b. It )ill de'end on ho) (our disease to radiation < but ost 'atients do )ell c. :ou kno) < no one can 'redict ho) long soeone )ill li/e < so tr( to focus on the 'resent d. 4ith ongoing aintenance cheothera'(< the 10 (ear old sur/i/al rate is /er( good 1*. ebra< )ho has o/arian cancer< tells (ou< 6I don;t think ( husband cares about e an(ore. Ae rarel( /isits e. 6uring the /isit of ebra;s husband (ou greeted hi and he told (ou.7I could not stand 44
to see ( )ife so ill and I don;t kno) )hat to sa( to her 64hat )ill be (our %PPR"PRI%T# nursing diagnosis in this situation> a. Interru'ted fail( 'rocesses related to effect of illness on fail( ebers b. !o'roised fail( co'ing related to disru'tion in lifest(le and role changes c. Risk for caregi/er role strain related to burden of care gi/ing res'onsibilities d. I'aired hoe aintenance related to 'ercei/ed role changes 1. Lenn( 0 (ear old single other of t)o school age children is hos'itali?ed )ith elastatic cancer of the o/ar(. :ou find her cr(ing< and she tells (ou that she does not kno) )hat )ill ha''en to her children )hen she dies. :our ost a''ro'riate res'onse is= a. For no) (ou need to concentrate on getting )ell. o not )orr( about (our children b. 4h( don;t )e talk about the o'tions (ou ha/e for the care of (ou children> c. &an( 'atients )ith cancer li/e for a long tie< so there is tie to 'lan for (our children. d. Perha's (our e- husband )ill take the children )hen (ou can;t care for the 1@. 4hen assessing Dera;s needs for 's(chologic su''ort after she has been diagnosed )ith stage I cancer of the colon< )hich questions )ill (ou ask to gi/e (ou the &"ST inforation> a. %re (ou failiar )ith the stages of eotional ad5ustent to a diagnosis like cancer of the colon b. Ao) long ago )ere (ou diagnosed )ith this cancer> c. Ao) do (ou feel about ha/ing a 'ossibl( terinal illness> d. !an (ou tell e )hat has been hel'ful to (ou in the 'ast )hen co'ing )ith stressful e/ents> 1C. 1>* Situatio 1=-Lui(, 9 %a$( o'. 0a( a./itt%. &o$ (u$"i#a' $%4ai$ o& a a%u$(/ i t)% a(#%.i" ao$ta .%t%#t%. t)$ou") a aua' 4)(i#a' %6a/iatio $%?ui$%. 2 t)% #o/4a 0)%$% Lui( i( #u$$%t' %/4'o%.* 19* 1G. 4hich of the follo)ing questions should the nurse include )hen conducting a health histor( to identif( a genetic risk of aortic aneur(s> a. Aa/e (ou e-'erienced neck and back 'ain> b. Ao) long ha/e (ou been h('ertensi/e> c. id an( of (our children ha/e h('ertension or ant heart 'roble> d. Aas aneur(s e/er been diagnosed in (our fail(> 1@0. 1@1. 1@2. 1@*. 1@. Ph(sician confired his diagnosis that Duis aortic aneur(s is the fusifor t('e of true aneur(s. The nurse recogni?es that this t('e of aneur(s= a. Is s'indle sha'ed and in/ol/es three la(ers of the /essel )all b. Is characteri?ed b( a tear in the tunica intia )ith blood in/ading la(ers of the /essel )all c. In/ol/es the entire diaeter of the ascending aorta d. Is sha'ed like a sac in/ol/ing onl( one la(er of the /essel )all 1@@. %s the client is being 're'ared for surger(< )hich of the follo)ing assessent data should the nurse re'ort I&&#I%T#D: to the 'h(sician> a. Positi/e abdoinal reflec. %bdoinal bruit b. Increased )hite blood cell count d. #le/ated blood 'ressure 1@C. Posto'erati/el( < nursing orders include close obser/ation for signs of arterial throbosis< )hich of the follo)ing assessent data should (ou N"T consider as a anifestation of this co'lication> a. %bsence of 'eri'heral 'ulses c. Increased abdoinal girth b. Increasing abdoinal and scrotal d. #le/ated bod( te'erature 'ain
45
1@E. Protaine sul'hate )as 'rescribed b( the 'h(sician as a PRN edication. The nurse understands that this 'rescri'tion is intended to a. Re/erse effects )arfarin thera'( b. Ser/e as an anticoagulant for arterial occlusion c. !ounteract ad/erse bleeding due to he'arin thera'( 1@. 1=* Situatio 5<- A u$(%( 4%$&o$/ t)%i$ $%(4o(i2i'iti%( i t)%i$ o2, t)% %#out%$ (ituatio( 0)i#) %64o(% t)%/ to 4o((i2'% 'a0(uit(* 1+<* 1C1. The nurse on night dut( assued that her 'atient is slee'. %t the bedside she discussed in detail the condition of the 'atient )ith another nurse. 4hich of the follo)ing a( be a 'ossible legal co'laint against the nurse> a. Poor bedside beha/ior b. Breach of confidentialit( c. Breach of 'ri/ac( d. Negligence 1C2. %n @ (ear old )oan diagnosed )ith &etastatic Breast !ancer< she has a colosto( and a fractured hi'. The night nurse docuented that she becae delusional and restraint )as a''lied. No relati/e could sa( )ith the 'atient during the da(. The incoing nurse recogni?es 'ossible liabilit( in the a''lication of the restraint. 4hich of the follo)ing )ill she do FIRST> a. iscuss concerns )ith relati/es b. "btain a edical order for a sedati/e c. !onsult attending 'h(sician d. Select a ore a''ro'riate and safe restraint 1C*. %fter cardiac catheteri?ation< a feale 'atient de/elo'ed chest 'ain and died. The fail( sued the hos'ital contending that. It had a dut( to infor the 'atient of the risk of the 'rocedure. The court decided in fa/our of the hos'ital. 4hich of the follo)ing is &"ST likel( the basis of the court;s decision> a. The 'h(sician is the best 'erson to infor the 'atient about the 'rocedure b. The re'resentati/e of the hos'ital )as not 'resent during the 'rocedure c. The hos'ital 'ractices qualit( control d. The infored consent )as signed b( the 'atient 1C. #li?abeth is a registered nurse )ho )orks in call center. Because she is a nurse< her co)orkers asked her to adinister their allerg( horone edications. 4hich of the follo)ing actions best to a/oid liabilit(> a. %dinister the edication after dut( hours in the call center b. #ncourage co)orkers to learn selfadinistration of drug c. %dinister the edication and dose correctl( d. Tell co)orkers to secure a )ritten edical 'rescri'tion )ith 'h(sicians license nuber 1C@. %n elderl( 'atient refused to take her cardiac edication. Thinking that she )as disoriented < the nurse crushed the tablets and i-ed the )ith the sou' and fed the 'atient. The nurse a( be held liable for= a. Negligence b. Batter( c. %ssault d. iolation of 'ri/ac( 1CC. 1CE. 1C. 1CG.
