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DISCLAIMER: This manuscript is a combination of actual past board examinations and high yield concepts. Answers are
well - research.
COMMUNITY HEALTH NURSING

Situation 1.Community Health Nursing is a unique blend of nursing and public health
practice woven into a human service that properly developed and applied has a
tremendous impact on human well being.
1. The primary goal of Community Health Nursing is to:
A. Support and supplement the efforts of the medical professions in the
promotion of health and prevention of illness
B. Enhance the capacity of individuals, families and communities to cope with
their heath needs
C. Increase the productivity of the people
D. Raise the level of health of the citizenry

Answer: B
Rationale: The primary goal of Community Health Nursing is to help communities
and families to cope with the discontinuities of health and threats in such a way as
to maximize their potential for high level wellness, as well as to promote
reciprocally supportive relationship between people and their physical and social
environment. (Community Health Nursing Services in the Philippines)

2. The context of Community Health Nursing is based on the nurse's evaluation about
the:
A. Existing health problems and needs of the people
B. Current health status of the people
C. Department of Heath (DOH) goals
D. Devolution of health

Answer: A
Rationale: The context of Community Health Nursing is based on the nurse's
evaluation about the existing health problems and needs of the people. One of the
principles of CHN states that Community Health Nursing is based on the recognized
needs of individuals, families, communities and groups. (Community Health Nursing
Services in the Philippines)

3. Community Health Nursing is a specialized field of nursing that follows the basic
principles in Community Development work. Which of the following statements best
described Community Development as a process of empowering people in the
community?
A. Community development may allow women to discover and strengthen
their innate capabilities to enjoy and utilize equal opportunities in all
aspects of development work
B. Sustainability aspects of development strategies can be taken into
consideration
C. Community development is solely confined to the meeting of the day to day
survival of the people
D. Community development is a learning process where both women and men
participate to improve their lives

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Answer: D
Rationale: Community Development is defined as an organized effort of people to
improve the conditions of the community life and the capacity of the people for
participation, self-direction and integrated efforts in community affairs in which
development is accomplished by the people. Everyone has something to contribute
to the life of the community.
It is not solely for women (option A) and not a short term process (option C). (C.E
Jimenez, CO-PAR)

4. If a particular health service fails, the most basic question is:
A. Is this what the people demanded?
B. What went wrong?
C. Is this what the people need?
D. Who is responsible for the failure?

Answer: C
Rationale: If a particular health service fails, it is important to reassess the felt
needs of the people not their demands (option A). (Community Health Nursing

5. Which of the following statement is correct?
A. If people are not attending to the services offered by the health staff, the team must
reassess the needs of the people
B. In participatory approach, the nurse must devotedly adhere to what the people want
C. In a peasant community where people are fighting for land ownership, the nurse must
not participate as this is not a health concern
D. Nurses must not join protest actions as nurses should always be neutral at all times

Answer: A
Rationale: If people are not attending to the services offered by the health staff, the
team must reassess the needs of the people. This is base on the principle that
Community Health Nursing is based on the recognized needs of individuals,
families, communities and groups. (Community Health Nursing Services in the
Philippines)

Situation 2. Nurse Sid, a public health nurse, prepares a community health nursing care
plan utilizing the nursing process, which is responsive to the health promotion needs of
the community.
6. To obtain a 100% population count of the community, Nurse Sid should need to do
a:
A. Survey C. Census
B. One to one interview D. Sampling of the population

Answer: C
Rationale: The assessment process involves the collection of relevant data. It
employs various methods to collect data. A census is the procedure of
systematically acquiring and recording information about the members of a given
population. It is a regularly occurring and official count of a particular population. It

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obtains a 100% population count of the community. (Public Health Nursing in the
Philippines)

7. Which of the following is a well-stated objective in a community health nursing care
plan?
A. To increase the number of mothers coming for prenatal check-up by 25% in 6 months
time
B. To increase the number of home visits by 50%
C. To increase the coverage for immunization in 1 year time
D. To increase the number of children receiving food assistance

Answer: A
Rationale: A well-stated objective should be SMART (Specific, Measurable,
Attainable, Realistic and Time-Bound).

8. Identification of health risks in the community is a step in formulating a community
health diagnosis. Which of the following methods Nurse Sid should do to best
facilitate the identification of health risks threatening the community?
A. Assess community resources and industries available
B. Familiarize with the prevalent lifestyle of the people within the community
C. Study health center records and reports
D. Review of vital statistics available

Answer: D
Rationale: To facilitate identification of health risks threatening the community, the
community health nurse reviews available vital statistics. Statistics refers to a
systematic approach of obtaining, organizing and analyzing numerical facts so that
conclusion may be drawn from them. Specifically, vital statistics refers to the
systematic study of vital events such as births, illnesses, marriages, divorce,
separation and deaths. The statistics of disease (morbidity) and death (mortality)
indicate the state of health of a community and the success or failure of health
work. (Public Health Nursing in the Philippines)

9. The community health diagnosis is an important input to the formulation of a
community health nursing care plan. In order to assure a successful
implementation of the care plan, the diagnosis must be carried out in a manner
where:
A. An outside consultant determines what data to collect
B. The community is directly involved in data collection and analysis
C. The nurse delegates the collection of data to the barangay health workers
D. All the members of the rural health unit participates in data collection

Answer: B
Rationale: In community health nursing, implementation involves various nursing
interventions which have been determined by the goals/objectives that have been
previously set. The public health nurse carry out nursing procedures which are
consistent with the nursing care plan, are adapted to present situations which
promote a safe and therapeutic environment.

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Public health nurses involve the patient and his/her family in the care provided in
order to motivate them to assume responsibility for his or their care and to be able
to teach and maintain a desired level of function. Explaining and answering
questions to clarify doubts, to maximize the patients confidence and ability to care
for himself/themselves. Thus, the role of the community health nurses shift from
direct care giver to that of a teacher. (Public Health Nursing in the Philippines)

10. Which criterion in priority setting of health problems is used only in
community health care?
A. Magnitude of the health problem
B. Preventive potential of the health problem
C. Nature of the problem presented
D. Modifiability of the problem

Answer: A
Rationale: Magnitude of the health problem refers to the percentage of the
population affected by a health problem.
(Public Health Nursing in the Philippines)

Situation 3.The application of the nursing process is rational method of planning and
providing nursing care. As basic tool in professional nursing practice, its utilization
ensures competent and safe practice. It is a scientific tool that is utilized also in
Community Health Nursing.
1. Which of the following is Community Health Nursing Assessment?
A. Auditing Nursing Record C. Prioritizing needs
B. Monitoring health services D. Intensive fact-finding

Answer: D
Rationale: Assessment is the systematic and continuous collection, organization,
validation, and documentation of data (information). All phases of the nursing
process depend on the accurate and complete collection of data. Data collection
(intensive fact-finding) is the process of gathering information about a client's
health status. It must be both systematic and continuous to prevent omission of
significant data and reflect a client's changing health status.
(Community Health Nursing Services in the Philippines)

2. When the nurse invites other members of the nursing team to develop evaluation
parameters, this process is called:
A. Interpreting data C. Planning nursing action
B. Tabulating data D. Putting plan of action

Answer: C
Rationale: In the planning phase, the nurse performs prioritization, evaluation of
parameters, goal setting, plan of action construction, and development of an
operational plan.

3. When the nurse performs appraisals, this process is called:
A. Assessment C. Evaluation

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B. Planning D. Diagnosing

Answer: C
Rationale: In the evaluation phase, the nurse perform auditing and appraisal. The
elements of evaluation includes: structural (inputs), process (methods), and outcome
(outputs).

4. Once the nurse initiates contact with a client, asking questions to gather data, this
process is called:
A. Implementation C. Planning
B. Evaluation D. Assessment

Answer: D
Rationale: Data collection is done during the Assessment phase. It is the process of
gathering information about a client's health status. It must be both systematic and
continuous to prevent omission of significant data and reflect a client's changing
health status. There are 4 phases of data gathering: data collection, collation,
presentation or tabulation, and analysis.

5. When the RHU nurse provides health teaching to individuals or families, this process
is called:
A. Intervention C. Assessment
B. Planning D. Evaluation

Answer: A
Rationale: During the implementation or intervention phase, the nurse carries out
interventions (such as providing health teachings) and utilizes resources.

Situation 4. There are several factors in the ecosystem which affect the optimum level of
functioning (OLOF) of individuals, families and communities. The nurse must be
knowledgeable on this.
6. The modern concept of health refers to:
A. How individuals maintain a maximum level of wellness
B. How individuals can be called disease-free
C. How individuals avoid diseases
D. How individuals can avail of their immune system

Answer: A
Rationale: The modern concept of health refers to the optimum level of functioning
(OLOF) or the maximum level of wellness of individual, families and communities.

7. In the Health Care Delivery System, ideally, rehabilitation services begin:
A. Upon admission of the client in the health care system
B. Upon discharge of the client from the health care system
C. After the client's physical condition stabilizes

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D. Soon after the client had requested for rehabilitation services

Answer: A
Rationale: In the Health Care Delivery System, ideally, rehabilitation services begin
upon admission of the client in the health care system. (Community Health Nursing
8. The factor in the ecosystem affecting the individuals health that is involved in the
provision of essential health services whether community-based, accessible,
sustainable and affordable is the:
A. Socio-economic influences C. Behavioral
B. Health Care Delivery System D. Political

Answer: B
Rationale: Health Care Delivery System is the factor in the ecosystem affecting the
individuals health that is involved in the provision of essential health services
whether community-based, accessible, sustainable and affordable. Although
promotive and preventive health measures are emphasized in community health,
the availability and accessibility of curative and rehabilitative services also affect
people's health. (Community Health Nursing Services in the Philippines)

9. The factor in the ecosystem affecting the individual's health that is involved in the
menace of pollution, basically man-made, is:
A. Behavioral C. Environmental influences
B. Socio-economic D. Health Care Delivery System

Answer: C
Rationale: Environmental influences are the factor in the ecosystem that is involved
in the menace of pollution, which has been growing over the years and has greatly
affected the health of the people. The disease today is largely man-made. Examples
of these are communicable diseases due to poor sanitation, poor garbage
collection, smoking, air pollution and utilization of chemicals such as pesticides.

10. Which is not an example of behavioral influences in OLOF on health status?
A. Cigarette smoking and alcohol drinking
B. Exposure to toxic substances in the workplace
C. Sedentary lifestyle of an office worker
D. A grandmother with an adult-onset diabetes

Answer: B
Rationale: Behavioral influences refer to the factor in the ecosystem affecting the
individuals health through certain habits that a person has. These may be in the form of
smoking, intake of alcoholic drinks, substance abuse or lack of exercise. The people's
lifestyle, health care and child rearing practices are shaped, to a large extent, by their
culture and ethnic heritage.

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Situation 5. Public health is dedicated to the common attainment of the highest level of
physical, mental and social well-being and longevity consistent with available knowledge
and resources at a given time and place.
11. According to Dr. C.E. Winslow, which of the following is the goal of Public
Health?
A. For promotion of health and prevention and diseases
B. For people to be organized in their health efforts
C. For people to have access to basic health services
D. For people to attain their birthrights and longevity

Answer: D
Rationale: Dr. C.E. Winslow defines public health as the science and art of preventing
disease, prolonging life, promoting health and efficiency through organized community
effort for the sanitation of the environment, control of communicable diseases, the
education of individuals in personal hygiene, the organization of medical and nursing
services for the early diagnosis and preventive treatment of disease, and the development
of the social machinery to ensure everyone a standard of living adequate for the
maintenance of health, so organizing these benefits as to enable every citizen to realize
his birthright of health and longevity. (Public Health Nursing in the Philippines)

12. According to Dr. Margaret Shetland, the philosophy of public health nursing is
based on which of the following?
A. The worth and dignity of man
B. The mandate of the state to protect the birthrights of its citizens
C. Health and longevity as birthrights
D. Public health nursing as a specialized field of nursing

Answer: A
Rationale: According to Dr. Margaret Shetland, the philosophy of community health
nursing is based on the worth and dignity of man. (Community Health Nursing

13. Which of the following is the most prominent feature of public health nursing?
A. It involves providing home care to sick people who are not confined in the hospital
B. Public health nursing focuses on preventive, not curative services
C. The public health nurse functions as part of a team providing a public health nursing
service
D. Services are provided free of charge to people within the catchment area

Answer: B
Rationale: The public health nurses in this country are using their nursing skills in the
application of public health functions and social assistance within the context of public
health programs designed to promote health and prevent diseases. Public health nursing
focuses on preventive, not curative services. (Public Health Nursing in the Philippines)

14. The public health nurse is the supervisor of rural health midwives. Which of
the following is a supervisory function of the pubic health nurse?
A. Referring cases or patients to the midwife
B. Providing technical guidance to the midwife

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C. Proving nursing care to cases referred by the midwife
D. Formulating and implementing training programs for midwives

Answer: B
Rationale: Generally, the public health nurse is the supervisor of the midwives and
other auxiliary health workers in the catchment area. This is in accordance with
agencys policies and in a manner that improves performance and promotes job
satisfaction. During the visit, the public health nurse identifies together with the
supervisee any issue or problem encountered and addresses them accordingly. If it
is a technical matter like a breach in the procedure or established protocol,
coaching is immediately instituted.
Option D is incorrect because if problems or issues identified needs further capacity
enhancement or training for the supervisee, then the nurse arranges, not formulate
or implement, for the conduct of this training. (Public Health Nursing in the
Philippines)

15. Qualifications to be a public health nurse includes which of the following:
1. Good physical and mental health
2. BSN graduate
3. Registered nurse
4. Masters degree in Nursing
5. 3 years experience as a Clinical Instructor
A. 1, 2 and 3 C. 1, 4 and 5
B. 1, 3 and 4 D. 2, 3 and 4

Answer: A
Rationale: The Standards of Public Health Nursing in the Philippines developed by the
National League of Philippine Government Nurses in 2005 described the qualification and
functions of a Public Health Nurse.The PHN has the professional, personal and other
qualifications that are appropriate to his/her job responsibilities. They are as follows: is a
graduate of BSN (2) and a Registered Nurse (3); has the following personal qualities and
professional competencies such as good physical and mental health (1), interest and
willingness to work in the community, with leadership potential, resourcefulness and
creativity, honesty and integrity, active membership to professional nursing organizations.

Situation 6. Primary Health Care as an approach to delivery of health care services
16. Which one is the goal of Primary Health Care in the Philippines?
A. Reorientation and reorganization of the national health care system with the
establishment of functional support mechanism
B. Essential health care made universally accessible, acceptable, available, and
affordable to all
C. Health for all Filipinos and health in the hands of the people by the year 2020
D. To strengthen the health care system, let the people manage their own health care

Answer: C
Rationale: The goal of Primary Health Care in the Philippines is Health for all Filipinos
and health in the hands of the people by the year 2020. (Public Health Nursing in the
Philippines)

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17. The mission of Primary Health Care refers to which of the following?
A. To strengthen the health care system, let the people manage their own health care
B. Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor,
and shall lead the quest for excellence in health
C. Health for all by the year 2020
D. Health for all Filipinos and health in the hands of the people by the year 2020

Answer: A
Rationale: The mission of Primary Health Care in the Philippines is To strengthen
the health care system, let the people manage their own health care.