1><* A1 PASSERS TRAINING, RESEARCH, REVIEW AND DEVELOPMENT COMPANY 1>1* PRE-;OARD EXAMINATION 1>5* 1E*. NURSING PRACTICE V-!are of !lients )ith Ph(siologic and Ps(chosocial %lteration 1E. 1E@. 1>+* GENERAL INSTRUCTIONS: 1EE. 1. This test booklet contains 100 test questions. 1E. 2. Read INSTR!TI"NS T" #$%&IN##S 'rinted on (our ans)er sheet. 1EG. *. Shade onl( one +1, bo- for each question on (our ans)er sheets. T)o or ore bo-es shaded )ill in/alidate (our ans)er. 10. . %"I #R%SR#S. 11. 195* INSTRUCTIONS: 1*. 1. etach one +1, ans)er sheet fro the botto of (our #-ainee I3%ns)er Sheet Set. 1. 2. 4rite the sub5ect title 6Nursing Practice I7 on the bo- 'ro/ided. 46
1@. *. Shade Set Bo- 6%7 on (our ans)er sheet if (our test booklet is Set %8 Set Bo- 6B7 if (our test booklet is Set B. 1C. 999999999999999999999999999999999999999999999999999999999999999999999999999999999 999999999
1E. 199* SITUATIONAL 1G. 1=<* Situatio 1- It i( t)% &i$(t .a o& O$i%tatio o& %0 u$(% at t)% P(#)iat$ Wa$.* T)% (u4%$3i(i" u$(% %/4)a(i@%( t)at it i( t)% $%(4o(i2i'it o& a'' /%/2%$( o& t)% it%$.i(#i4'ia$ t%a/ to (a&%"ua$. 4ati%t( $%#o$.( &$o/ 'o(( o& .%(t$u#tio o$ &$o/ 4%o4'% ot aut)o$i@%. to $%a. it* 1. It is unethical to tell ones friends and fail( ebers data about 'atients because doing so is a /iolation of 'atients rights to= a. Infored consent c. !i/il libert( b. !onfidentialit( d. Secrec( 2. The nurse ust see to it that the )ritten consent of entall( ill 'atients ust be taken fro a. Da) enforceent agencies c. octor b. Social )orker d. Parents or legal guardian *. In an e-tree situation and )hen no other resident or intern is a/ailable< should a nurse recei/e < tele'hone orders< the order has to be correctl( )ritten and signed b( the 'h(sician )ithin= a. 2 hours c. 12 hours b. hours d. *C hours . To facilitate identification of 'ersons relationshi'< the fail( nurse utili?es this diagraatic re'resentation of ebers of a fail( and their relationshi's a. Mardec. enogra b. Flo) chart d. %lgorith @. The &"ST significant e/ent the nurse records regarding 's(chosocial )ell being are a. The 'atient slee'ing < eating and eliination 'atterns b. The beha/ior 'atterns and inter'ersonal interactions of the client c. Soatic treatents< edications and their effects d. Signs and s('tos and 'h(sical a''earance C. >* Situatio 5- M(* Co$4u@, t)% 4(#)iat$i# u$(% at t)% &a/i' (%#tio o& t)% Out-Pati%t D%4a$t/%t &o''o0( u4 &a/i'i%( o& .i(#)a$"%. (#)i@o4)$%i# 4ati%t(* T)%(% &o''o0 u4 3i(it( 4$o3i.% o44o$tuiti%( &o$ 4(#)o(o#ia' t$%at/%t o& 4ati%t( a. t)%i$ &a/i'i%(* . To ensure a-iu 'artici'ation of fail( ebers in follo) u' sessions )ith &s. !or'u?. 4hich of these eleents of effecti/e fail( inter/ention is basic> a. Fail( social su''ort c. Training in 'roble in 'roble sol/ing b. I'ro/eent in fail( counication d. &utuall( agreed u'on goals G. The 'riar( goal of 's(chosocial treatent for failies of discharged 's(chiatric 'atients as a. Pro/ide gainful e'lo(ent b. %eliorate 'o/ert( and social ills in the counit( c. Pro/ide education on edication anageent d. #nhance co'ing efforts and reduce stressful life e/ents 10. 4hich of the follo)ing is a cultural factor that a barrier to a/ail of fail( inter/ention> a. Resources and tie c. Shae and stigati?ation b. nres'onsi/e go/ernent 'olicies d. Traditional 'ractices 11. %ll of these are )ithin the sco'e of the generalist nurses role< #$!#PT= a. Social skills training c. Fail( thera'( b. Indi/idual and fail( assessents d. Aealth education on 's(chotro'ic drugs
12. 1*. 1. 1@. 1C. !ogniti/e beha/ior 'rinci'les are utili?ed in 's(chosocial treatent. In such inter/entions 'atients )ho are rehabilitating fro schi?o'hrenia are. a. Taught to unlearn alada'ti/e beha/iours through desensiti?ation b. %ssisted to )ork through their unconscious internal conflicts c. Taught to refrae 's(chotic s('tos as co'ing atte'ts rather than signs that the( are cra?( or )eak d. &ade to recogni?e the i'ortance of 's(chotro'ic drugs to cobat delusions and hallucinations 1E. 19* Situatio 8- o%, 8< %a$( o'. 0a( a./itt%. to t)% P(#)iat$ Wa$. 2%#au(% o& #)a"%( i 2%)a3io$ (u#) a( %"'%#t o& (%'& #a$%* Wit).$a0a' &$o/ $%'atio( 0it) 4%o4'% ta'!i" to )i/(%'& a. 2%'i%&( t)at )% i( 2%i" 4%$(%#ut%.* H% )a( 2%% .ia"o(%. 0it) S#)i@o4)$%ia .i(o$.%$* 1=*
47
20. Nurse ina )as assigned to take care of Loe. She a''roached and greeted Loe and sat )ith hi to start interaction. Ae o/ed back to distantiate hiself and e/aded e(e contact. Nurse ina recogni?ed that in order to establish a nurse'atient relationshi'< it is i'ortant Loe to ha/e= a. Self confidence c. Ra''ort b. Self )orth d. Trust 21. Nurse ina obser/ed that Loe ke't ubling unintelligible )ords )hich ade no sense to her acco'anied )ith ina''ro'riate facial griaces as if he is talking to soeone. Ae clais he is in a 'rison ca'. Nurse ina inter'rets these beha/iours as a. e'ersonali?ation c. Dack of insight b. %nhedonia d. %bi/alence 22. The ultidisci'linar( tea shared obser/ations of Loe and discussed 'lans for treatent Nurse ina antici'ates that fro e/idenced based 'ractice< the &"ST likel( treatent 'lan to be initiated is a. Beha/ior odification c. Reoti/ation thera'( b. Relationshi' thera'( d. Pharacothera'( 2*. % sociali?ation 'rogra is scheduled for the da(. % thera'eutic inter/ention of Nurse ina is= a. &inii?e en/ironent stiuli and ha/e Loe engage in ales stiulating acti/it( b. Present the 'lan for the da( and ha/e Loe decide c. Aa/e a friendl( in/ite Loe to the sociali?ation 'rogra to o/ercoe his )ithdra)al fro social relations d. Refer the atter to the occu'ational thera'ist 2. % thera'eutic attitude in dealing )ith Loe is b( being a. Denient and ha/e no deands c. Si'l( ob5ecti/e and businesslike b. %cti/el( friendl( )ith hi d. %* Situatio - T)% u$(% i( #a$i" &o$ a %'.%$' #'i%t 0)o )a( a (%3%$% )%a$i" i/4ai$/%t 2@. 4hich of the follo)ing is the &"ST i'ortant 'art of assessing a client )ith hearing loss> a. !hange in st(le of counication d. se of si'le nonin/asi/e )a( to test b. 4eariness or une-'lained irritabilit( hearing c. Aistor( of a client 2C. The nurse is 're'aring a nursing histor( . in counicating )ith the client< )hich of the follo)ing is the &"ST a''ro'riate technique> a. S'eak loud enough to be heard c. Sit bedside the client )ith the affected b. S'eak directl( and clearl( facing the ear client d. se cardboard )hen asking question 2E. The nurse is 'erforing a 'h(sical e-a on the client. 4hich of the follo)ing is the &"ST a''ro'riate ethod to be used b( the nurse> a. Bone conduction c. %udiogra b. 4his'er test d. "tosco'e 2. %n elderl( client asked the nurse )h( older adults are ore 'rone to conducti/e hearing loss and tinnitus. The nurse addresses a''ro'riatel( the quer( of the client )hen she states that it is i'ortant to INITI%DD: rule out= a. In5ur( to the iddle air b. Aardened ceruen lodged in the e-ternal ear c. aage to the t('anic ebrane 2G. 4hich of the follo)ing is an a''ro'riate nursing inter/ention for the client )ith hearing i'airent> a. et an inter'reter e/er( tie the nurse akes contact )ith the client b. Pre'are set of questions and res'onses of client c. &inii?e en/ironent noise before s'eaking )ith the client d. Place the client in a quiet )ell /entilated roo *0. *1. *2. **. *. *@. Situatio - Nu$(% F'%$i.a, t)% Co//uit H%a't) u$(%, att%.%. a ;a$a"a /%%ti" 0)%$% 4$o2'%/ o& T$ou2'%. t%%a"%$( 0)o a$% .%'i"u%t(, 4o((i2'% .$u" a. a'#o)o' a2u(%$( a. "%t i3o'3%. i o##a(ioa' 3io'%#%** 0a( .i(#u((%.* S)% a44$oa#)%. G%$$, t)% P$%(i.%t o& Sa""uia Ja2ataa a. t)% ta'!%. a2out .%3%'o4i" a (t$at%" 0)i#) $%(u't%. i (%$i%( o& /%%ti"( 0it) t%%a"%$( i t)% ;a$a"a. *C. %n inforal first eeting )ith soe teenagers )as held in basketball court in order to engage the teenagers to talk about their concerns< it )as essential for Nurse Flerida and SM err( to= a. #stablish a contract )ith the b. #nsure confidentialit( of their discussions c. %/oid bringing an( gadget that the teenagers can get sus'icious of d. Lust listen ore than talk 48
*E. "n the third eeting < 20 teenagers sho)ed u'. The teen started to talk about their 'robles and about ari5uana< acid < e-'erienters< frequent users< 'ushers< etc.. at this 'oint. It )ould be thera'eutic for Nurse Flerida and err( to= a. &ake effort offer solutions or ans)ers to their 'robles b. Practice oralistic 5udgent c. &aintain acti/e listening d. Translate t the teenagers )hat is going on in their )orld *. The thees of the con/ersations )ith the teenagers centered around< 6 No one e/er listens<7 and 6 4e tried to talk )ith our teacher< then the guidance counsellor< the other teachers < the coach and still others but the( 5ust don;t ha/e tie..7 The nurse infers that these (oung 'eo'le= a. %re ha/ing reaction foration c. es'eratel( )ant relationshi's )ith b. Priaril( )ant to a/oid 'rison adults sentences d. 4orr( about 'arental 'unishent *G. uring the fourth eeting 0 adolescents attended< all )ere eager to talk< share e-'eriences an offer ideas. The adolescents asked about the 'ersonal li/es of Nurse Flerida and err( and )ho the( had shared inforation about their situations. This ust be taken as due to= a. e/elo' ob5ecti/it( c. ee'en trust in the relationshi' b. &aintain 'rofessionalis d. #stablish control of the situation 0. %fter the fourth eeting< Nurse Flerida and err( e-'lored ideas about future directions. In bringing in a counit( leader to listen and talk to these teenagers< the 'riorit( ob5ecti/e of such eeting )ould be to=
a. b. c. %* &*
%/oid confineent in ental hos'itals #-'lore o'tions and sol/e 'robles !ircu/ent hea/( 'rison sentences
d. o health screening aong the teenagers
Situatio +- A o- %64%$i/%ta' , o% "$ou4, 4$%t%(t 4o(ti%(t $%(%a$#) .%(i" 0a( u(%. to %3a'uat% t)% %&&%#ti3%%(( o& a %0' .%3%'o4%. t$aii" 4$o"$a/ &o$ u$(%( 0o$!i" 0it) %'%#t$o#o3u'(i3% t)%$a4 ECTB &o$ 4(#)iat$i# 4ati%t(* 1. Sub5ects )ere selected because the( ha''en to be a/ailable for 'artici'ation in the stud( the 'rocess used is a. Rando sa'ling c. Probabilit( sa'ling b. !on/enience sa'ling d. Pur'osi/e sa'ling 2. The stud( )as a''ro/ed b( the health Ser/ices #thics !oittee. Prior to co'leting questionnaire at the start of the training 'rogra< the consent )ould be 'ro/ided b(= a. Nurse su'er/isors c. Aos'ital edical director b. Patients undergoing #!T d. Nurse 'artici'ants *. %n e/aluation questionnaire included 1 TrueFalse ites )hich easured Nurses kno)ledge of ke( co'onents of 'ro/iding assistance in an #!T 'rocedure. In this stud( 'artici'ants kno)ledge )ere easured. a. Solel( after the training c. Before and after the training b. Solel( before the training d. In the iddle of the training . Si- ites of the e/aluation questionnaire used a 10 'oint scale+ ranging fro not all confident to /er( confident, to easure nurses 'ercei/ed le/el of confidence )ith setting u' an a''ro'riate #!T achine. The t('e of scale used is a. Inter/al scale b. "rdinal scale c. Ratio scale d. Noinal scale @. Table changes in Partici'ants Mno)ledge Before and %fter the #!T Progra +NG2, In the table )here NG2< NG2 eans a. Percentage of nurses res'onding correctl( in the 'ost test b. Nuber of nurses )ho 'artici'ated in his stud( c. Nuber of nurses currentl( )orking in the field of #!T d. Percentage of nurses )ho co'leted both 'retest and 'osttest questionnaire C. E. 9* Situatio >-P(#)iat$i# u$(i" 4$a#ti#% )a( %3o'3%. &$o/ a i(titutioa'i@%. (%tti" to a /o$% )u/a% a44$oa#)* I.