18. The law that provided mandate for the implementation of Primary Health
Care in the Philippines is:
A. R.A. 7160 C. R.A. 8423
B. LOI 949 D. R.A. 9255

Answer: B
Rationale: Primary Health Care was declared during the First International Conference on
Primary Health Care held in Alma Ata, USSR on September 6-12, 1978 by WHO. The goal
was Health for All by the year 2000. This was adopted in the Philippines through Letter
of Instruction (LOI) 949 signed by President Marcos on October 19, 1979 and has an
underlying theme of Health in the hands of the people by 2020.

19. Which of the following is not a corner stone of Primary Health Care?
A. Support mechanisms made available
B. Active community participation
C. Intra and intersectoral solicitation linkages
D. Use of appropriate technology

Answer: C
Rationale: The four corner stones or pillars in PHC are as follows: active community
participation (option B); intra and inter-sectoral linkages (option C); use of appropriate
technology (option D); and support mechanism made available (option A).

20. Which does not describe Primary Health Care?
A. It emphasizes partnership between health care providers and the people
B. It is a total approach to community development
C. It stresses the importance of linkages
D. It aims to provide free health services to the people

Answer: D
Rationale: Option D is incorrect because PHC aims to provide affordable, not free, health
services to the people. (Public Health Nursing in the Philippines)

Situation 7.Clinic Visit is done at the health center or health station so that the community
health nurse can provide the necessary health care services to the people in the
community. On the other hand, home visit is a family-nurse contact which allows the

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health worker to assess the home and family situations in order to provide necessary
nursing care.
21. During clinic visit, which among the following activities is done during pre-
consultation conference?
A. One-on-one counselling C. First come, first served queuing
B. Record preparation D. Pre-clinic lecture

Answer: D
Rationale: Pre-clinic lecture is usually done during pre-consultation conference that is
conducted prior to the admission of patients, which is one way of providing health
education. (Public Health Nursing in the Philippines)

22. Certain DOH programs utilize an acceptable decision to which the nurse has
to follow. What should the public health nurse do to a program-based case?
A. Manage the case C. Provide first aid treatment
B. Refer to the physician D. Refer the case to the next level of care

Answer: A
Rationale: In triaging, a public health nurse manages a program-based case. Certain
programs of the DOH like the IMCI utilize an acceptable decision to which the nurse has to
follow in the management of a simple case. All non-program based cases are refer to the
physician (option B). All emergency cases are provided with first aid treatment and refer
the case to the next level of care (option C and D). (Public Health Nursing in the
Philippines)

23. Clinic visit is being executed by a health team. Who acts as a leader in
planning the clinical activities?
A. Barangay Health Worker C. Public Health Nurse
B. Physician-in-Charge D. Rural Health Midwife

Answer: B
Rationale: The Physician-in-Charge is the leader in planning the clinical activities. (Public
Health Nursing in the Philippines)

24. The following best describes a home visit, except:
A. May or may not be recorded
B. Extension of the services of the health center
C. A professional contact made by the nurse
D. Should have an objective

Answer: A
Rationale: Home visit is a professional contact made by the nurse and an extension of the
services of the health center. When preparing for a home visit, it should have a purpose or
objective. Home visit should always be recorded or documented (making option C
incorrect). (Public Health Nursing in the Philippines)

25. Planning for a home visit is an essential tool in achieving best results in
health care. The following are principles in a home visit, except:
A. Planning should be flexible and practical

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B. Home visit should have a purpose
C. Plans are based in available information including those from other agencies that may
have rendered services to the family
D. Planning of continuing care must be developed by the nurse

Answer: D
Rationale: The following are principles of home visits: A home visit must have a purpose
or objective (option)

Situation 8. The following procedures are very important to the public health nurse in
rendering effective nursing care to clients in varied settings.
36. The nurse should understand which rationale when performing the bag
technique?
A. It should not overshadow the concerns for the client
B. It should render effective nursing care to clients or other family members
C. It should minimize or prevent the spread of infection
D. It should save time and effort when performing nursing procedures

Answer: B
Rationale: The rationale when performing the bag technique is that it should render
effective nursing care to clients or other family members. (Community Health Nursing

37. Tourniquet test or Rumpel-Lead's test is used as screening for dengue. If the
nurse counted 10 petechial spots in the imaginary one square inch just below the
BP cuff or in the antecubital fossa, this should be interpreted as:
A. Positive C. Alarming
B. Negative D. Warning

Answer: B
Rationale: Tourniquet test or Rumpel-Lead's test is used as screening for dengue. An
imaginary one square inch just below the BP cuff or in the antecubital fossa is made to
check for the presence of petechial rashes. If it manifested 20 or more petechial rashes, it
indicates a positive dengue result. If it is less than 20 it means that the test is negative.

38. The nurse utilizes three different agents when wiping the thermometer after
use. Arrange them according to sequence:
A. 3x soap, 3x water, 3x alcohol C. 3x soap, 3x water, 1x alcohol
B. 1x soap, 1x water, 1x alcohol D. 1x soap, 1x water, 3x alcohol

Answer: C
Rationale: When wiping the thermometer after use, clean the thermometer in a
downward spiral motion from the stem to the bulb, holding it over the waste paper bag
using the following technique: 1
st
- 3 cotton balls moistened with soap. Discard. 2
Nd
- 3
cotton balls moistened with water. 3
Rd
- 1 cotton ball moistened with alcohol, then wrap
around the bulb of the thermometer and lay it inside the kidney basin. (Community Health
Nursing Services in the Philippines)

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39. An orange result of a Benedict's test should be interpreted by the nurse as to
which extent of glucosuria?
A. (-) B. + C. ++ D. +++

Answer: D
Rationale: An orange result of a Benedict's test indicates a+++ result.

40. I the result of a Heat and Acetic acid test is clear, the nurse knows that:
A. Albuminuria is abnormal
B. Protein is traced in the urine
C. This is a positive result of protein leak
D. There is no albumin in the urine

Answer: D
Rationale: If the result of a Heat and Acetic acid test is clear, there is no albumin in the
urine. If it is cloudy, the nurse should repeat the procedure. If on the second test, the
result is still cloudy then it is interpreted as positive protein leak or positive proteinuria.

Situation9. COPAR (Community Organizing Participatory Action Research) recognizes
people's participation as a tool for community development.
41. Arrange the activities of community organizing as a continuous sustained
process for community development.
A. Organization, Education, Mobilization
B. Organization, Mobilization, Education
C. Education, Organization, Mobilization
D. Education, Mobilization, Organization

Answer: C
Rationale: Community organizing as a continuous sustained process for community
development involves the process of Education, Organization and Mobilization.

42. The following statements pertain to Community Organizing, except:
A. Its goal is community development
B. A never-ending process once started
C. Can apply for increasing awareness
D. A process for increasing organization and initiating responsible action

Answer: B
Rationale: Community Organizing is a process by which people, health services and
agencies of the community are brought together to learn about the common problems,
identify these problems as their own, plan the kind of action needed to solve these
problems and act on this basis. Its goal is community development (option A). It can be
applied to increase the awareness of the community (option C). It is also a process for
increasing organization and initiating responsible action (option D).
Option B is incorrect because it sets up action pattern to solve problems, not a never-
ending process once started. (Community Health Nursing Services in the Philippines)

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43. Which among the following does not pertain to Participatory Action
Research?
A. Problem identification involves the community or group experiencing the problem
B. Method of data gathering is determined by local culture and innovativeness
C. Use of research results is within the full control of the people
D. It is done by an outsider utilizing technical quantitative techniques for publication use

Answer: D
Rationale Option D is incorrect because it is not done by an outsider. (Community Health

44. Manageable units of the community to facilitate service delivery and people's
participation is called the:
A. Core group C. Spot map
B. Small group D. Organizing group

Answer: A
Rationale: Core group is the manageable units of the community to facilitate service
delivery and people's participation. (Community Health Nursing Services in the
Philippines)

45. The basic reasons why community organizers need to phase out from the
community is to enable the:
A. People to exercise self-reliance
B. Nurse to open community organization work in other depressed communities
C. People's organization to expand their coverage
D. People to test their unity and strength

Answer: A
Rationale: The reason why community organizers need to phase out from the community
is to enable the people to exercise self-reliance. People are given a chance to study their
problems, offer solutions and give a chance to plan an action. (Community Health Nursing

Situation 10. Community Organization is a process wherein people in the community,
health care providers and agencies in the community are brought together.
46. Which of the following is the primary principle involved in community
organization?
A. Technique in asking questions
B. Assembly of community leaders
C. Defined functions in each group
D. Planning group needs

Answer: D
Rationale: The primary principle involved in community organization is planning group
needs to represent all people concerned and the discussion must include people with
technical knowledge of health problems. (Community Health Nursing Services in the
Philippines)

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47. Which one of the following is not an objective of community organization?
A. Learn about common problems
B. Plan the kind of action needed to solve problems
C. Never to act on issues presented
D. Identify problems as their own

Answer: C
Rationale: Community Organizing is a process by which people, health services and
agencies of the community are brought together to learn about the common problems
(option A), identify these problems as their own (option D), plan the kind of action needed
to solve these problems (option B) and act on this basis. (Community Health Nursing

48. Which basic method can determine the extent to which the basic needs are
met for the health workers to bring about the adjustment between need and
resources?
A. Fact finding C. Determination of needs
B. Program formation D. Education and Interpretation

Answer: A
Rationale: Fact finding is the basic method that serves to identify needs, determine the
extent to which the basic needs are met and make known gaps and overlaps in existing
services. This will also help health workers to bring about the adjustment between need
and resources. (Community Health Nursing Services in the Philippines)

49. As a nurse, you have gained entry in the community. Which initial step is
done?
A. List names of persons to contact
B. Gather information from persons and records
C. Arrange the first meeting
D. Prepare the agenda

Answer: B
Rationale: The initial step when the nurse gained entry in the community is gathering
initial information about the community from other members of the RHU or from records
and reports. (Community Health Nursing Services in the Philippines)

50. Which of the following should a nurse do if the purpose in community
organizing is to integrate with the people?
a. Live with the people
b. Assign community officers
c. Be punctual in reporting at the Rural Health Unit (RHU)
d. Reside in the home of the Municipal Health Officer

Answer: A
Rationale: When integrating with the people, it is crucial for the nurse to reside in his/her
area of assignment. This is the first act of integrating with the people. Living with them
will give the nurse an in depth participation in community health problems and needs.

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Situation 11. Community Assessment through Vital Statistics and Epidemiology
51. Major factors affecting population include the following, except:
A. Morbidity C. Migration
B. Mortality D. Births

Answer: A
Rationale: Major factors affecting population include the following: Mortality or the
number of deaths, Birth rates and even Migration or movement of people from one
locality to another.
Option A is incorrect because morbidity doesn't affect population change; it only
determines the number of people acquiring diseases or illnesses. (Community Health

52. The town of Bagong Pag-asa has a population of 100,000 as of July 1, 2008
(midyear) as per calendar year 2008 (January to December) 2,000 died. Which
formula below should be used to compute the crude death rate?
A. 100,000 / 100,000 x 1,000
B. 2,000 / 100,000 x 100
C. 100,000 / 2,000 x 1,000
D. 2,000 / 100,000 x 1,000

Answer: D
Rationale: Crude death rate is a measure of one mortality from all causes which
may result in a decease of population. The formula of CDR is: total number of
deaths registered in a given calendar year (e.g., 2,000 in 2008) divided by the
estimated population as of the same year (e.g., 100,000 in July 1, midyear)
multiplied by 1,000. (Community Health Nursing Services in the Philippines)

53. Incidence rate means new cases as percent of population and prevalence rate
means cases in a given period of time as percent of population. Which formula
below is a prevalence rate?
A. Number of cases of a specific disease / 1,000 estimated population x 100
B. Total number of cases of a disease (old + new) / 1,000 estimated population at the
time x 100
C. Number of cases of a specific disease during a specific time / Estimated population
exposed to that disease during that time x 100
D. Total number of cases of a disease (old + new) at a given time / Estimated population
at the time x 100

Answer: D
Rationale: Prevalence rate measures the proportion of the population which
exhibits a particular disease at a particular time. This can only be determined
following a survey of the population concerned. It deals with the total (old and new)
number of cases. The formula of PR is: Total number of cases of a disease (old +
new) at a given time divided by the estimated population examined at same given
time multiplied by 100. (Community Health Nursing Services in the Philippines)

54. The following are steps in data processing. As a nurse, you should know its

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proper sequencing:
1. Data analysis
2. Data collection
3. Data presentation
4. Data collation
A. 2, 4, 3 and 1 C. 2, 4, 1 and 3
B. 2, 3, 4 and 1 D. 2, 3, 1 and 4

Answer: A
Rationale: The proper sequencing of steps in data processing are as follows: Data
collection, data collation, data presentation or tabulation, and data analysis.

55. Which of the following patterns is intermittent and confined to a certain
geographical area or locality?
A. Pandemic C. Epidemic
B. Endemic D. Sporadic

Answer: D
Rationale: Sporadic is an epidemiological event that is intermittent in nature and confined
to a certain geographical area or locality. (Community Health Nursing Services in the
Philippines)

Situation 12.The Department of Health implements various health programs and projects
in order to achieve its goals and objectives. As a Public Health Nurse, you are one of the
implementers of these programs at the municipal level.
56. The mission of the Department of Health is:
A. The leader, staunch advocate and model in promoting Health for All in the Philippines
B. Health for all Filipinos
C. Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor
and shall lead the quest for excellence in health
D. To strengthen the health care system, let the people manage their own health care

Answer: C
Rationale: The mission of the Department of Health is Guarantee equitable, sustainable
and quality health for all Filipinos, especially the poor and shall lead the quest for
excellence in health.

57. Which among the following is not considered as a specific role of the DOH
based on Executive Order 102?
A. Leader in health
B. Reformist for health development
C. Enabler and capacity builder
D. Administrator of specific services

Answer: B
Rationale: The specific role of the DOH based on Executive Order 102 are as follows:
Leadership in health (option A); Enabler and capacity builder (option C); and Administrator
of specific services (option D). (Public Health Nursing in the Philippines)

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58. The following are included in the 8 Millennium Development Goals that are
based on the fundamental values of freedom, equality, solidarity, tolerance, health,
respect for nature, and shared responsibility. Which is not health related?
A. Eradicate extreme poverty
B. Improve maternal health
C. Promote gender equality and empower women
D. Ensure environmental sustainability

Answer: C
Rationale: The 8 Millennium Development Goals are based on the fundamental values of
freedom, equality, solidarity, tolerance, health, respect for nature, and shared
responsibility. All four options are part of the MDGs, however, only option C (Promote
gender equality and empower women) is not health related. (Public Health Nursing in the
Philippines)

59. The goal of the DOH is Health Sector Reform Agenda (HSRA), with the
National Objectives for Health (NOH) serving as the road map for all stakeholders in
health. All of the following are reasons for health sector reform, except:
A. Slowing down in the reduction of both Infant and Maternal Mortality Rates
B. Rising and high burden from chronic, degenerative diseases and infectious diseases,
respectively
C. Unattended emerging health risks from environmental and work related factors
D. Burden of disease is heaviest on the affluent

Answer: D
Rationale: The goal of the DOH is Health Sector Reform Agenda (HSRA), with the National
Objectives for Health (NOH) serving as the road map for all stakeholders in health. The
following are the rationale or reasons for health sector reform: Slowing down in the
reduction of both Infant (IMR) and Maternal (MMR) Mortality

60. The Health Sector Reform Agenda (HSRA) utilizes FOURmula ONE for Health
as its framework having four components such as health financing, health
regulation, health service delivery and good governance. Which of the following is
not included in the goals of this framework?
A. Better health outcomes
B. More responsive health systems
C. Streamlining health system bureaucracy
D. Equitable health care financing

Answer: C
Rationale: The Health Sector Reform Agenda (HSRA) utilizes FOURmula ONE for Health as
its framework having four components such as health financing, health regulation, health
service delivery and good governance. The goals of FOURmula ONE for Health are as
follows: Better health outcomes (option A); More responsive health systems (option B);
and Equitable health care financing (option D). (Public Health Nursing in the Philippines)

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Situation 13. There are other fields of nursing where public health nurses are working.
They are in schools and work settings.

61. Nurse Feng is a newly hired school nurse. She wants to know the objectives of
school nursing. The following are specific objectives of school nursing, except:
A. To promote and maintain the health of the school populace by providing
comprehensive and quality nursing care
B. Provide quality nursing service to the school population
C. Establish/strengthen linkages with government and non-government
organization/agencies for school community health work
D. Conduct and participate in researches related to nursing care

Answer: A
Rationale: To promote and maintain the health of the school populace by providing
comprehensive and quality nursing care is the general objective of school nursing.

62. The following are duties and responsibilities of Nurse Feng, except:
A. Community outreach like attending community assemblies and organizing school
community health councils
B. Health and nutrition assessment including other screening procedures such as vision
and hearing
C. Supervision of the health and safety of the school plant
D. Coordinates with other government agencies relative to the implementation of the
implementing rules and regulations

Answer: D
Rationale: Coordinates with other government agencies relative to the implementation of
the implementing rules and regulations is one of the duties of an occupational health
nurse.

63. One of the functions of Nurse Feng is health assessment. Which of the
following is not true regarding the conduct of a health assessment?
A. Health assessment should include appraisal of the general physical and mental
condition
B. Before the health assessment, the nurse should conduct a classroom health lecture
C. Every school child should be examined twice a year
D. Three to five children at a time should be in waiting for the assessment

Answer: C
Rationale: Health assessment aims to discover the signs of illness and physical defects in
order to correct them, check on the health habits of pupils and prevent the progress of
those which cannot be corrected. Every school child should be examined once, not twice,
a year and as the need arises like during epidemics.

64. Nurse Cezar is a newly hired occupational health nurse in an international
company. He knows that the following are functions of an occupational health
nurse, except:
A. Recommends to Local Health Authority the issuance of license/business permits and
suspensions or revocation of the same

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B. Height and weight measurement and nutritional status determination
C. Provide control measures to reduce noise, dust, health and other hazards
D. Informs all affected workers regarding the nature of hazards and the reasons for the
control measures and protective equipment

Answer: B
Rationale: Height and weight measurement is a procedure for evaluating the tallness or
the shortness and the heaviness of a pupil. It offers the most acceptable parameter and is
the simplest way to determine the nutritional status of school children. It is one of the
duties and responsibilities of a school nurse.

65. Nurse Cezar is oriented on the mission of occupational health and safety,
which is:
A. To conduct and/or assist other health personnel in outbreak investigation
B. To assure so far as possible every working man and woman in the country is safe and
in healthful working conditions
C. To promote and maintain the health and safety of workers through a systematic
process of assessment, planning, intervention and evaluation
D. To provide summary of data on health services delivery and selected program
accomplished indicators at the barangay, municipality/city, district, provincial, regional
and national levels

Answer: B
Rationale: The mission of occupational health and safety is to assure so far as possible
every working man and woman in the country is safe and in healthful working conditions.

Situation 14. The following are programs aimed at preventing non-communicable
diseases.
66. The following are nutrition-related problems that lead to non-communicable
disease, except:
A. Obesity
B. Increased intake of processed/instant foods
C. Increased dietary fiber
D. Increased fat intake

Answer: C
Rationale: Eating a balanced diet is important to health. Studies prove that following
nutrition guidelines can prevent major non-communicable diseases. The following are
nutrition-related problems that lead to non-communicable disease:

67. One of the roles of the public health nurse in promoting a smoke-free
environment is assisting smokers to quit. The following are the four As used in
helping smokers to quit, except:
A. Ask C. Arrange follow up
B. Announce D. Advise to stop smoking

Answer: B
Rationale: Realizing that health workers in most communities do not have much time nor
resources, WHO has a simplified recommendation that any health worker can apply

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readily to any client and in any setting. This involves the four As in helping smokers to
quit.
A - ASK
Step 1 Assess smoking status. Identify all tobacco users at every visit.
A - ADVISE TO STOP SMOKING AND THAT SMOKING CAN CAUSE DISEASE, EVEN
DEATH
Step 2 Target clients motivation to quit.
Step 3 Encourage complete cessation.
Step 4 Discuss alternatives and substitutes to smoking.
A - ASSIST
Step 5 Develop a quit plan with the smoker. Set a QUIT DATE.
Step 6 Provide supplementary materials to assist the smoker.
Step 7 Develop a plan to prevent relapse.

A ARRANGE FOLLOW-UP

Step 8 Set follow-up sessions to monitor progress and prevent relapses.

68. Sedentary lifestyle, a life spent with little or no physical activity, has grave
consequences to ones health. The following are health benefits of regular physical
activity, except:
A. Promotes psychological well-being and reduces feelings of stress
B. Reduces the risk of developing colon cancer
C. Helps reduce blood pressure in people who already have hypertension
D. Lowers both total blood cholesterol and triglycerides and may increase low-density
lipoproteins

Answer: D
Rationale: Sedentary lifestyle, a life spent with little or no physical activity, has grave
consequences to ones health. The lack of adequate physical activity has been associated
with increased risk for cardiovascular diseases, diabetes mellitus, and obesity. It also
increases the risks of colon and breast cancer, high blood pressure, lipid disorder,
osteoporosis, depression and anxiety.

69. Which of the following is the leading cause of visual impairment and of
bilateral or monocular low vision?
A. Errors of refraction C. Optic atrophy
B. Glaucoma D. Cataract

Answer: A
Rationale: Errors of refraction is the leading cause of visual impairment and of bilateral or
monocular low vision.

70. What is the vision of the National Prevention of Blindness Program?
A. Institutionalize visual acuity screening for all sectors by 2010
B. Strengthen partnership among and with stakeholders to eliminate avoidable blindness
in the Philippines

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C. Reduce the prevalence of avoidable blindness in the Philippines through the provision
of quality eye care
D. All Filipinos enjoy the right to sight by year 2020

Answer: D
Rationale: All Filipinos enjoy the right to sight by year 2020 is the vision of the National
Prevention of Blindness Program.

Situation 15. Tuberculosis ranks sixth among the leading causes of morbidity and
mortality in the Philippines.
71. The goal of the National Tuberculosis Control Program which is also reflected
in the Millennium Development Goal is:
A. A country where TB is no longer a public health problem
B. Ensure that TB DOTS services are available, accessible, and affordable to communities
in collaboration with the LGUs and other partners
C. To reduce prevalence and mortality from TB by half by the year 2015
D. Cure at least 85% of the sputum smear-positive TB patients discovered

Answer: C
Rationale: The goal of the National Tuberculosis Control Program which is also reflected in
the Millennium Development Goal is to reduce prevalence and mortality from TB by half
by the year 2015.

72. Smearing , fixing, and staining of sputum specimens, as well as recording and
reporting results for DSSM shall be performed only by trained medical technologists
or microscopists. However, in far flung areas, who are allowed to do the DSSM as
long as they have been trained?
A. Rural Health Midwife C. Public Health Nurse
B. Barangay Health Worker D. PTB Community Patient

Answer: B
Rationale: Only trained medical technologists or microscopists shall perform DSSM or
Direct Sputum Smear Microscopy (smearing, fixing, and staining of sputum specimens, as
well as reading, recording, and reporting of results). However, in far flung area, BHWs
(Barangay Health Workers) may be allowed to do smearing and fixing of specimens, as
long as they have been trained and are supervised by their respective NTP medical
technologists or microscopists. (Public Health Nursing in the Philippines)

73. Camela, is a new known patient of PTB with three consecutive negative
results in DSSM yet PTB positive-extensive as revealed in CXR. Camela should be
classified as Category:
A. 1 B. 2 C. 3 D. 4

Answer: A
Rationale: Category 1 patients include: new smear-positive PTB; new smear-negative PTB
with extensive parenchymal lesions on CXR as assessed by the TBDC (TB Diagnostic
Committee); Extra-pulmonary TB; and severe concomitant HIV disease.

74. Nurse Bulilit knows that Camela should start the treatment with which of the

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following anti-TB drugs?
A. Rifampicin and Isoniazid
B. Rifampicin, Isoniazid, and Ethambutol
C. Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol
D. Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, and Streptomycin

Answer: C
Rationale: The initial treatment regimen for Category 1 (Intensive phase) is a combination
of Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol. In addition, it is also the Intensive
phase treatment for Category 3.

75. The most important among the elements of the DOTS strategy is:
A. Sustained political strategy
B. Access to quality-assured sputum microscopy
C. Standardized short-course chemotherapy
D. Uninterrupted supply of quality-assured drugs

Answer: A
Rationale: DOTS is the internationally-recommended TB control strategy and combines
five elements. The five elements are the following: sustained political strategy or
commitment (option A); access to quality-assured sputum microscopy (option B);
standardized short-course chemotherapy (option C) for all cases of TB under proper case
management conditions, including direct observation of treatment; uninterrupted supply
of quality-assured drugs (option D); and recording and reporting system enabling outcome
assessment of all patients and assessment of overall program performance.
Option A is the best answer because sustained political strategy or commitment is the
most important element. (Public Health Nursing in the Philippines)

Situation 16. Environmental health is a branch of public health that deals with the study of
preventing illnesses by managing the environment and changing people's behavior to
reduce exposure to biological and non-biological agents of disease and injury.
76. Which of the following is responsible for the promotion of health
environmental conditions and prevention of environmental related diseases?
A. Rural Health and Sanitary Office
B. Environmental Sanitation Code of the Philippines
C. Center for Health and Development
D. Environmental and Occupational Health Office

Answer: D
Rationale: The Environmental and Occupational Health Office (EOHO) is responsible for
the promotion of health environmental conditions and prevention of environmental
related diseases. (Public Health Nursing in the Philippines)

77. A protected well or a developed spring with an outlet but without a
distribution system is known as:
A. Point Source C. Stand Post
B. Communal Faucet D. Waterworks System

Answer: A

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Rationale: Point Source or Level I water supply facilities are protected wells or developed
springs with an outlet but without a distribution system.

78. Pour flush toilet and aqua privies are classified under which level of approved
toilet facilities?
A. Level I C. Level III
B. Level II D. Level IV

Answer: A
Rationale: Level I toilet facilities include pour flush toilet and aqua privies (non-water
carriage toilet facility). No water is necessary to wash the waste into the receiving space.
Level II toilet facilities (option B) are on site toilet facilities of the water carriage type with
water-sealed and flush type with septic tank/vault disposal facilities.
Level III toilet facilities (option C) are water carriage type or toilet facilities connected to
septic tanks and/or sewerage system to treatment plant.
There is no Level IV toilet facility. (Public Health Nursing in the Philippines)

79. The four rights in food safety include the following, except:
A. Right source C. Right preparation
B. Right handling D. Right cooking

Answer: B
Rationale: The four rights in food safety include the following: Right source; Right
preparation; Right Cooking; and Right Storage. (Public Health Nursing in the
Philippines)

80. Which among the following is an important requirement for registration and
renewal of licenses of newly constructed and existing hospitals?
A. Incineration system of hazardous hospital wastes
B. Municipal refuse disposal system
C. Hospital waste management program
D. Disinfection treatment to prevent transmission of diseases

Answer: C
Rationale: Hospital waste management program is an important requirement for
registration and renewal of licenses of newly constructed and existing hospitals. (Public
Health Nursing in the Philippines)

Situation 17. Alternative medicines include the use of herbal medicines, and the practice
of acupressure, acupuncture and aromatherapy.
81. Which of the following laws paved way for the creation of the Philippine
Institute of Traditional and Alternative Health Care?
A. R.A. 7610 C. R.A. 7160
B. R.A. 8423 D. P.D. 965

Answer: B
Rationale: Republic Act 8423 or the Traditional and Alternative Medicine Act paved
way for the creation of the Philippine Institute of Traditional and Alternative Health
Care.

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82. The herbal plant used as an anti-helmintic, which expels round worms that
cause ascariasis, is:
A. Tsaang gubat C. Lagundi
B. Niyug-niyogan D. Bayabas

Answer: B
Rationale: Niyug-niyogan (Quisqualis indica L.) is the herbal plant used as an anti-
helmintic. It expels round worms that cause ascariasis. The seeds are taken 2 hours after
supper. If no worms are expelled, the dose may be repeated after one week. It should not
be given to children below 4 years old.

83. The herbal plant used for the treatment of rheumatism and gout as it lowers
uric acid level is:
A. Sambong C. Akapulko
B. Yerba Buena D. Ulasimang bato

Answer: D
Rationale: Ulasimang bato or Pansit-pansitan (Peperonia pellucida) is the herbal
plant used for the treatment of rheumatism and gout as it lowers uric acid level.

84. Which of the following refers to ear acupuncture?
A. Auriculotherapy C. Moxibustion
B. Homeopathy D. QiGong

Answer: A
Rationale: Auriculotherapy is also known as ear acupuncture.

85. Based on the principle that life is the result of Qi or life energy, what is the
alternative medicine practice that maintains health, treats diseases, and alleviates
pain by massaging certain points on the body surface?
A. Tai Chi C. Acupressure
B. Cupping D. Acupuncture

Answer: C
Rationale: Based on the principle that life is the result of Qi or life energy, Acupressure is
the alternative medicine practice that maintains health, treats diseases, and alleviates
pain by massaging certain points on the body surface.

Situation 18. Vaccines are administered to induce immunity thereby causing the
recipients immune system to react to the vaccine that produces antibodies to fight
infection. Vaccinations promote health and protect children from disease-causing agents.
86. What day of the week is designated as immunization day and is adopted in all
parts of the country?
A. Monday C. Wednesday
B. Tuesday D. Thursday

Answer: C

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Rationale: Every Wednesday is designated as immunization day and is adopted in all
parts of the country. In a barangay health station, immunization is done monthly while in
far flung areas it is done quarterly. However, some areas adopted local practices to
provide everyday vaccination in their areas to cover all targets. (Public Health Nursing in
the Philippines)

87. Which of the following Expanded Program on Immunization (EPI) vaccines is
stored in the freezer?
A. Measles vaccines C. Hepatitis B vaccine
B. DPT D. Tetanus toxoid

Answer: A
Rationale: Vaccines are substances very sensitive at various temperatures. To avoid
spoilage and maintain its potency, vaccines need to be stored at correct temperature.
Measles vaccine and OPV are highly sensitive to heat, requiring storage in the freezer (-
15C to -25C).