%a( a2out /%ta' i''%((, )u/a atu$% a. t)% %3i$o/%t #otiu% to #)a''%"% $o'%( o& u$(%* G. Ps(chiatric treatent encourages clients inde'endence. The nurse recogni?ed )hich of these setting to be D#%ST restricti/e a. Aalf)a( hoes c. Fail( of orientation b. State hos'itals d. Nursing hoes @0. %s the date for discharge a''roaches< a client becoes increasingl( an-ious and regresses< thus dela(ing staff decision to discharge client. The client beha/iour follo)ing this decision< i'ro/es and this 'attern gets re'eated. The staff decision to dela( discharge acts as a. a. Negati/e reinforce b. !onditioner 49
c. Punishent d. Positi/e reinforcer @1. !hronic schi?o'hrenic 'atients are assisted to learn self hel' beha/iour b( )a( of tokens for good grooing. 4hich in turn are used to 'resent at dinner to be ser/ed their eals . this is an inter/ention used in a. Social thera'( c. Beha/iour odification b. Relationshi' thera'( d. !ounit( in/ol/eent @2. !lient is 's(chotic and confused< 'riorit( in 'lanning is to a. Pro/ide structural controls c. &aintain safet( of other 'atients b. &aintain client safet( d. %/oid daage to en/ironent @*. 4hich of these o''ortunities )ill the nurse create to teach clients a sense of res'onsibilit( and learn the consequences of their actions> a. Reoti/ation grou's c. !lient go/ernent b. %cti/it( grou's d. iscussion grou's e. &* Situatio 9- T)% u$(% i a )a'& 0a )ou(% 0)%$% #)i'.$% at $i(! a$% ta!% #a$% o& t)% &o''o0i" (ituatio( a$% %#out%$%. @. %t night the children )ere being 're'ared to go to slee'< the nurse heard fro a frightened child7 AYAW KO MATULOG MAG-ISA, MAY MULTOO7 +I don;t )ant to slee' alone There;s a ghostO7, the nurse assess this beha/iour as need for a. Biological integrit( c. Safet( and securit( b. Do/e and belongings d. Trust @@. &ost street children coe fro broken failies. The ost effecti/e role for the nurse to facilitate de/elo'ent of trust is a. &other surrogate c. !hild thera'ist b. Teacher d. %cti/it( thera'ist @C. 4hen a child is called her nae< clothed a''ro'riatel( and gi/en age a''ro'riate tasks < she= a. e/elo's a sense of co'etence c. e/elo's sense of identit( b. Dearns to trust in self and in others d. %cquires a sense of 'ersonal 'o)er @E. Pre/enti/e inter/entions for children at risk are B#ST achie/ed through a. N"s and other )orkers 'a(ing attention in conflict ridden or 'robleatic counit( b. Su''ort and caring to children during fail( crisis situations c. Pla( and acti/it( thera'ist d. Fail( thera'( for the d(sfunctional failies @. &ina )as a frequent )itness to doestic /iolence. Aer father )ould al)a(s coe hoe drunk and beat u' &ina;s other. %s an effect of this e-'erience she had nightares s'eechless for )eeks8 inabilit( to slee'< tension and 'al'ations lasting for ore than a onth. &ina is e-'eriencing= a. %n-iet( disorder c. Post trauatic stress disorder b. %d5ustent disorder d. Phobic disorder %* &* Situatio =- Jat% i( = %a$ o'.* Ho$$i2' (%6ua'' a2u(%. 2 )%$ &at)%$, ()% )a. .%3%'o4%. a 0a o& 2%)a3i": ()% t$i4( a!%.* U$iat%( o t)% &'oo$ a. 3o/it(* Fo$ (o/% $%a(o, ()% t)i!( it i( a'$i")t &o$ )%$ to (t$i4: u$iat% o t)% &'oo$ a. )it a. !i#! o t)% (ta&&, a. t)% a(!( (0%%t' &o$ a )u"* S)% i( t)% o% o& t)% !i.( o t)% #)i'. a. A.o'%(#%t Uit o& t)% )o(4ita'* @G. For the fail( histor( of Mate the nurse infers that a fundaental issue is Mate;s a. Dack of aternal care an )arth b. Feelings of hostilit( of o)n fail( c. Inconsistent eotional and 'h(sical relationshi's d. Inabilit( to trust relationshi's C0. 4ith other beha/iourall( disturbed children in the unit. Mate siles )ith glee )atching adult staff struggle to take tie to fi- the 'lace and 'ut things in order e/er( tie these kids create chaos. This 'attern of beha/iour is. a. Aostile c. &ani'ulati/e b. %ssaulti/e d. eanding C1. C2. C*. C. Mate has de/elo'ed hostile attitudes as sho)n in her hitting and kicking beha/iour. The 's(chod(naics of Mate beha/iour ost likel( )ould 'oint to a. Inabilit( to co'e )ith conflict and frustration b. Dack of role odels in her gro)ing u' c. !r( for 'lea for 'rotection of children rights d. Inabilit( to discern )hat is acce'table fro unacce'table beha/iour C@. In creating a thera'eutic en/ironent for Mate and kids of the sae situation < it is F"R#&"ST to= a. e/elo' a 'ositi/e self iage c. Pro/ide /alues education b. Pro/ide thera'eutic liit setting d. Pro/ide /alues education 50
e. "bser/e 'h(sical h(giene and adequate nutrition CC. In the unit< it is uncoon to hear loud bangs and thuds )ith (elling< screaing and cursing of these children )ith the co'an( of Mate. % thera'eutic acti/it( that the staff can 'ro/ide is a. S'orts that foster coo'eration and tea)ork b. Painting and art )ork c. %cti/e ball gaes that are not co'etiti/e d. "rgani?ing scra'book clubs e. CE.