88. Unused BCG should be discarded how many hours after reconstitution?
A. 2 hours C. 6 hours
B. 4 hours D. At the end of the day

Answer: B
Rationale: While the unused portion of other vaccines in the EPI may be given until the
end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG
immunization is scheduled only in the morning. (Public Health Nursing in the Philippines)

89. You will not give DPT 2 if the mother says that the infant had:
A. Abscess formation after DPT 1
B. Local tenderness for 3 days after DPT 1
C. Fever for 3 days after DPT 1
D. Seizures a day after DPT 1

Answer: D
Rationale: Seizures within 3 days after administration of DPT is an indication of
hypersensitivity to Pertussis vaccine, a component of DPT. This is considered a
specific contraindication to subsequent doses of DPT. (Public Health Nursing in the
Philippines)

90. A 2-months old infant was brought to the health center for immunization.
During assessment, the infants temperature registered at 38.1C. Which of the
following is the best course of action by the nurse?
A. Give Paracetamol and wait for his fever to subside
B. Advise the infants mother to bring him back for immunization when he is well
C. Refer the infant to the physician for further assessment
D. Go on with the infants immunizations

Answer: D
Rationale: In the Expanded Program on Immunization (EPI), fever up to 38.5C is not a
contraindication to immunization. Mild acute respiratory tract infection, simple diarrhea,

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cough, vomiting and malnutrition are not contraindications either. Generally, one should
immunize unless the child is so sick that he needs to be hospitalized. (Public Health
Nursing in the Philippines)

Situation 19. Children with various health conditions although considered common
diseases are difficult to manage. The DOH adopted the recommended integrated case
management process on childhood illnesses.
91. If a 5-year-old child with a fever of 38.8C is blood smear positive with no
runny nose, the nurse should do the following as forms of specific treatment,
except:
A. Treat the child with an oral antimalarial drug
B. Give first dose of quinine
C. Give one dose of paracetamol
D. Advise to follow up in 2 days if fever persists

Answer: B
Rationale: A child with a positive blood smear with no runny nose is classified under the
yellow row (Malaria). The following are specific treatments to be given: Treat the child with
an oral antimalarial drug (option A); Give one dose of paracetamol (option C) in health
center for high fever (38.5C or above); Advise to follow up in 2 days if fever persists
(option D); and if fever is present every day for more than 7 days, refer for
assessment.Option B is under the pink row. (Integrated Management of Childhood Illness
Chart)

92. A 4-year-old child who has visible severe wasting and severe palmar pallor
should be classified as:
A. Anemia or Very low weight
B. Moderate malnutrition/anemia
C. Severe malnutrition/anemia
D. Malnutrition with severe anemia

Answer: C
Rationale: A child manifesting visible severe wasting or severe palmar pallor or edema on
both feet should be classified under the pink row (Severe malnutrition/anemia). Option A
is incorrect because a child can be classified under the yellow row (Anemia or Very low
weight) if the patient has some palmar pallor or very low weight for age.

93. While on treatment, Rica, 18 months old weighed 18 kgs and her
temperature registered at 37C. Her mother says she developed cough 3 days ago.
Rica has no general danger signs. She has 45 breaths/minute, no chest indrawing,
no stridor. With Rica's condition, what should the nurse do?
A. Classify the child's condition as severe pneumonia
B. Classify the child's condition as pneumonia
C. Give amoxicillin BID for 3 days
D. Assess further the condition of the child by giving a trial of rapid-acting inhaled
bronchodilator

Answer: D

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Rationale: Before classifying the child as Pneumonia, the child is assessed further by
giving a trial of rapid-acting inhaled bronchodilator. This is to rule out Asthma, since
children with asthma also exhibits fast breathing. If the symptom still persists then by
now the child can be classified as having pneumonia. The patient in the situation is
manifesting fast breathing because base on her age, which is 18 months, it is considered
fast breathing when her respiratory rate exceeds 40 breaths/minute (1-5 years old).
(Integrated Management of Childhood Illness Chart)

94. Junival, 4 years old, has had diarrhea for 5 days. He weighs 15 kg. There is no
blood in the stool, he is irritable. His eyes are sunken. Nurse Herbert offers fluid to
the child and he drinks eagerly. When the nurse pinched the abdomen, it goes back
slowly. Nurse Herbert should classify the child's condition as:
A. No dehydration C. Severe dehydration
B. Some dehydration D. Severe persistent diarrhea

Answer: B
Rationale: The child is classified under Some dehydration because he manifested more
than 2 symptoms in the yellow row. They are as follows: irritable, sunken eyes, drinks
eagerly and skin pinch goes back slowly. (Integrated Management of Childhood Illness
Chart)

95. If the child does not have ear problem, what should the nurse do following the
protocol of IMCI chart?
A. Check for other problems C. Check for immunization status
B. Check for danger signs D. Check for nutritional status

Answer: D
Rationale: In performing IMCI, the nurse should follow the correct sequence of
assessment. They are as follows: IMCI ARI, IMCI CDD, IMCI Fever, IMCI Ear problem,
Malnutrition, Immunization and other local bacterial infection. (Integrated Management of
Childhood Illness Chart)

Situation 20. Project NARS is a training cum deployment project designed to mobilize
registered nurses in the poorest municipalities of the Philippines to improve the delivery
of health care services.
96. Project NARS is otherwise known as:
A. Nurses Assigned in Regional Station Project
B. Nationwide Assignments of Registered nurses Service Project
C. Nurses Assigned in Rural Service Project
D. National Affiliation of Registered nurses Project

Answer: C
Rationale: Project NARS, otherwise known as Nurses Assigned in Rural Service Project, is
a training cum deployment project designed to mobilize registered nurses in the poorest
municipalities of the Philippines to improve the delivery of health care services. This
project will create a pool of adequately trained, competent and readily available
registered nurses for local and overseas employment. (www.nars.dole.gov.ph)

97. What is the general objective of the NARS project?

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A. To provide registered nurses with necessary competencies that encompasses both
community health practice as well as clinical skills
B. To augment the nursing workforce of hospitals and rural health units from identified
poor municipalities of needed clinical and public health nurses
C. To provide deployment opportunities for nurses in rural areas and undeserved
communities
D. To improve the delivery of health care services and create a pool of registered nurses
with enhanced clinical and preventive health management competencies for national
public and private sector and overseas employment

Answer: D
Rationale: The general objective of the NARS project is to improve the delivery of health
care services and create a pool of registered nurses with enhanced clinical and preventive
health management competencies for national public and private sector and overseas
employment.

98. Project NARS is built within the frameworks of the Economic Resiliency Plan
of the Arroyo Administration and the Department of Healths Formula One for
Health. The following are aims of the project, except:
A. Aggravate the impact of the Global Financial Crisis
B. To save and create as many jobs as possible
C. Expand social protection
D. Help achieve better health service and care for the people

Answer: A
Rationale: The NARS project aims to mitigate, not aggravate, the impact of the Global
Financial Crisis, to save and create as many jobs as possible and expand social protection
and help achieve better health service and care for the people, especially those in the
poorest municipalities of the country. (www.nars.dole.gov.ph)

99. The NARS trainees shall be warriors of wellness in their hometowns to do the
following, Is, except:
A. Initiate B. Implement C. Inform D. Immunize

Answer: B
Rationale: NARS trainees (option A) initiate primary health, school nutrition, maternal
health programs and first line diagnosis; (option C) inform the public on community water
sanitation practices and perform health surveillance; and (option D) immunize children
and mother. (www.nars.dole.gov.ph)

100. It is the competencies required of registered nurses in their secondary and
tertiary-level care practice within health facilities:
A. Public Health skills C. Clinical skills
B. Technical skills D. Millennium Development Goals

Answer: C
Rationale: Clinical skills are competencies required of registered nurses in their secondary
and tertiary-level care practice within health facilities. Option A is incorrect because public
health skills are competencies required of registered nurses in primary health care level

CODES I 29
well - research.
practice for the prevention of diseases. Option D is incorrect because Millennium
Development Goals is a summary of commitments set by 189 countries at the Millennium
Summit in 2000 to achieve development and poverty reduction, towards the
implementation of the United Nations Millennium Declaration. (www.nars.dole.gov.ph)

MEDICAL-SURGICAL NURSING

Situation 1: You are the nurse taking care of a 65-year-old client diagnosed with left-sided
heart failure.

26. When assessing a patient with left-sided heart failure, you would expect to detect:
a. Distended neck veins
b. Edema of the lower extremities
c. Dyspnea on exertion
d. Hepatomegaly
Answer: C
Rationale: Diminished left ventricular function allows blood to pool in the ventricle and
atrium and eventually back up into the pulmonary veins and capillaries. As the
pulmonary circulation becomes engorged, rising capillary pressure pushes sodium and
water into the interstitial space, causing pulmonary edema leading to dyspnea.
(Lippincotts Fluids and Electrolytes Made Incredibly Easy, 4
th
Edition)

27. The patient receives daily doses of furosemide (Lasix) and digoxin (Lanoxin) for
treatment of heart failure. The patient is more likely to develop a toxic reaction to
digoxin if he has concurrent:
a. Hyponatremia
b. Hyperkalemia
c. Hypernatremia
d. Hypokalemia
Answer: D
Rationale: Hypokalemia, which can occur with diuretic therapy, may lead to digoxin
toxicity. (Lippincotts Fluids and Electrolytes Made Incredibly Easy, 4
th
Edition)

28. His serum potassium level is 3.1 mEq/L. Which associated electrocardiogram
changes would you expect?
a. Peaked T wave
b. Depressed ST segment
c. Narrow QRS complex
d. Absent P waves
Answer: B
Rationale: Hypokalemia causes flattened/inverted T wave, depressed ST segment, and
a prominent U wave. (Lippincotts Fluids and Electrolytes Made Incredibly Easy, 4
th

Edition)

29. As part of the patients treatment for hypokalemia, the doctor prescribes IV
potassium supplementation. At which rate should it be administered?
a. 5 mEq/hour c. 15 mEq/hour
b. 10 mEq/hour d. 20 mEq/hour

CODES I 30
well - research.
Answer: B
Rationale: When supplemental potassium is given by IV infusion, it should be
administered at a rate of 10mEq/hour. (Lippincotts Fluids and Electrolytes Made
Incredibly Easy, 4
th
Edition)

30. The patient calls you to her room because hes short of breath. You assess him and
find that his heart failure is worsening. Which type of fluid volume excess is the patient
experiencing because of his heart failure?
a. Intravascular c. Intracellular
b. Extracellular d. Interstitial
Answer: B
Rationale: Because the heart doesnt pump effectively in a patient with heart failure,
fluid imbalances develop. The most common fluid imbalance associated with heart
failure is extracellular fluid volume excess. This results from the hearts failure to pump
blood forward, consequent vascular pooling, and the sodium and water reabsorption
triggered by the RAAS. (Lippincotts Fluids and Electrolytes Made Incredibly Easy, 4
th

Edition)

Situation 2: A client, who suffered major burn injures, is rushed to hospital. The patient is
a 155-lb male and is estimated at having 50% of his total body surface area burned.
31. During the fluid accumulation phase of a major burn injury, fluid shifts from the:
a. Intravascular space to the interstitial space
b. Interstitial space to intravascular space
c. Intracellular space to interstitial space
d. Intravascular space to intracellular space
Answer: A
Rationale: During the fluid accumulation phase, which occurs within the first 24 to 36
hours after a burn injury, fluid shifts from the intravascular space to the interstitial
space (third-space shift). (Lippincotts Fluids and Electrolytes Made Incredibly Easy, 4
th

Edition)

32. You insert an IV line and begin fluid resuscitation. The doctor wants you to use the
Parkland formula. What amount of Lactated Ringers solution should you administer
over the first 8 hours?
a. 700 mL c. 1,400 mL
b. 7,000 mL d. 6,000 mL
Answer: B
Rationale: The formula is 4 mL x TBSA x weight in kg. So, 4 mL x 50% x 70 kg = 14,
000 mL of Lactated Ringers solution in the first 24 hours. Therefore, you would give
7,000 mL (or half) in the first 8 hours. (Lippincotts Fluids and Electrolytes Made
Incredibly Easy, 4
th
Edition)

33. 48 hours after the burn injury, what physiologic changes can be expected?
a. Edema development
b. Increased blood volume
c. Decreased hemoglobin level
d. Profuse urination
Answer: D

CODES I 31
well - research.
Rationale: During remobilization phase, which starts about 48 hours after the initial
injury, fluid shifts back to the vascular compartment. Edema to the burn site decreases
and blood flow to kidneys increases, which increases diuresis. (Lippincotts Fluids and
Electrolytes Made Incredibly Easy, 4
th
Edition)

34. During the fluid remobilization phase, the nurse would expect to see signs of which
electrolyte imbalance?
a. Hypokalemia c. Hypernatremia
b. Hyperkalemia d. Hypovolemia
Answer: A
Rationale: Hypokalemia occurs in the fluid remobilization phase as potassium shifts
from the extracellular fluid back into the cells. (Lippincotts Fluids and Electrolytes
Made Incredibly Easy, 4
th
Edition)

35. Burn wound sepsis develops and mafenide acetate 10% (Sulfamylon) is ordered
BID. While applying Sulfamylon to the wound, it is important for the nurse to prepare
the client for expected responses to the topical application which include
a. Severe burning pain for a few minutes following application
b. Possible severe metabolic alkalosis with continued use
c. Black discoloration of everything that comes in contact with this drug
d. Chilling due to evaporation of solution from the moistened dressings
Answer: A
Rationale: Mafenide acetate 10% (Sulfamylon) causes burning on application. An
analgesic may be required before the ointment is applied.

Situation 3: A 66-year-old woman, who survived a cardiac arrest, was admitted to the
intensive care unit. She experienced a prolonged episode of hypotension and is now in
acute renal failure.
36. Which type of renal failure did the patient experience?
a. Intrarenal c. Postrenal
b. Prerenal d. Renal
Answer: B
Rationale: The patients renal failure was due to hypotension, which is a prerenal
cause. Prerenal conditions are those conditions outside of the kidneys that diminish
blood flow to the kidneys.
(Lippincotts Fluids and Electrolytes Made Incredibly Easy, 4
th
Edition)

37. Laboratory results associated with acute renal failure include:
a. Increased BUN level and decreased serum creatinine level
b. Decreased BUN level and increased urine output
c. Increased BUN and serum creatinine levels
d. Increased BUN level and increased urine output
Answer: C
Rationale: The patient with ARF has increased BUN and serum creatinine levels, and
decreased urine output. (Lippincotts Fluids and Electrolytes Made Incredibly Easy, 4
th

Edition)

38. Which acid-base imbalance is this patient most likely to experience?
a. Respiratory acidosis

CODES I 32
well - research.
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
Answer: C
Rationale: As the kidneys lose their ability to excrete hydrogen ions, theres a buildup
of hydrogen, which leads to metabolic acidosis. (Lippincotts Fluids and Electrolytes
Made Incredibly Easy, 4
th
Edition)

39. Which of the following is the optimal diet for a patient with renal failure?
a. High-calorie, low-protein, low-sodium, low-potassium
b. High-calorie, high-protein, high-sodium, high-potassium
c. Low-calorie, high-protein, low-sodium, low-potassium
d. High-calorie, low-protein, low-sodium, high-potassium
Answer: A
Rationale: A high-calorie, low-protein, low-sodium, low-potassium is the optimal diet for
a patient with renal failure. The patient should follow a high-calorie diet to meet daily
requirements and to prevent breakdown of body protein. A low protein diet will reduce
end products of protein metabolism that the kidneys are unable to excrete. The diet
should also restrict phosphorus sodium, and potassium. (Lippincotts Fluids and
Electrolytes Made Incredibly Easy, 4
th
Edition)

40. While caring for the client with acute renal failure, the nurse should expect that
hypertonic glucose, insulin infusions, and sodium bicarbonate will be used to treat
which complication?
a. Hyperkalemia c. Hyperlipidemia
b. Hypocalcemia d. Hyponatremia
Answer: A
Rationale: Hyperkalemia is a common complication of ARF. Glucose administration
and regular insulin infusion (with sodium bicarbonate, if necessary) can temporary
prevent cardiac arrest by moving potassium into the cells and temporarily reducing
potassium levels. Less critical levels of hyperkalemia may be treated with oral sodium
polysterene sulfonate. (Straight As in Pathophysiology)

Situation 4: Juan is admitted to the hospital with chief complaint of seizures. Client
reported reduced urine output and weight gain. He is diagnosed with Syndrome of
Inappropriate Diuretic Hormone (SIADH).
41. Which of the following laboratory findings would the nurse expect to find?
a. BUN level of 45 mg/dL
b. Serum osmolality level of 250 mOsm/kg
c. Serum sodium level of 145 mEq/L
d. Urine specific gravity of 1.001
Answer: B
Rationale: Serum osmolality level will be decreased in SIADH secretion due to fluid
retention.
(Gingrich, Medical-Surgical Nursing, 2
nd
Edition)

42. Which nursing diagnosis is most appropriate for Juan who has hyponatremia?
a. Risk for injury related to seizure activity
b. Impaired skin integrity related to peripheral edema

CODES I 33
well - research.
c. Fluid volume excess related to increased thyrotropin secretion
d. Impaired gas exchange related to pulmonary edema
Answer: A
Rationale: Patients with hyponatremia are at high risk for seizures. Nursing
interventions should be aimed at safety and protection, including using padded
siderails, administering supplemental oxygen, and keeping an oral airway readily
available.

43. Juan is thirsty and frequently asks the nurse for water. The most appropriate
response would be to:
a. Keep adequate water at his bedside
b. Give him extra fluids with his medications
c. Explain that his fluid intake must be restricted to 27 to 34 oz (800 to 1,000 ml) per
day
d. Prepare an IV infusion of hypotonic saline
Answer: C
Rationale: Along with meticulous intake and output, fluid restriction is an important
nursing intervention in syndrome of inappropriate antidiuretic hormone (SIADH) to
prevent further dilutional hyponatremia. Ice chips may be offered for severe thirst.
nd
Edition)

44. Juans treatment plan should include which of the following to combat fluid
imbalances with SIADH secretion?
a. Hypotonic saline solution
b. Fluid restriction
c. Colloids
d. 5% dextrose solution
Answer: B
Rationale: SIADH secretion is characterized by excessive amounts of antidiuretic
hormone secreted from the posterior pituitary. Key features of antidiuretic hormone
excess include water retention, hyponatremia, and low osmolality level. Treatment
includes fluid restriction, and administration of hypertonic saline solution. (Gingrich,
Medical-Surgical Nursing, 2
nd
Edition)

45. Which sign suggests that a patient with SIADH has developed complications?
a. Tetanic complications
b. Neck vein distention
c. Weight loss
d. Polyuria
Answer: B
Rationale: SIADH causes fluid retention, which can lead to vascular fluid overload
signaled by neck vein distention.
nd
Edition)

Situation 5: The nurse is discussing the prevention of osteoporosis with a group of clients.
46. Which among the following factors do NOT keep the bones strong?
a. An adequate calcium intake
b. Maintenance of a low weight
c. Sufficient estrogen levels

CODES I 34
well - research.
d. Weight-bearing exercises
Answer: B
Rationale: Low weight is not a requirement for bone strength. It is indicated for persons
with osteoarthritis.
(NSNA NCLEX-RN Review, 4
th
Edition)

47. The nurse suggests that the clients diet include adequate amounts of:
a. Vitamin A c. Vitamin E
b. Vitamin D d. Vitamin K
Answer: B
Rationale: Vitamin D is essential for normal formation of bones and teeth, and for the
absorption of calcium and phosphorus form the GI tract. Sources: saltwater fish,
sardines, organ meats, egg yolk
th
Edition)

48. A woman reports all of the following. Which should the nurse recommend she stop
doing to help reduce the risk of osteoporosis?
a. Smoking
b. Overeating
c. Biting her nails
d. Skipping breakfast
Answer: A
Rationale: Smoking causes a decrease in bone density.
th
Edition)

49. To prevent or treat osteoporosis, adequate calcium intake:
a. Is essential throughout the lifespan
b. Is only necessary after menopause
c. Can only be obtained by supplements
d. Is important only until bone density peaks
Answer: A
Rationale: Adequate calcium intake is essential during childhood, adolescence, and
early adulthood to maximize bone density. Later in life, continued calcium intake can
minimize bone loss. Dietary intake of calcium-rich foods and calcium-fortified foods is
important for all age groups. (Gingrich, Medical-Surgical Nursing, 2
nd
Edition)

50. Which two hormones regulate calcium and phosphate levels in the blood and
stimulate (or inhibit) bone cell activity?
a. Parathyroid hormone and calcitonin
b. Vitamin D and erythropoietin
c. Serotonin and acetylcholine
d. Thyroid hormone and cortisol
Answer: A
Rationale: Parathyroid hormone is released in response to a negative feedback
mechanism that is triggered by an abnormally low serum calcium level. The secretion
of parathyroid hormone results in the release of calcium from the bones (stimulation of
bone cell activity), conservation of calcium by the kidney, and increased intestinal
absorption of calcium. Calcitonin is released in response to increased blood calcium
levels and acts to inhibit the release of calcium from bones (inhibition of bone cell

CODES I 35
well - research.
activity) and decrease renal reabsorption of calcium. (Chernecky, NCLEX-RN Review
Guide)

Situation 6: A nurse working in the orthopedic ward is assigned to handle clients with
various cases of fracture.
51. Kulas, age 18, is admitted to the hospital with possible fractured tibia. The x-ray
shows that the bone is in alignment but a fracture line extends around the ankle. This
type of fracture is called a:
a. Comminuted fracture
b. Colles fracture
c. Transverse fracture
d. Greenstick fracture
Answer: C
Rationale: A fracture straight across a bone is a transverse, or linear fracture.
nd
Edition)

52. Bebong has a short-leg cast applied. 6 hours later, he complains that pain has
increased, especially when his leg is elevated, and that the pain is not relieved by
prescription analgesics. The nurse should:
a. Instruct him to keep his leg elevated and apply ice continuously
b. Call the doctor immediately
c. Tell him this is normal and the pain should lessen in 24 to 48 hours
d. Give ibuprofen (Motrin) with his pain medication to enhance its effectiveness
Answer: B
Rationale: A significant increase in pain that is unrelieved by analgesics and worsened
by elevation of the extremity indicates compartment syndrome. This is a serious
complication caused by bleeding and swelling that must be treated within 6 hours to
prevent irreversible ischemia of the leg. The doctor must be notified immediately, and
actions must be taken to relieve the pressure. (Gingrich, Medical-Surgical Nursing, 2
nd

Edition)

53. To decrease tissue pressure and maintain arterial perfusion to the lower arm, the
nurse would prepare to assist the doctor in:
a. Giving vasodilators IV
b. Splitting or removing the cast
c. Taking the patient to the operating room
d. Elevating the arm on a pole
Answer: B
Rationale: The primary treatment for compartment syndrome is to relieve the source of
the pressure. The cast would be removed or split to relieve the external pressure.
nd
Edition)

54. The client in balanced suspension traction needs to be repositioned toward the
head of the bed. During repositioning, the nurse should:
a. Place sight additional tension on the traction cords
b. Release the weights and replace immediately after positioning
c. Lift the traction and the client during repositioning
d. Maintain the same degree of traction tension

CODES I 36
well - research.
Answer: D
Rationale: Traction is used to reduce the fracture and must be maintained at all times,
including during repositioning. (Straight As Medical-Surgical Nursing, 2
nd
Edition)

55. Which complication would the nurse suspect when assessing a client with a
fractured femur and pelvis who becomes restless, exhibits dyspnea and has petechiae
over the chest area and crackles on auscultation?
a. Compartment syndrome
b. Deep vein thrombosis
c. Fat embolism
d. Osteomyelitis
Answer: C
Rationale: Restlessness, dyspnea, chest petechiae, and crackles strongly suggest a fat
embolism. The presenting features of fat embolism typically include mental status
changes, tachypnea, dyspnea, crackles, wheezes, and large amounts of thick, white
sputum.

Situation 7: Mang Edgardo, found lying unconscious in an enclosed parking space, is
rushed to the emergency room. Carbon monoxide poisoning is suspected.
56. The nurse expects the physician to prescribe which of the following to confirm the
diagnosis?
a. Carboxyhemoglobin
b. Complete blood cell count
c. Pulse oximetry
d. CT scan of the head
Answer: A
Rationale: The diagnosis of carbon monoxide poisoning is confirmed by the
measurement of carboxyhemoglobin levels in the client's blood.
(Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 4
th
Edition)

57. Mang Edgardo suffering from carbon monoxide poisoning:
a. Appears intoxicated
b. Presents with severe hypertension
c. Appears hyperactive
d. Will always present with a cherry red skin coloring
Answer: A
Rationale: A person suffering from carbon monoxide poisoning appears intoxicated
(from cerebral hypoxia). Other signs and symptoms include headache, muscular
weakness, palpitation, dizziness, and mental confusion.

58. A nurse is setting up oxygen for Mang Edgardo. He is to receive oxygen at 10 L per
non-rebreather mask. It is important for the nurse to do the following EXCEPT:
a. Adjust the flow rate to keep the reservoir bag inflated greater than 2/3 full during
inspiration
b. Monitor the patient carefully for risk of aspiration
c. Make sure the valves and rubber flaps are patent, functional, and not stuck
d. Remind the client and his wife of the smoking policy
Answer: B

CODES I 37
well - research.
Rationale: This is appropriate for a client with a face mask because the face mask
limits the clients ability to clear the mouth if vomiting occurs.
th
Edition)

59. A nurse is monitoring the results of serial arterial blood gases of Mang Edgardo who
is asking for the oxygen mask to be removed. The nurse determines that the oxygen
may be safely removed once the carboxyhemoglobin level decreases to less than:
a. 5% c. 15%
b. 10% d. 25%
Answer: A
Rationale: Oxygen may be removed safely from the client with carbon monoxide
poisoning once carboxyhemoglobin levels are less than 5%. (Silvestri, Saunders
Comprehensive Review for the NCLEX-RN Examination, 4
th
Edition)

60. A nurse evaluates Mang Edgardo following treatment for carbon monoxide
poisoning. The nurse would document that the treatment was effective when the:
a. Client is awake and talking
b. Carboxyhemoglobin levels are less than 5%
c. Heart monitor shows sinus tachycardia
d. Client is sleeping soundly
Answer: B
Rationale: Normal caboxyhemoglobin levels are less than 5% for an adult (0.05 to 2.5
% for a non-smoker and 5 to 10% for a heavy smoker).
(Silvestri, Saunders Comprehensive Review for the NCLEX-RN Examination, 4
th
Edition)

Situation 8: A-75-year-old man with a 10-year history of Parkinsons disease is admitted
to the hospital because his condition is deteriorating.
61. The symptom of Parkinsons disease that would be most obvious during the
admission assessment is:
a. Confusion c. Pallor
b. Intention tremor d. Pill rolling
Answer: D
Rationale: Rhythmic flexion and contraction of the muscles cause a characteristic
tremor called a pill-rolling tremor. This is characteristic of Parkinsons disease.
th
Edition)

62. Amantadine hydrochloride (Symmetrel) is prescribed for a client with Parkinsons
disease. The client asks how the drug works. In formulating a response, the nurse
recalls that the drug:
a. Allows accumulation of dopamine
b. Corrects mineral deficiencies
c. Elevates the clients mood
d. Replaces enzymes
Answer: A
Rationale: Amantadine hydrochloride (Symmetrel) is a synthetic antiviral agent with an
unknown mechanism of action that allows dopamine to accumulate in extracellular or
synaptic sites. Parkinsons disease is characterized by dopamine deficiency. (NSNA
NCLEX-RN Review, 4
th
Edition)

CODES I 38
well - research.
63. In planning care for the client with severe Parkinsons disease, which of the
following is of the highest priority?
a. Positioning
b. Encouraging independence
c. Increasing activity
d. Preventing aspiration
Answer: D
Rationale: Persons with advanced Parkinsons disease usually have difficulty
swallowing and are in danger of choking. Aspiration pneumonia must be prevented
and is the highest priority.
th
Edition)

64. Which activity is most likely to be effective in alleviating fatigue?
a. Getting him to bed on time
b. Avoiding high carbohydrate food
c. Collaborating with him when scheduling activities
d. Providing for morning and afternoon naps while he is in the hospital
Answer: C
Rationale: Scheduling activities in collaboration with the client will allow him to
proceed at his own pace and maximize his strength.
th
Edition)

65. When does the nurse encourage a client with Parkinsons disease to schedule the
most demanding physical activities to minimize the effects of hypokinesia?
a. Early in the morning, when the clients energy level is high
b. To coincide with the peak action of drug therapy
c. Immediately after a rest period
d. When family members will be available
Answer: B
Rationale: Demanding physical activity should be performed during the peak action of
dug therapy. Clients should be encouraged to maintain independence in self-care
activities to the greatest extent possible.

Situation 9: Brian, 55 years old, is admitted to the oncology ward. He has a history of
weight loss, persistent cough that has increased, and blood- tinged sputum for 2 weeks.
He has smoked up to two packs of cigarettes a day for 20 years. He is being admitted for
further evaluation and treatment.
66. An early sign or symptom or lung cancer seen in the clients history is:
a. Persistent cough c. Weight loss
b. Hemoptysis d. Dyspnea
Answer: A
Rationale: Unfortunately, the only early symptom of lung cancer is a persistent cough.
Many smokers, the largest group of people to have lung cancer, have a chronic cough.
Many people do not notice the cough until they begin to cough up blood.

67. An MRI evaluation is scheduled. You prepare Brian for this study by telling him that:
a. He will have to take laxatives before the study
b. A dye will be injected into his veins just before the test
c. No physical preparation is needed before the test

CODES I 39
well - research.
d. A nuclear medication is administered by the radiology department 24 hours before
the test
Answer: C
Rationale: A magnetic resonance imaging scan does not require any preparation. The
MI is not a radiographic examination but instead uses magnetically stimulated images.