C.
CG.
E0.
E1.
&* Situatio 1<- Ro"%$, 5 %a$ o'., (u(tai%. &$a#tu$% o& t)% $i")t ti2ia a. &i2u'a &o''o0i" a /oto$##'% a##i.%t* T)% 4)(i#ia o$.%$%. a44'i#atio o& 'o" '%" #a(t* The 'h(sician a''lied to cast to iobili?e the fracture leg. The 'laster of 'airs cast is da' and the client /erbali?ed that his leg feels /er( hot. 4hat should be the a''ro'riate action of the nurse> a. Reassure the client that it is a coon effect after the a''lication of the cast b. #le/ate the lib to facilitate dr(ing of the cast c. Tell the client that he )ill e-'erience feeling hot for se/eral hours as the oisture e/a'orates and the cast hardens d. Notif( the 'h(sician as the cast is constricting the legs< causing so uch 'ressure To facilitate the dr(ing of the long leg cast< the nurse should do )hich of the follo)ing easures> a. #le/ate the affected leg on a bed board c. Place the bed in cool 'lace b. Instruct the client to assue one 'osition d. #-'ose the cast full( to the air The nurse is assessing the client )ith long leg cast. She noticed that the clients toes are 'ale< cool and ca'abilit( refill is dela(ed for fi/e seconds. Ao) should the nurse inter'ret this finding> a. The ner/es in the toes are threatened b. Stasis of /enous blood in the toes c. The finding is noral for this reco/er( tie 'eriod d. ecrease of arterial blood su''l( in the toes Se/eral hours after the a''lication of the long leg cast< the nurse notices that the client toes are edeatous< the nurse refers her obser/ation to the attending 'h(sician< the 'h(sician decided to bi/al/e the cast. The client asks the nurse )hat the 'rocedure is. The nurse e-'lains to the client that this 'rocedure is done b(= a. S'litting the cast near the toes to relie/e constriction b. Placing the client leg in a de'endent 'osition c. S'litting and s'reading the cast on each side d. !utting the cast and rea''l( after 2 hours The nurse is 're'aring the client to abulate. To 're'are the client< the nurse should encourage the client to= a. Sit u' in bed for *0 inutes t)ice a da( b. Mee' the affected lib in straight alignent c. Mee' the affected lib in straight alignent d. Practice sitting using a tra'e?e to strengthen uscles e. Perfor e-ercise in bed to strengthen the u''er e-treities
>5* >8* Situatio 11- Ca$' , i( a 59 %a$ o'., &%/a'% 4ati%t, a./itt%. to t)% 4(#)iat$ uit 0it) a .ia"o(i( o& #)$oi# u.i&&%$%tiat%. (#)i@o4)$%ia* S)% .%(#$i2%( )%$(%'& a( ;ii2ii" Pi'i4ia( Ui3%$(%a. )%$ /i((io i( to $%4$%(%t t)% #out$ a. 2% a a/2a((a.o$ o& "oo. 0i'' &o$ t)% Fi'i4io 4%o4'%* S)% 0a( o2(%$3%. to 2% ta'!i" a 'ot a. 'au")i" 2 )%$(%'&* H%$ t)ou")t( 0%$% i#o)%$%t a. .i(o$"ai@%.* S)% 0a( a'(o a'oo& i $%'ati" 0it) ot)%$( E. !arl(n clai of being 6Binibining Pili'inas ni/erse7 is an= a. elusion c. "bsession b. Iagination d. Illusion E@. The nurse inter'rets !arl(n thought of being an abassador of good )ill for the Fili'ino 'eo'le as a a. %tte't to o/ercoe lo) self estee b. &echanis to connect )ith realit( c. Personal /ision that is realistic and laudable d. Regressi/e beha/iour
e. f. g. h. i. EC. 4hich of these inter/entions )ould N"T be thera'eutic in decreasing !arl(n;s an-iet(> a. Disten to her thoughts and feelings b. Loke about her thoughts to hel' her fetal at ease c. o not challenge her 'erce'tion d. Si'l( acce't EE. 4hich of the follo)ing is a PRI"RIT: inter/ention for the nurse> a. %cti/it( thera'( c. Beha/iour odification b. &ilieu thera'( d. Relationshi' thera'( E. In order to assist !arl(n to co'e and be 're'ared for discharge< it is B#ST for the nurse to focus on= 51
a. b. c. d.