68. Brian is scheduled for a bronchoscopy so that the lesion can be evaluated for
biopsy. Preoperative teaching will include an explanation that following the biopsy he
will:
a. Be unable to talk for several days
b. Have nothing by mouth until his gag reflex returns
c. Be unable to swallow for 12 hours
d. Experience no soreness of the throat
Answer: B
Rationale: When a client has bronchoscopy, local anesthesia is used in the back of the
throat to deaden the gag reflex. Nothing can be taken by mouth until the gag reflex
returns so that the client does not choke. It usually takes several hours for this reflex to
return.

69. Which of the following would not be a common method of obtaining a specimen to
diagnose lung cancer?
a. Thorancentesis
b. Needle biopsy
c. Mediastinoscopy
d. Wedge resection
Answer: D
Rationale: Specimens can be obtained without surgery. Chest tubes are required if a
wedge resection is done. This procedure would be performed if a small tumor had
already been diagnosed and needed to be resected.

70. To assist Brian and his family to cope with his diagnosis, the nurse should:
a. Explain procedures and their purposes before they are carried out
b. Tell him the physician will have to tell him about the tests
c. Limit the number of visitors for a few days
d. Provide extensive teaching regarding his illness
Answer: A
Rationale: It is important for the client and family to be well informed of the tests and
procedures to be done. Fear of the unknown is one the most anxiety-producing
problems for ill client.

Situation 10: Pain is considered the fifth vital sign. Clients have the right to appropriate
assessment and management of pain.
71. The pain associated with migraine headaches is believed to be caused by:
a. Dilation of the cranial arteries
b. A temporary decrease in intracranial pressure
c. Irritation and inflammation of the openings of the sinuses
d. Sustained contraction of muscles around the scalp and face
Answer: A

CODES I 40
well - research.
Rationale: Vascular disturbance involving branches of the carotid artery is believed to
cause migraine
attacks. Vasoconstriction of blood vessels apparently occurs first. The extracranial
arteries then dilate, causing the headache.

72. When the nurse administers meperidine hydrochloride, its effectiveness as an
analgesic is related to its ability to:
a. Reduce the perception of pain
b. Decrease the sensitivity of pain receptors
c. Interfere with pain impulses traveling along sensory nerve fibers
d. Block the conduction of pain impulses along the central nervous systems
Answer: A
Rationale: Opioid analgesics relieve pain by reducing or altering the perception of
pain.

73. The client asks the nurse why she has migraine headaches. What is the nurses best
response?
a. Migraine headaches are believed to be caused by dilation of the cranial arteries
b. Migraine headaches are believed to be caused by a temporary decrease in
intracranial pressure
c. Migraine headaches are believed to be caused by irrigation and inflammation of the
opening of the sinuses
d. Migraine headaches are believed to be caused by sustained contraction of muscles
around the scalp and face
Answer: A
Rationale: Migraine headaches are believed to be caused by a vascular disturbance
involving branches of the carotid artery, where vasoconstriction of blood vessels
apparently occurs first. The extracranial and intracranial arteries then dilate, causing
the headache.

74. A client, who crashed her motorcycle, suffered a tibial fracture that required casting.
Approximately 5 hours later, the client begins to complain of increasing pain distal to
the left tibial fracture despite the morphine injection administered 30 minutes
previously. The nurses next action should be to assess for which of the following?
a. Presence of a distal pulse
b. Pain with a pain rating scale
c. Vital sign changes
d. Potential for drug tolerance
Answer: A
Rationale: The nurse should assess the clients ability to move her toes and for the
presence of distal pulses, including a neurovascular assessment of the area below the
cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after
the onset of casting or trauma may be the first sign of compartment syndrome, which
can lead to permanent damage to nerve and muscles.

75. The nurse teaches the client with chronic cancer pain about optimal pain control.
Which of the following recommendations is most effective for pain control?
a. Get used to some pain and use a little less medication than needed to keep from
being addicted

CODES I 41
well - research.
b. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent
pain
c. Take analgesics only when pain returns
d. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a
day to block the pain
Answer: B
Rationale: The regular administration of analgesics provides a consistent breakthrough
pain. Therefore, taking the prescribed analgesics on a regular schedule is the best way
to manage chronic cancer-related pain.

Situation 11: Care of clients undergoing surgery extends until after the surgical procedure
is done. Nurses must know how to handle post-op clients.
76. The nurse is caring for a client who has just had a splenectomy. When planning care
in the immediate postoperative period the nurse should avoid using which position?
a. Left side-lying c. Semi-Fowlers
b. Right side-lying d. Supine
Answer: D
Rationale: The supine position allows abdominal organs to rise, permitting less space
for lung expansion. With a high abdominal incision, such as used for splenectomy,
incisional pain and irritation at the surgical site predispose the client to respiratory
complications.

77. The nurse is assessing a client who has had kidney transplant. Which of the
following assessment findings would indicate to the nurse that the client might be
developing acute rejection of the kidney?
a. Oliguia or anuria
b. Temperature range of 37.2 at 37.7
0
C
c. Decreased blood pressure
d. Stabilization of urine and blood chemistry values
Answer: A
Rationale: Acute rejection of a kidney transplant can be differentiated from chronic
rejection. Oliguria or anuria are signs of acute rejection. Signs of rejection include signs
of organ failure.

78. A client who is scheduled for a bowel resection tomorrow has just completed
preoperative teaching by nurses. Which of the following statements to the nurse
indicates the client needs further instruction on postoperative care?
a. I know Ill have pain after surgery, but I can call the nurses for medicine.
b. They will be taking my pulse and blood pressure many times after the operation.
c. The intravenous needle will be removed in the recovery room.
d. Ill show you how I can deep breathe and cough.
Answer: C
Rationale: Intravenous fluids are necessary post-op to maintain fluid and electrolyte
balance and as a route for medications. The intravenous infusion will be left in until
fluids can be taken by mouth.

79. An adult client is scheduled for a colonoscopy under anesthesia. Which statement
by the client indicates he understands the prescribed preparation regimen?
a. All I need to do is give myself a packaged enema the morning of the procedure.

CODES I 42
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b. I will eat only jello and drink clear liquids for two days before the test.
c. I will take the dye tablets with water the night before the test.
d. All I have to do is not eat anything after midnight the night before the test.
Answer: B
Rationale: The client is given laxatives for 2 days before the procedure and must have
only clear liquids during this time. He will be NPO the night before the procedure.

80. Your client has just had major surgery. He refuses to reposition or deep breathe
because of fear of pain. He also refuses to take pain medication for fear of addiction.
Your best response to this client is to:
a. Praise him for wanting to be drug-free
b. Inform him that he has to take the pain medication
c. Educate him about the benefits of pain relief and risk addiction
d. Inform him that the physician is ordering him to take the pain medication
Answer: C
Rationale: This client is showing lack of understanding related to pain relief and
helping him understand the minimal risk of addiction will most likely decrease his
fears and increase his compliance level. This decreases the risk of postsurgical
complications. Praising the client for wanting to be drug-free may lead him to believe
that addiction is a high risk for him. Unless under legal commitment, clients have the
right to refuse medications.

Situation 12: A client has been diagnosed with adenocarcinoma of the stomach and is
scheduled to undergo a subtotal gastrectomy (Billroth II procedure).
81. During the preoperative teaching, the nurse is reinforcing information about the
surgical procedure. Which of the following explanations is most accurate?
a. The procedure will result in enlargement of the pyloric sphincter
b. The procedure will result in anastomosis of the gastric stump to the jejunum
c. The procedure will result in removal of the duodenum
d. The procedure will result in repositioning of the vagus nerve
Answer: B
Rationale: A Billroth II procedure bypasses the duodenum and connects the gastric
stump directly to the jejunum. The pyloric sphincter is removed, along with some of the
stomach fundus.

82. After a subtotal gastrectomy, care of the clients nasogastric tube and drainage
system should include which of the following nursing interventions?
a. Irrigate the tube with 30 ml of sterile water every hour, if needed
b. Reposition the tube if it is not draining well
c. Monitor the client for nausea, vomiting and abdominal distention
d. Turn the machine to high suction if the drainage is sluggish on low suction
Answer: C
Rationale: Nausea, vomiting, or abdominal distention indicates that gas and secretions
are accumulating within the gastric pouch due to impaired peristalsis or edema at the
operative site and may indicate that the drainage system is not working properly.
83. Which of the following systems would be indicative of the dumping syndrome?
a. Hunger c. Diaphoresis
b. Vomiting d. Heartburn
Answer: C

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Rationale: Symptoms of the dumping syndrome usually begin 15 to 30 minutes after
eating and include weakness, dizziness, diaphoresis, palpitations, a sense of fullness,
abdominal cramps, and diarrhea. These symptoms result when a large bolus of
hypertonic fluid enters the small intestine and causes a sudden decrease in plasma
volume as fluid is shifted into the bowel. D. Heartburn is the result of gastric reflex, not
the dumping syndrome.

84. Which measure helps prevent dumping syndrome?
a. Sitting up after meals
b. Drinking fluids between meals rather than with meals
c. Eating large amounts of carbohydrates
d. Eating four to six small low-protein meals during the day
Answer: B
Rationale: Dumping syndrome (rapid gastric emptying) causes distention of the
duodenum or jejunum. Drinking fluids between meals rather than with meals helps to
avoid distention.
(Straight As in Pathophysiology)

85. Which of the following would be an expected nutritional outcome for a client who
has undergone a subtotal gastrectomy for cancer?
a. Regain weight loss within 1 month after surgery
b. Resume normal dietary intake of three meals a day
c. Control nausea and vomiting through regular use of antiemetics
d. Achieve optimal nutritional status through oral or parenteral feedings
Answer: D
Rationale: An appropriate expected outcome is for the client to achieve optimal
nutritional status through the use of oral feedings or total parenteral nutrition (TPN).
TPN may be used alone if the client cannot tolerate oral feedings.

Situation 13: Mang Rolando was long diagnosed with Chronic Renal Failure. You are his
nurse and the following questions will assess your knowledge on the different fluid and
electrolyte imbalances associated with chronic renal failure.
86. Mang Rolando is scheduled for hemodialysis. The main indicator for the need for
hemodialysis is:
a. Ascites c. Hypertension
b. Acidosis d. Hyperkalemia
Answer: D
Rationale: Severe hyperkalemia is considered a medical emergency, and is an
absolute indication for hemodialysis. It could precipitate cardiac arrhythmias leading to
cardiac arrest. Hemodialysis is started immediately to correct this electrolyte
abnormality.

87. Mang Rolando misses two sessions of hemodialysis. Blood was drawn and is sent
for analysis. Which electrolyte disturbance is expected in a client with CRF?
a. Hyponatremia c. Hypomagnesemia
b. Hyperkalemia d. Hypercalcemia
Answer: B
Rationale: Hyperkalemia occurs as the kidney's ability to excrete potassium is
impaired.

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(Fluids and Electrolytes Made Incredibly Easy)

88. In Mang Rolando's ECG tracing, you would expect to find:
a. Depressed T wave
b. Presence of U wave
c. A peaked T wave
d. Inverted T wave
Answer: C
Rationale: With hyperkalemia, ECG tracings show tall, peaked T waves; a widened QRS
complex; and disappearing P waves.
(Fluids and Electrolytes Made Incredibly Easy)

89. When the GFR is 30% to 59% of normal during chronic renal failure, the client is
experiencing?
a. Reduced renal reserves
b. Renal insufficiency
c. Renal failure
d. End-stage renal disease
Answer: B
Rationale: Renal insufficiency phase GFR of 30%
to 59% of normal.
Reduced renal reserves GFR of 60% to 89% or normal
Renal failure GFR of 15% to 29% or normal
End-stage renal disease GFR Less than 15% of normal (Straight As in
Pathophysiology)

90. As Mang Rolando's condition continues to worsen, the client undergoes renal
transplant. Mang Rolando is started on Cyclosporine therapy to prevent graft rejection.
Which of the following is a major complication of this drug therapy?
a. Depression c. Infection
b. Hemorrhage d. Peptic ulcer disease
Answer: C
Rationale: Cyclosporine inhibits proliferation and function of T-lymphocytes. It places
the patient susceptible to opportunistic infections due to cyclosporine-induced
immunosuppression.

Situation 14: A 74-year-old man with a 3-day history of worsening Chronic Obstructive
Pulmonary Disease (COPD) is hospitalized. His breathing is labored; breath sounds are
congested with rhonchi throughout; and his SaO2 (as measured by pulse oximetry) is 89%.
91. The client is placed on a 35% aerosol mask, and blood is drawn for arterial blood
gas analysis. The results are pH 7.33; PaO2 68 mmHg; PaCO2 53 mmHg, and
bicarbonate 18 mEq/L. Which acid-base imbalance does the patient most likely have?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
Answer: C

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Rationale: When a patients PaCO2 is elevated, carbonic acid is retained leading to
acidosis. Because the acidosis is respiratory in origin, the patient most likely has
respiratory acidosis. (Lippincott's Fluids and Electrolytes Made Incredibly Easy)

92. When attempting to improve the client's blood gas values through improved
ventilation and oxygen therapy, which is the client's primary stimulus for breathing?
a. High PCO2 c. Normal pH
b. Low PO2 d. Normal HCO3
-
Answer: B
Rationale: A chronically elevated PCO2 level (above 50 mmHg) is associated with
inadequate response of the respiratory center to plasma carbon dioxide. The major
stimulus to breathing now becomes hypoxia (low PO2). (Lippincott's Review Series:
Medical-Surgical Nursing. 4
th
Edition)

93. Why is it important for supplemental oxygen to be carefully monitored in this
patient?
a. Increasing PaO2 beyond what is needed will lead to oxygen toxicity
b. High oxygen levels will promote microbial growth in the patient's lungs
c. Increased PaO2 levels can depress the drive to breathe in patients with COPD
d. Increased PaO2 levels can elevate the drive to breathe in patients with COPD
Answer: C
Rationale: Increased PaO2 levels can depress the drive to breathe, which is largely
driven by hypoxemia. (Lippincott's Fluids and Electrolytes Made Incredibly Easy)

94. The client is complaining of increased dyspnea. Upon assessment, the client's
respiratory rate is 22 breaths per minute. The appropriate nursing action is to:
a. Determine the need to increase the oxygen
b. Conduct further assessment of the client's respiratory status
c. Call a code
d. Reassure the client that there is no need to worry
Answer: B
Rationale: Obtaining further assessment data is the appropriate nursing action.
(Silvestri, Saunders Q&A Review for the NCLEX-RN Examination)

95. Why should the nurse who is caring for a client with COPD encourage the client to
quit smoking?
a. Smoking decreases the amount of mucus production
b. Smoking allows hemoglobin to become highly oxygenated
c. Smoking shrinks the alveoli in the lungs
d. Smoking damages the ciliary cleaning mechanism
Answer: D
Rationale: Smoking damages the ciliary action in the respiratory tract, which is a
protective mechanism. (Chernecky, NCLEX-RN Review Guide)

Situation 15: Jacob, 45 years old, presents to the emergency department with nausea,
and steady epigastric pain centered near the navel that radiates to the back. Blood
studies reveal elevated amylase, lipase, and while blood cell count levels. The client is
diagnosed with acute pancreatitis.