Insight into 'ersonal 'robles %ttitudes of societ( to)ards the entall( ill Skills for aintaining dail( li/ing %)areness of inter'ersonal interactions
EG. 9<* Situatio 15- M$* ; 0a( a 4o(t-o4%$ati3% 4ati%t 0)o .i%. &$o/ iu$i%( (u(tai%. i a &a'' &$o/ )i( t)i$. &'oo$ 0i.o0* A44a$%t', )% )a. t$i%. to #'i/2 .o0 o a i/4$o3i(%. $o4%* At t$ia' t)% u$(% t%(ti&i%. t)at .u$i" )%$ 'a(t %3%i" 3i(it 0it) )i/, )% )a. %64%$i%#%. a %4i(o.% o& ta#)#a$.ia a. )4%$t%(io, $%&u(i" a'' u$(i" #a$% a. 4$%(#$i2%. /%.i#atio !o0 to )a3% a.3%$(% %&&%#t( i#'u.i" #o&u(io a. a6i%t* T)% u$(% .i. ot $%4o$t to t)% 4)(i#ia a. t%(ti&i%. a'(o t)at 0)% ()% 4a((%. 2 t)% 4ati%t at /i.i")t, )% a44%a$%. to 2% ('%%4i" a. .i. ot $%a((%(( )i( 3ita' (i"(* 1. The nurse negligence includes a. Failure to docuent d. Failure to assess and onitor and b. Failure to follo) standards of care failure to counicate c. Failure to act as 'atient ad/ocate 2. Failing to aintain a safe en/ironent in this instance is a 5oint accountabilit( of the nurse and the a. Nursing staff c. Aos'ital b. octor d. Securit( 'ersonnel *. 4hen the nurse testified that the 'atient a''eared to be slee'ing < )hich of these co'etencies did she fail to do> a. Ins'ect c. %nal(?e b. Plan d. "bser/e . Full docuentation of care on the 'atients chart in addition to being factual< accurate< and co'lete includes being a. Thorough c. Tid( b. Truthful d. Tiel( @. 4hen this incidence of fall is re/ie)ed< )hat is the 'riar( basis for considering this to be a nursing negligence> a. Nurse 'ractice act c. Nursing 'rocedure anual b. Nursing su'er/isor e/aluation d. Aos'ital rules and 'olicies e. &* Situatio 18- Nu$(% Li.a i( a ou" 4$o/i(i" u$(% 0)o #)o(% to (ta$t a 4$o&%((ioa' #a$%%$ a( a /%ta' )%a't) 4(#)iat$i# u$(%* Pa$t o& )%$ o$i%tatio a. t$aii" a( a 2%"ii" 4$o&%((ioa' u$(% i( %)a#i" &a#i'itat% 4%$(oa' #)a$a#t%$i(ti#(* C. Nurse Dinda recogni?es that thera'eutic effecti/eness is B#ST acquired through a. Auan relations laboratories b. #ducation in the beha/ioural sciences c. 4orksho's like sensiti/it( sessions d. Mno)ledge and 'ractice of s'ecific inter'ersonal skills in e/er(da( life E. %nne is a ne) client of Nurse Dinda. She offers Dinda a gift. Nurse Dinda res'onds thera'euticall( b(= a. !larif(ing client;s intent< 6I )onder )h( (ou are offering e a gift.7 b. Reacting e'haticall( 6No it is unethical to recei/e gift fro a clients c. !iting a hos'ital 'olic(< 6It is against hos'ital 'olicies.7 d. %cce'ting )ith an ackno)ledgeent< 6I feel uncofortable doing this but I don;t )ant to disa''oint (ou. . 4ho is the follo)ing clients ust Nurse Dinda refrain fro use of touch> a. &arissa )ho is aggressi/e and hostile b. Rodolf )ho is de'ressed )ith lo) le/el of energ( c. %go )ho is looking for a other d. &ico )ho has /er( lo) self estee G. Resistance is often istaken seen as the clients struggle against a. !hange c. Res'onsibilit( for actions b. Selfa)areness d. The nurse G0. G1. G2. G*. G. #stablish a thera'eutic contract is the goal of )hich 'hase of the nurse 'atient relationshi'> a. "rientation 'hase c. Pre orientation 'hase b. 4orking 'hase d. &iddle 'hase e. &* Situatio 1- Ja$%, a1= %a$ o'. u$(i" (tu.%t, &ait( i t)% La.i%( Roo/ o& t)% Ui3%$(it ;oo!(to$%7 a (ta&& 4%$(o .i(#o3%$( )%$ a. #a''( a a/2u'a#%* I $out% to t)% E/%$"%# D%4a$t/%t, ()% .$i&t( i a. out o& #o(#iou(%((* H%$ 2'oo. 4$%((u$%* 52
><5 //H" i( 2a$%' au.i2'%7 4u'(% +5 2%at( 4%$ /iut%, %$$ati# a. .i&&i#u't to 4a'4at%* W)% ()% a$$i3%( at t)% ED, a IV o& 1,<<< DW i( (ta$t%. Ja$% i( #o(#iou( 2ut 0%a!* G@. Maren aditted to the nurse that 6she took about a handful of la-ati/es o/er the course of C hours...7to )hich the nurse res'onded 6That;s7not too bright. The chart sa(s (ou;re a nursing student. :ou should kno) better than that< h>7the a''roach is a. %cce'ting because she is 5ust stating an inforation fro her chart b. #ncouraging client to use her 5udgent a''ro'riatel( c. Si'l( a atter of fact attitude d. Not thera'eutic because she is adonishing GC. Maren is diagnosed to ha/e Buliia Ner/osa. This characteri?ed b( binging and t('ical beha/iour is a. #-cessi/e an-iet( of hos'itali?ation and encountering health 'ractitioners that 'robe into her 'ri/ate life b. #ating larger aounts of food than ost 'eo'le do under siilar and circustances c. ncontrolled urge to seek secondar( gain fro other 'eo'le d. Seating unusual and non nutriti/e kinds of foods and substances GE. % nurse counsellor talked to Maren after her eergenc( needs ha/e been attended to )hich of the follo)ing questions should the nurse a/oid= a. Ao) often are (ou o/ing (our bo)els> b. Aa/e (ou tried to ake (ourself thro) u' to relie/e (ourself of stoach distress> c. 4h( do (ou take la-ati/es to feel thinner or to loss )eight> d. o (ou soeties take soething to o/e (our bo)els along> G. !lients like Maren their illness because of= a. Pretending to seek hel' c. ncontrolled urge b. Fear of being 5udged d. Non threatening nature of the illness GG. The long ter goal of the nurse counsellor is a. #ducate on 'ersonal and ental h(giene b. Increase self estee essential to health c. e/elo' trusting relationshi's d. #ducate on 'ro'er food ser/ings and dietar( requireents 100. 1<1* Situatio 1- T%'%3i(io a. %0(4a4%$ $%4o$t t)at .