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96. The pancreas functions as both an exocrine and endocrine gland. Which of these is
an example of its exocrine function?
a. The pancreas produces hydrochloric acid
b. Amylase is produced in the acinar cells
c. Insulin is produced into islets of Langerhans
d. The pancreas secretes its enzymes into the stomach
Answer: B
Rationale: The production of amylase in the acinar cells is an example of exocrine
function.
A, C and D are endocrine functions. (Lippincotts Fluids and Electrolytes Made
Incredibly Easy)

97. The most common cause of acute pancreatitis is:
a. Alcohol
b. Eating low-fat foods
c. Gallstones
d. Pregnancy
Answer: C
Rationale: Gallstones are the most common cause of acute pancreatitis.
A. Alcohol consumption is the second most common cause. (Lippincotts Fluids and
Electrolytes Made Incredibly Easy)

98. Which of these imbalances typically occur in acute pancreatitis?
a. Hypovolemia
b. Hypercalcemia
c. Hypernatremia
d. Hypermagnesemia
Answer: A
Rationale: In acute pancreatitis, fluid shifting from the intravascular space into the
interstitial spaces and retroperitoneum causes hypovolemia. (Lippincotts Fluids and

99. The patient with acute pancreatitis may report that his pain decreases:
a. When he lies on his stomach
b. After vomiting
c. After eating a large meal
d. When he lies on his side with his knees drawn toward his chest
Answer: D
Rationale: Pain caused by acute pancreatitis is commonly relieved when the patient
lies on his side with his knees drawn toward his chest. (Lippincotts Fluids and

100. Patients recovering from acute pancreatitis should eat foods that are:
4. Low in carbohydrates, and high in fats and proteins
5. Low in carbohydrates, proteins, and fats
6. High in carbohydrates and fats, and low in proteins
7. High in carbohydrates, and low in fats and proteins
Answer: D

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Rationale: The patient recovering from acute pancreatitis should eat foods that are
high in carbohydrates and low in fats and proteins. (Lippincotts Fluids and Electrolytes
Made Incredibly Easy)

Situation 16: Aguada, a client with leukemia, is in a clinic for her routine check-up.
101. Which of the following is unlikely when assessing Aguada?
a. Small abdomen
b. Bruises and petechiae
c. Increased WBC count
d. Dyspnea during exercise
Answer: A
Rationale: A client with leukemia has a distended abdomen due to enlarged liver and
spleen.
(Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 11
th
Edition)

102. The most appropriate examination for Aguada is:
a. RBC count c. CBC
b. WBC count d. BMA
Answer: D
Rationale: In bone marrow aspiration, the soft tissue contained in the medullary canals
of long bones and interstices of cancellous bones is removed under local anesthesia.
Hematologic analysis of the bone marrow specimen that reveals positive for leukemic
blast phase cells is diagnostic of leukemia. (Brunner and Suddarth's Textbook of
th
Edition)

103. In order to maintain oral hygiene, the client should be encouraged to:
a. Use regular toothbrush
b. Gargle with mouthwash
c. Use cotton pledget only
d. Use soft toothbrush
Answer: D
Rationale: Soft-bristled toothbrushes should be used to prevent bleeding
th
Edition)

104. Which of the following are the three main consequences of leukemia?
a. Bone deformities, infection and anemia
b. Anemia, infection and bleeding tendencies
c. Leukopenia, thrombocytopenia and anemia
d. Leukoctytosis, thrombocytopenia and polycythemia
Answer: B
Rationale: Leukemia is characterized by unregulated proliferation of immature WBCs
in the bone marrow (leukocytosis). The proliferation of leukemic cells leaves little room
for normal cell production resulting to reduced production of RBCs, hematocrit,
hemoglobin, and platelets (thrombocytopenia). These cause anemia, and place the
client at risk for infection and bleeding. (Brunner and Suddarth's Textbook of Medical-
Surgical Nursing, 11
th
Edition)

105. Aguada experiences nasal bleeding. The client should be instructed to:
a. Lie supine with her neck extended

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b. Sit upright, leaning slightly forward
c. Blow her nose and then put lateral pressure on her nose
d. Hold her nose while bending forward at the waist
Answer: B
Rationale: For epistaxis, instruct the client to sit upright with the head tilted forward to
prevent swallowing and aspiration of blood.
(Brunner and Suddarth's Textbook of Medical-Surgical nursing, 11
th
Edition)

Situation 18: You are the nurse assigned to care for a client diagnosed with Peptic Ulcer
Disease.
106. The client asks the nurse what causes a peptic ulcer. You appropriately respond that
recent research indicates that many peptic ulcers are the result of which of the
following?
a. Work-related stress
b. Helicobacter pylori infection
c. Diets high in fat
d. A genetic defects in the gastric mucosa
Answer: B
Rationale: Most peptic ulcers are caused by Helicobacter pylori, which release toxins
that destroy the gastric and duodenal mucosa. (Straight As in Pathophysiology)

107. A client with peptic ulcer disease tells you that he has black stools, which he has not
reported to his physician. Based on this information which nursing diagnosis would be
appropriate for this client?
a. Ineffective Coping related to fear of diagnosis of chronic illness
b. Deficient Knowledge related to unfamiliarity with significant signs and symptoms
c. Constipation related to decreased gastric motility
d. Imbalanced Nutrition: Less than Body Requirements related to gastric bleeding
Answer: B
Rationale: Black, tarry stools are an important warming sign of bleeding in peptic ulcer
disease. Digested blood in the stool causes it to be black. The odor of the stool is very
offensive. Clients with peptic ulcer disease should be instructed to report to incidence
of black stools promptly to their primary healthcare provider.

108. Which of the following would be an expected outcome for a client with peptic ulcer
disease?
a. The client will demonstrate appropriate use of analgesics to control pain
b. The client will explain the rationale for eliminating alcohol from the diet
c. The client will verbalize the importance of monitoring hemoglobin and hematocrit
every 3 months
d. The client will eliminate contact sports from his or her lifestyle
Answer: B
Rationale: Alcohol is a gastric irritant that should be eliminated from the intake of the
client with peptic ulcer disease.

109. You are preparing to teach a client with a peptic ulcer about the diet that should be
followed after discharge. You should explain that the diet will most likely consist of
which of the following?
a. Bland foods

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b. High-protein foods
c. Any foods that are tolerated
d. Large amounts of milk
Answer: C
Rationale: The client can eat three regular meals a day. Specific dietary restrictions
vary from client to client.
(Lippincotts Review Series: Medical-Surgical Nursing, 4
th
Edition)

110. Which instruction would be included in the teaching plan for the client taking
antacids?
a. Take the antacid with 8 oz of water.
b. Avoid taking other medications within 2 hours of this one.
c. Continue taking antacids even when pain subsides.
d. Weigh yourself daily when taking this medication.
Answer: B
Rationale: Antacids neutralize gastric acid and decrease the absorption of other
medications. The client should be instructed to avoid taking other medications within 2
hours of the antacid.
(Lippincotts Review Series Medical-Surgical Nursing, 4
th
Edition)

Situation 19: Cancer of the prostate is the leading cancer in men other than skin cancer.
The following questions will assess your knowledge and theoretical foundation in dealing
with clients with prostate cancer.
111. Among the following population groups, who has a higher risk in the development
of prostate cancer?
a. African-American c. Asian
b. Caucasian d. Hispanics
Answer: A
Rationale: The worldwide incidence of prostate cancer is highest in African American
men, which may be related to their lower engagement in the health care system,
disparities in health care, and cultural and structural constraints. (Brunner and
Suddarth's Textbook of Medical-Surgical Nursing, 11
th
Edition)

112. Which among the following is NOT a risk factor for prostate cancer?
a. A family member with prostate cancer
b. Advancing age
c. Diet high in fat and red meats
d. Smoking
Answer: D
Rationale: Smoking is not a risk factor for prostate cancer.
th
Edition)

113. At the initial sign and symptoms of prostate cancer, before diagnosis, the physician
can perform a screening test to detect a characteristic stony hard prostate and
nodules at the prostate area using:
a. Cystoscopy c. DRE
b. PSA d. MRI
Answer: C

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Rationale: With the use of routine repeated rectal palpation of the gland, early cancer
may be detected as a nodule within the substance of the gland or as an extensive
hardening in the posterior lobe. The more advanced lesion is stony hard and fixed.
th
Edition)

114. To diagnose the presence of prostate cancer, the physician will perform:
a. Transrectal needle biopsy of the prostate
b. Test to identify the PSA level
c. Transurethral ultrasound
d. Radiolabeled monocional antibody capromab pendetide with iridium-111
Answer: A
Rationale: The diagnosis of prostate cancer is confirmed by a histologic examination of
the tissue removed surgically by transurethral resection, open prostatectomy, or
transrectal needle biopsy.
th
Edition)

115. In testing for the PSA, the nurse will collect which specimen?
a. Blood c. Feces
b. Urine d. Prostatic fluid
Answer: A
Rationale: PSA is a nuetral serine protease produced by both normal and neoplastic
ductal epithelium of the prostate. By measuring the amount of this antigen in the
blood, it is possible to detect prostate cancer. (Brunner and Suddarth's Textbook of
th
Edition)

Situation 20: You are the nurse caring for a client with hyperthyroidism, who is scheduled
for a subtotal thyroidectomy.
116. The physician has ordered Lugols solution for the client. You understand that the
primary reason for giving Lugols solution preoperatively is to:
a. Decrease the risk of agranulocytosis postoperatively
b. Prevent tetany while the client is under general anesthesia
c. Reduce the size and vascularity of the thyroid
d. Potentiate the effect of the other pre-op medications so less medicine can be given
while the client is under anesthesia
Answer: C
Rationale: The client may receive iodine solution (Lugols solution) for 10 to 14 days
before surgery to decrease vascularity of the thyroid and thus prevent excess bleeding.
(NCNA NCLEX-RN Review, 4
th
Edition)

117. In planning care for the client post thyroidectomy, you know that it is most
important to:
a. Carry out range of motion exercises to the neck and shoulders every shift
b. Maintain bed rest with client in supine position at all times
c. Ask client questions every hour or two to assess for hoarseness
d. Provide tracheostomy care every shift and suction PRN to maintain paten airway
Answer: C
Rationale: Damage to the recurrent laryngeal nerve is a major complication of thyroid
surgery. Hoarseness immediately following surgery is often related to intubation during

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surgery. However, persistent or worsening hoarseness must be reported immediately
to the physician because it may be the first sign of nerve injury.
th
Edition)

118. The client begins to complain of circumoral tingling. You assess a positive
Chovsteks sign and a positive Trousseaus sign. You understand that the most
common cause of these symptoms is which of the following?
a. Inadvertent removal of the parathyroid glands
b. Overuse of radioactive iodine given preoperatively
c. History of insufficient iodine intake
d. Overstimulation of parathormone during surgery
Answer: A
Rationale: The symptoms suggest hypocalcemia. The four pea-seized parathyroid
glands, which regulate calcium and phosphorous balance, are imbedded in the thyroid.
Inadvertent removal during thyroidectomy is a common cause of postoperative
hypocalcemia.(NSNA NCLEX-RN Review, 4
th
Edition)

119. Following a thyroidectomy, the client experiences hemorrhage. You would prepare
for which emergency intervention?
a. IV administration of calcium
b. Insertion of an oral airway
c. Creation of a tracheostomy
d. IV administration of thyroid hormone
Answer: C
Rationale: Following a thyroidectomy, postoperative hemorrhage may cause
compression of the trachea, necessitating an emergency tracheostomy to maintain
airway patency. (Lippincotts Medical-Surgical Nursing, 4
th
Edition)

120. Twelve hours post thyroidectomy, the client develops stridor on exhalation. What is
your best first action?
a. Reassure the client that the voice change is temporary
b. Document the finding as the only action
c. Hyperextend the clients neck
d. Call for emergency assistance
Answer: D
Rationale: Stridor on exhalation is the hallmark sign of respiratory distress, usually
caused by obstruction resulting from tissue edema. A tracheostomy set is usually kept
at the bedside in case of such emergencies, and the physician is summoned at the first
indication of respiratory distress. (Chernecky, NCLEX-RN Review Guide)

Situation: Mr. Calvo is admitted to your ward. The physician ordered Prepare for
thoracentesis this pm to remove excess air from the pleural cavity.
121. Which of the following nursing responsibilities is essential for Mr. Calvo who will
undergo thoracentesis?
a. Support and reassure client during the procedure
b. Ensure that informed consent has been signed
c. Determine if client has allergic reaction to local anesthesia
d. Ascertain if chest x-rays and other tests have been prescribed and completed
Answer: D

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Rationale: Chest x-ray done before the procedure is essential to serve as a baseline
data, in order to have a basis for comparison with the chest x-ray done post-procedure.

122. Mr. Calvo, who is for thoracentesis, is positioned by the nurse to which of the
following?
a. Trendelenburg position
b. Supine position
c. Dorsal Recumbent position
d. Orthopneic position
Answer: D
Rationale: Patients for thoracentesis should be placed on a straddling position with the
arms placed on the back of the chair, or on sitting position leaning forward
(orthopneic), with arms placed over a desk or bedside table. If a client cannot sit up,
the client is placed lying on bed on the unaffected side with the head of the bed
elevated at 45 degrees.

123. During thoracentesis, which of the following nursing interventions will be most
crucial?
a. Place patient in a quiet and cool room
b. Maintain strict aseptic technique
c. Advice patient to sit perfectly still during needle insertion until it has been withdrawn
from the chest
d. Apply pressure over the puncture site as soon as the needle is withdrawn
Answer: C.
Rationale: The patient should be informed not to cough, move or breathe deeply during
the procedure, to prevent trauma to the lungs.

124. To prevent leakage of fluid in the thoracic cavity, how will you position the client
after thoracentesis?
a. Place flat in bed
b. Turn on the unaffected side
c. Turn on the affected side
d. On bed rest
Answer: B
Rationale: Client should be placed on the opposite side (unaffected side) for 1 hour to
promote lung expansion.

125. Chest x-ray was ordered after thoracentesis. When your client asks what is the
reason for another chest x-ray, you will explain:
a. To rule out pneumothorax
b. To rule out any possible perforation
c. To decongest
d. To rule out any foreign body
Answer: A
Rationale: Mr. Calvo is admitted to the hospital due to presence of air in the lungs
(pneumothorax). Postthoracentesis, and x-ray is necessary to rule out the presence of
air in his lungs.

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LEADERSHIP, MANAGEMENT & RESEARCH WITH PROFESSIONAL ADJUSTMENT

Situation 1: Nurse David, 35 years old, has just been promoted as a nurse supervisor. As a
nurse supervisor, he is aware that he is accountable and responsible for accomplishi ng
goals, coordinating and integrating resources, and using the management process.
1. Nurse David is aware that there are three levels of skills, which he should possess as
nurse manager. These are:
a. Conceptual skills, literary skills, technical skills
b. Political skills, conceptual skills, human skills
c. Interpersonal skills, technical skills, human skills
d. Conceptual skills, interpersonal skills, technical skills
Answer: D
Rationale: Literary, political and human skills are not included.

2. There are two major types of planning: strategic planning and operational planning.
Which is NOT true about strategic planning?
a. It is long-ranged planning
b. It focuses on the entire organization
c. It determines where an organization is going over the next year or more
d. It deals with day-to-day maintenance activities
Answer: D
Rationale: Day-to-day maintenance activities are under operational planning.
A, B and C all describe strategic planning.