$u" a2u(% i( a (%$iou( (o#ia', %#oo/i# a. 4o'iti#a' 4$o2'%/ i ou$ (o#i%t* Nu$(%( a$% #otiua'' #)a''%"%. to 4'a a $o'% i a2%tti" i t)% #o//uit 102. Street children are introduced earl( to harful substances such as inhaling rugb(. This obser/ation underscores the need to address the 'roble at its core. Nurses contribute best at the 're/enti/e le/el b( 'rooting= a. Social )elfare for under 'ri/ileged failies b. Res'onsible 'arenthood c. Fail( 'lanning 10*. Teen agers )ho 5oin fraternities and gangs are high risk grou's for substance abuse )hich 's(chosocial need is best et through 'er counselling> a. Recognition c. Belonging b. Self estee d. Securit( 10. Ben5ie is using ari5uana< )hich of the follo)ing beha/iours )ould be obser/ed> a. 4ater( e(es< rhinitis< snee?ing < (a)ning b. %''ears drunk )ith staggering gait c. ses dark glasses to conceal bloodshot e(es d. %''ears alert and confident )ith dilated 'u'ils 10@. % college student client states that his addiction to or'hine is due to a cheical ibalance. The nurse understands that researches that 'oint to biocheical theor( of addiction su''ort that drugs of abuse ha/e in coon < stiulation of )hich of the follo)ing neurotransitter> a. Nore'ine'hrine c. %cet(lcholine b. Serotonin d. o'aine 10C. 10E. 10. 10G. 110. 111. %t the #ergenc( Roo< a (oung gu( )as brought in and succubed to sudden heart attack. The 'arents re'orted that their son had al)a(s been health(. a re'ort )as ade that substance use )as 'ositi/e. &"ST coonl( abused substance b( this age is a. &ari5uana c. !ocaine b. Steroids d. %lcohol e. &* Situatio 1+- T)% &o''o0i" a$% 2%)a3iou$a' it%$a#tio( 0)i#) )a3% o##u$$%. 0it)i t)% 0a$. /i'i%u i 0)i#) 4ati%t a. (ta&& )a3% %#out%$( 53
112. 4hile the 'atients )ere gathering in the g( for the orning e-ercise< Laelie a''roached the nurse and re'orted about a 6bad7 beha/iour of another 'atient. The nurse obser/ed Laelies re'eated 'attern of brining essages about isbeha/ing 'atients. The nurse inter'rets this correctl( as a3an a. !o'ulsi/e beha/iour b. Policing beha/iour )hich hel's to ensure disci'line in the )ard c. %tte't to enhance her 'o)er )ith the nurse d. &atter of fact beha/iour that does not necessaril( ha/e an( intended eaning 11*. uring the )ard eeting. an interru'ts to ask the nurse. 64hat tie is it>7 #/en though that )all clock is /isible the e/er(bod(. it is best for the nurse to a. Aa/e hi refer t the clock c. Res'ond< 6% I (our tie kee'er b. Ignore this beha/iour d. Si'l( tell the tie 11. uring the Nurse'atient interaction< the 'atient rearked )ithout trigger< it bothers e7 as he sho)ed disturbed beha/iour. The nurse res'onds thera'euticall( )hen she a. "bser/es and reains client b. %sks< )hen (ou sa( it )hat are (ou talking about> c. erbali?e back< (ou are bothered d. Reflects back<7 :ou are bothered 11@. #d)ard has been noted to ha/e the re'eated 'attern of relating his thoughts as (ou kno) or e/er(bod( kno)s.7It is the best for the nurse to a. Interru't as this a( lead to obsessi/e thinking b. Take this as si'l( a atter of e-'ression c. "bser/e for ideas of reference d. Res'ond b( asking details 11C. irgilio< a ne)l( aditted 'atient claied< 6the( are talking about e 7as began to be u'set and irritable . a thera'eutic res'onse of the nurse )ould be to a. %sk 6)ho are the(>7 d. %llo) hi to continue his thought b. Sa(< 6tell e )hat is u'setting (ou> 'rocess c. Inquire on )hat is being talked about.7 e. &* Situatio 1>- T)% u$(% 0at( to .%3%'o4 a #'i%t %.u#atio 4$o"$a/ to i#$%a(% t)% out4ati%t #'i%t ( !o0'%."% a. (!i'' $%"a$.i" /%.i#atio /aa"%/%t 11E. #ffecti/eness of this 'rogra is B#ST deonstrated )ith the clients a. Rigidl( follo)ing doctors orders regarding drug intake b. Self reliant< self care beha/iors and res'onsible use of 'rescribed edications in the counit( setting c. Religiousl( recording the intake of their edications d. Increased frequenc( of counication )ith the health care tea to consult for an( 'roble that a( arise 11. The INITI%D goal this 'rogra )ould be a. !reate ore 'roducti/e alliance bet)een the client and ebers of the interdisci'linar( ental health care tea b. Increase treatent co'liance c. I'art the inforation necessar( for inde'endent edication anageent d. Teach res'onsible 'roble sol/ing and decision aking skills regarding edication 11G. 4hich of the follo)ing ste's reflects the client a)areness of the first ste' in the correct 'rocedure to be used )hen taking edications> a. "'en the bottle and 'our the correct aount into the bottle ca' or other container b. Read the label or the doctors orders carefull( c. Take the edication )ith a full glass 5uice or )ater d. !lose the bottle tightl( and double check the doctors order 120. :ou )ant to ha/e the client deonstrate asserti/eness skill in counicating )ith the health care tea. %n a''ro'riate ethod for iediate feedback is= a. Nurse 'atient relationshi' c. Ps(chothera'( b. Role 'la( d. !ounselling 121. 122. 12*. 12. 12@. 4hich of the follo)ing offer social su''ort regarding edication co'liance> a. se a calendar to tract edication usage b. Mee' a 5ournal or record edications c. Aa/e the doctor recoend the use of affordable generic edications d. Aa/e fail( and friends attend a edication education grou' )ith the client 15+* 15>* Situatio 19- Ma$ia, +> %a$ o'. )a( a )i(to$ o& /%ta' i''%(( i )%$ /i..'% a"% a. t$%at/%t &o$ %a$' /%o4au(%*M%.i#atio( 0%$% "i3% &o$ .%4$%((io 0)i#) 2$ou")t )%$ ito %/i((io7 ()% 54
&u#tio%. &ai$' 0%'' 2ut 0a( 4$o% to 4a$aoi. i.%atio, (o#ia' i(o'atio a. 2%#a/% (%3%$%' a6iou( 0)% (t$%((%.* S)% 0a( 2$ou")t to t)% )o(4ita' .u% to 4$o&ou. .%4$%((io 0it) /oo. #)a"%( /ai&%(t%. 2 'itt'% ('%%4, )i") %%$", )(t%$i#a' 'au")t%$, a. 2i@a$$% 2%)a3iou$* 12. Dithiu )as initiated< the nurse )as effecti/e in her health teaching )hen the client rearked= a. I need to lessen ( calorie and salt intake but ha/e enough fluids b. I need to ha/e regular diet )ith adequate sodiu and fluid intake c. I should restrict ( salt and fluids d. I should s)eat a lot )ith e-ercise to reduce ( bod( fluids 12G. &aria claied that she had been hearing frightening otorc(cle noises< angr( /oices and sounds of rushing floor )ater. The 'riorit( need at this 'oint is a. Trust c. Self estee b. Do/e and belongingness d. Safet( and securit( 1*0. &aria )as started on anti's(chotic edication. The follo)ing are effects of hato'eridol #$!#PT= a. %kathisia b. Pseudo'arkinsonis c. !ontrol the affecti/e s('tos d. oices decreased in both intensit( and content 1*1. The nurse )atches for earl( lithiu to-icit(. 4hich of the follo)ing ust be 'art of health teaching> a. Sei?ures and anuria c. Aigh fe/er and tach(cardia b. Fine treors< nausea< /oiting and d. !huffing gait and restlessness diarrhea 1*2. 4hen agranuloc(tosis is noted< anti's(chotic edication should be )ithheld and the 'atient is )atched for a. !hanges in sensoriu c. A('ertension b. In/oluntar( uscle o/eent d. Signs of infection
55
e. &* Situatio 1=- /aa"%/%t o& (4ia' #o$. iu$i%( 3a$ &$o/ t)% /aa"%/%t 4)a(% t)$ou") $%)a2i'itatio* T)% u$(% &a#%( #)a''%"%( )o0 to /a6i/i@% )%a't) (tatu( to 4$%(%$3% ?ua'it o& 'i&%* 1**. Nurse !arol is assigned in the Neurological 4ard. She is talking care of Bobb( )ith s'inal cord in5ur(. The goals of anageent for Bobb( should include )hich of the follo)ing a. Skeletal fracture reduction and traction < and 'haracological thera'( b. !ontinuous onitoring of /ital signs and iobilit( c. Pre/ent further in5ur( and obser/e for s('tos of 'rogressi/e neurological deficit d. Pharacological and 'h(sical thera'( 1*. Nurse !arol is testing the otor abilit( of Bobb(. She 'erfors this 'rocedure b( a. %sking the client to o/e his u''er and lo)er e-treities b. sing a )as' of cotton fro the shoulder do)n the lo)er e-treities c. entl( 'inching the skin )ith a tongue blade staring at the shoulder le/el do)n to both lo)er e-treities d. %sking the client to s'read the fingers< squee?e the nurse hand and o/e the toes or turn the feet 1*@. In taking care of client )ith s'inal cord in5ur(< the nurse &ST obser/e )hich of the follo)ing nursing inter/entions> a. Prooting adequate breathing < i'ro/ing obilit(< ada'tation to sensor( and 'erce'tual alteration< aintaining skin integrit( and eliination< and 'ro/iding cofort easures b. &aintaining iobilit(< adequate nutrition and eliination< cofort easures 'haracological and res'irator( thera'( to ada'ting sensor( and 'erce'tual alterations c. I'ro/ing eliination < ada'ting to sensor( and 'erce'tual alteration 'haracological and res'irator( thera'( and aintaining skin integrit( d. %da'ting to sensor( and 'erce'tual function< aintaining iobilit( < 'ro/iding cofort easures and i'ro/ing bo)el functions 1*C. "ne of the client assigned to nurse !arol is Noran< )ho is in Aalo Traction. 4hile adinistering the =00 %. &. &edication< she notices that one of the 'ins )as detached< )hich of the follo)ing should be her INITI%D action> a. %sk assistance fro the other staff nurses to iobili?e the client lea/e the client in his 'osition and call for hel' )ith other staff b. Dea/e the client in his 'osition and call for hel' )ith other staff c. !all the neurosurgeon d. Stabili?e the head in a neutral 'osition and ask another nurse to notif( the neurosurgeon e. f. g. h. i.
1*E. Nursing care of Noran )ith Aalo Traction requires eticulous care under the halo /est )hich of the follo)ing nursing easures &ST be done in 'ro/iding care to Noran> a. Ins'ect for e-cessi/e 'ers'iration < redness and skin blistering< )ash the torso and change liner 'eriodicall( b. Ins'ecting the skin for redness and blistering < and o'en the /est 'eriodicall( to 'roote cofort c. 4ash the torso and lea/e the liner in the bod( of the client and a''l( 'o)der es'eciall( on the bon( 'roinences d. %''l(ing 'o)der inside the /est to 're/ent skin breakdo)n after )ashing the torso e. &* Situatio 5<- M$* La@o, a >9 %a$ o'. /a'% 0a( a./itt%. to t)% )o(4ita' to $u'% out a iu$ t)at /a )a3% $%(u't%. &$o/ a &a'' 0)i'% "oi" u4 t)% (tai$( o& )i( )o/%* H% )a( o $%#o''%#tio o& 0)at #au(%. )i/ to &a''* W)i'% i t)% )o(4ita', M$* La@o %6)i2it%. /%ta' (tatu( #)a"%( i#'u.i" .i(o$i%tatio a. #o&u(io* "* 1*. 4hich of these questions )ould the nurse ask to gather data about &r. Da?o;s orientation status> a. %sk client the brothers and sisters naes< children and grandchildren;s naes b. %sk the client to re'eat C to E digits for)ard c. %sk client;s nae< address< current location< date< tie and (ear d. Nae of * ob5ects +e.g. < table < s'oon< shirt, and ha/e client re'eat the three ob5ects ask the client to re'eat the again after @ inutes. 1*G. In order to 're/ent co'lications for )hich &r. Da?o a( be at risk. 4hich of these )ill the nurse 'rioriti?e in 'lanning and outcoe identification> &r. Da?o )ill= a. 4ill aintain e-isting abilit( to 'erfor acti/ities of dail( li/ing b. Reain safe and free fro further in5ur( c. 4ill follo) /aried schedules of acti/it( and rest d. ernonstrate decreased an-iet( le/els 10. Prior to the fall accident < the )ife noted &r. Da?o;s changes in slee'ing and eating habits getting irritated easil( and lacking interest in usuall( 'leasurable things. The nurse infers correctl( a 'ossibilit( of the 'resence of a. "bsession