3. The number of people reporting to Nurse David as nurse supervisor represents his:
a. Unity of Command c. Span of Control
b. Unity of Direction d. Scalar Chain
Answer: C
Rationale: Span of Control pertains to the number of subordinates directly to a
superior.

4. As a nurse supervisor, Nurse David should understand the interrelationships among
authority, responsibility, and accountability. Which of the following statements is NOT
correct?
a. Managers should always be assigned responsibility with concomitant authority
b. If authority is not commensurate to the responsibility, role confusion occurs
c. A nurse is being accountable for the responsibilities inherent in her position
d. Responsibility is an agreement to accept the consequences of one's actions
Answer: D
Rationale: Accountability, not responsibility, is an agreement to accept the
consequences of one's actions.

5. Nurse David has implemented a change in the method of the nursing delivery system
from functional to team nursing. A nursing assistant is resistant to the change and is
not taking an active part in facilitating the change process. Which of the following
would be the best approach in dealing with the nursing assistant?
e. Ignore the resistance
f. Exert coercion with the nursing assistant
g. Provide a positive reward system for the nursing assistant

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h. Confront the nursing assistant to encourage verbalization of feelings regarding the
change
Answer: D
Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-
face meetings to confront the issue at hand will allow verbalization of feelings,
identification of problems and issues, and development of strategies to solve the
problem.
(Saunders, 3
rd
Edition)

Situation 2: Ensuring the overall quality of care given to groups of clients is an essential
professional accountability.
6. The cardiac catheterization lab has established a procedure for achieving hemostasis
of the cardiac catheter insertion site. Which type of standard does this exemplify?
a. Structure c. Outcome
b. Process d. Performance
Answer: B
Rationale: A process standard is a statement of the standardized processes used to
accomplish a desired outcome. It can be used to evaluate performance and
achievement of goals. Competent performance of the procedure by the catheterization
lab staff to achieve catheter site hemostasis should prevent the complication of groin
hematomas. (Chernecky, NCLEX-RN Review Guide)

7. One of the functions of a nurse manager is staffing. The medical-surgical unit has 16
registered nurses and 9 nursing assistants. How many registered nurses and nursing
assistants should the nurse manager assign for the night shift?
a. 6 registered nurses and 3 nursing assistants
b. 3 registered nurses and 2 nursing assistants
c. 4 registered nurses and 2 nursing assistants
d. 7 registered nurses and 4 nursing assistants
Answer: B
Rationale: This is the distribution for the night shift.
A. This is the distribution for the PM shift.
D. This is the distribution for the AM shift.

Distribution:
45% for the AM shift
37% for the PM shift
18% for the night shift

16 x 0.18 = 3 registered nurses
9 x 0.18 = 2 nursing assistants

8. This pertains to a measurement tool to articulate the nursing workload for a specific
patient or groups of patient over a specific period of time.
a. Staffing pattern
b. Skill mix
c. Benchmarking
d. Patient classification
Answer: D

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Rationale: Patient classification is a system that categorizes patients according to
nursing care hours per patient per day and ratio of professionals and non-
professionals.
Hour
s
Ratio
Level I
minimal care
1.5 55 is to
45
Level II
moderate care
3 60 is to
40
Level III
intensive care
4.5 65 is to
35
Level IV
highly specialized
critical care

6.0
7.0
or >

70 is to
30
80 is to
20

9. A part of the controlling process in which employee's performance is evaluated against
a standard. It is the most valuable tool in controlling human resources and productivity.
It reflects how well the nursing personnel have performed during a specific period of
time.
a. Performance appraisal
b. Quality assurance
c. Quality improvement
d. Benchmarking
Answer: A
Rationale: Performance appraisal, also known as employee appraisal, is a method by
which the job performance of an employee is evaluated.

10. Among the following standards, which is considered a structure component?
a. The client verbalized satisfaction of the nursing care received
b. Checking ID band prior to giving medications
c. All patients shall have their weight taken and recorded
d. The number and categories of nursing personnel
Answer: D
Rationale: Structural standards describe environmental and organizational
characteristics that influence care, such as number and categories of nursing
personnel (staffing), and equipment.

Situation 3: A professional nurse must uphold his/her legal, moral and ethical
responsibilities.
11. A toddler screams and cries noisily after parental visits, disturbing all the other
children. When the crying is particularly loud and prolonged, the nurse puts the crib in a
separate room and closes the door. The toddler is left there until the crying ceases, a
matter of 30 to 45 minutes. Legally:
a. The child needed to have limits set to control the crying
b. The child had a right to remain in the room with the other children

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c. Keeping the child segregated alone for more than 30 minutes was too long
d. The other children had to be considered, so the child needed to be remove
Answer: B
Rationale: A child cannot legally be locked in a room (isolated) unless there is a threat
or danger involved either to the client or to other clients.
12. A primary care provider's orders indicate that a surgical consent form needs to be
signed. Since the nurse was not present when the primary care provider discussed the
surgical procedure, which statement best illustrates the nurse fulfilling the client
advocate role?
a. The doctor has asked that you sign this consent form.
b. Do you have any questions about the procedure?
c. What were you told about the procedure you are going to?
d. Remember that you can change your mind and cancel the procedure.
Answer: C
Rationale: This is the best answer because the nurse is assessing the client's level of
knowledge as a result of the discussion with the primary care provider. Based on this
assessment, the nurse may initiate other actions.

13. A client is brought to the Emergency Room after a serious accident is unconscious
and bleeding profusely. Surgery is required immediately in order to save the client's
life. In regard to informed consent for the surgical procedure, which of the following is
the best nursing action?
a. Try to obtain the spouses telephone number and call the spouse to obtain
telephone consent before the surgical procedure
b. Transport the client to the operating room immediately as required by the physician
without obtaining an informed consent
c. Ask the friend who accompanied the client to the emergency room to sign the
consent form
d. Call the nursing supervisor to initiate a court order for the surgical procedure
Answer: B
Rationale: When an emergency situation exists, no consent is necessary because
inaction at such time may cause greater injury.

14. This doctrine states that the accident itself gives reasonable evidence that the injury
resulted from lack of care and therefore no further proof/explanation is needed.
a. Res ipsa loquitur
b. Facio ut des
c. Respondeat superior
d. Force majeure
Answer: A
Rationale: Res ipsa loquitur means the thing speaks for itself.

15. You are commuting to work riding the LRT. An older person collapsed and nobody
seems to notice her. The security guard tried to make her sit down but she remained
unconscious. You saw what happened and you decided to help. With help, you brought
the patient to the nearest hospital. You learned that the woman is diabetic. She was on
her way to the diabetic clinic to have her fasting blood sugar. She developed
hypoglycemia. You were able to save a life. What principle was applied?
a. Advocacy c. Justice

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b. Beneficence d. Autonomy
Answer: B
Rationale: Beneficence promotes doing acts of kindness and mercy that directly
benefit the patient, such as bringing the patient to the nearest hospital for medical
management.

Situation 4: The learning process in nursing is a continuous rite, and the nurse bears the
responsibility to enhance ones self both personally and professionally.
16. Beneficiaries of the Comprehensive Nursing Specialty Program will be obliged to
serve in any Philippine Hospital for at least how many years?
a. 1 year c. 3 years
b. 2 years d. 4 years
Answer: B
Rationale: Beneficiaries of the Comprehensive Nursing Specialty Program will be
obliged to serve in any Philippine Hospital for at least 2 years (RA 9173 Section 32).

17. The following are purposes of the Philippine Nursing Association except:
a. To attain minimum level of professional standards
b. To work for the welfare of member nurses
c. To respond to the changing health needs of the Philippine society
d. To establish linkages with other agencies
Answer: A
Rationale: The PNA serves to attain optimal level of professional standards.

18. A registered nurse can opt to work as a Private Nurse Practitioner. A private nurse
practitioner must have the following qualifications except:
a. Have at least 1 year of bedside nursing experience in a general hospital
b. Be a full time private duty nurse
c. Be a certified IV therapist by the ANSAP
d. Preferably have undergone a Critical Care Nursing Course
Answer: A
Rationale: A private nurse practitioner must have at least 2 years of bedside nursing
experience in a general hospital.

19. The following are qualifications for Commission in the Reserve Force Nurse Corps
except:
a. Not more than 32 years old at the time of commission
b. Minimum height of 64 inches for males, and 62 inches for females
c. A natural-born-Filipino Citizen
d. Single or has never been married for both male and female
Answer: B
Rationale: This is the height requirement for the Regular Force Nurse Corps. For the
Reserved Force Nurse Corps, the minimum height is 62 inches for male, and 60 inches
for females.
20. This is the umbrella term for nurses who have specialized education and experience
beyond the basic nursing program.
a. Nurse Specialist
b. Nurse Clinician
c. Independent Nurse Practitioner

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d. Advanced Practice Nurse
Answer: D
Rationale: The Advanced Practice Nurse is an umbrella term for nurses who have
specialized education and experience beyond the basic nursing program.

Situation 5: There are plenty of laws affecting health and nursing practice in the
Philippines. Nurses must be familiar with these existing laws and standards that govern
safe nursing practice.
21. The Board of Nursing has adopted certain rules and regulation in professional
nursing practice as the Code of Nursing Ethics in the Philippines through:
a. Board Resolution No. 223 series of 1989
b. Republic Act 9173
c. Board Resolution No. 220 series of 2004
d. Republic Act No. 7160
Answer: C
Rationale: Board Resolution No. 220 series of 2004 Code of Ethics

22. The Magna Carta for public health workers is embodied in?
a. RA 7305 c. RA 7600
b. RA 6425 d. RA 6809
Answer: A
Rationale: RA 7305 Magna Carta for Public Health Workers

23. Nurse Sharon, who worked for 25 years at Al Kayhid Medical Center in Saudi,
decides to return to the Philippines. As a Filipino professional, she can practice her
profession in the country in pursuant of:
a. PD 541 c. PD 856
b. PD 603 d. PD 807
Answer: A
Rationale: PD 541 Balikbayan Law

24. The night differential is equivalent to what percent of the salary per day?
a. 10% b. 20% c. 15% d. 30%
Answer: A
Rationale: In Section 18 (Night-Shift Differential) of Republic Act 7305, otherwise
known as the Magna Carta of Public Health Workers, Public Health Workers shall be
granted additional night shift differential pay of ten percent (10%) of his/her regular
wage for each hour of work performed during the night shifts.

25. A nurse accepts an assignment in a remote area. The nurse is entitled to how many
percent additional of salary to her basic pay?
a. 15% b. 20% c. 30% d. 50%
Answer: D
Rationale: In Section 25 (Remote Assignment Allowance) of Republic Act 7305,
otherwise known as the Magna Carta of Public Health Workers, Doctors, dentists,
nurses, and midwives who accept assignments as such in remote areas or isolated
stations shall be entitled to an incentive bonus in the form of remote assignment
allowance equivalent to fifty percent (50%) of their basic pay, and shall be entitled to

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reimbursement of the cost of reasonable transportation to and from and during official
trips.

Situation 6: The Philippine Nursing Act of 2002 regulates the practice of Nursing in the
Philippines. It is therefore a must for Filipino nurses to be familiar with this nursing law.
26. Which of the following institutions or organizations is responsible for approving the
certificate to operate as a nursing school in the Philippines?
a. Board of Nursing
b. Commission on Higher Education
c. Philippine Nurses Association
d. Professional Regulatory Commission
Answer: B
Rationale: The authority to open and close colleges of nursing and/or nursing
education programs shall be vested on CHED upon written recommendation of the
Board. The BON only serves as the recommending body.

27. The certificate of registration can be revoked or suspended for the following acts,
EXCEPT:
a. Serious ignorance
b. Accused of immoral an dishonorable conduct
c. Gross incompetence
d. Illegal practice
Answer: B
Rationale: The license can be revoked if a person has been charged guilty of
dishonorable or immoral conduct.

28. A nurse was apprehended after carrying 25 grams of methamphetamine
hydrochloride inside patient's room. The following are the possible liabilities or
sanctions for him, EXCEPT:
a. Revocation of license c. Fines
b. Suspension d. Imprisonment
Answer: B
Rationale: The nurse is guilty of a criminal offense, which is a ground for revocation of
license. A fine of not less than fifty thousand pesos nor more than one hundred
thousand pesos or imprisonment of not less than one year not more than six years
shall also be imposed.

29. All of the following are qualifications of the Chairperson and Members of the Board
of Nursing, except:
a. Citizen and resident of the Philippines
b. Holder of a Masteral degree in Nursing
c. Have at least 5 years of continuous practice in the profession
d. Member of the Philippine Nurses Association
Answer: C
Rationale: In Section 4, Article III RA No. 9173, the Chairperson and Members of the
Board shall possess the following qualifications:

30. Which of the following is an additional function of the Board of Nursing as a
departure from Republic Act No. 7164?

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a. Issue, revoke, or suspend COR for the practice of nursing
b. Promulgate decision for the improvement of nursing as a profession
c. Recommend the opening and closure of the college of nursing
d. Conduct the licensure examination for nurses
Answer: C
Rationale: In Section 9, Article III of RA 9173, the authority to open and close colleges
of nursing and/or nursing education programs shall be vested on CHED upon written
recommendation of the Board. The BON only serves as the recommending body. (De
Belen, Nursing Law, Jurisprudence & Professional Ethics)

Situation 7: The advent of Nursing Research has greatly improved client care.
31. The easiest way to participate in research is to:
a. Be a good consumer of research
b. Analyze related studies
c. Conduct a research study
d. Participate in your facilitys internal review board
Answer: A
Rationale: Begin by reading research articles and judging whether theyre applicable to
your practice. Research findings arent useful if they arent incorporated into practice.
(Lippincotts Emergency Nursing Made Incredibly Easy)

32. The purpose of evidence-based practice is to:
a. Validate traditional nursing practices
b. Improve patient outcomes
c. Relate traditional nursing practices
d. Establish a body of knowledge unique to nursing
Answer: B
Rationale: Although evidence-based practices may validate or refute traditional
practice, their purpose is to improve patient outcomes. (Lippincotts Emergency
Nursing Made Incredibly Easy)

33. Which of the following studies is based on quantitative research?
a. A study examining the bereavement process in couples with still birth deliveries
b. A study measuring the effects of sleep derivation on wound healing post cesarean
delivery
c. A study on client's feelings before and after a vaginal delivery
d. A study exploring factors influencing weight control behavior of pregnant women
Answer: B
Rationale: Quantitative research collects numerical data. Sleep deprivation can be
defined by the number of hours without sleep, and wound healing can be measured by
the size of wound in relation to the period of time.

34. Which of the following is the primary advantage of using computers while
conducting nursing research?
a. Locating potential participants
b. Designing the steps of the research plan
c. Analyzing the quantitative data
d. Disseminating the research findings
Answer: C

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Rationale: Although all steps of the research process can be accomplished without
computers, electronic data analysis helps ensure accuracy and speeds the analysis
immensely. (Kozier & Erb's Fundamentals of Nursing, 8
th
Edition)

35. Which of the following is a nursing responsibility when critiquing published nursing
research?
a. Assume that the research was properly conducted since it has been published
b. Evaluate whether findings are applicable to the nurse's specific clients
c. Implement the research findings if at least two studies have shown the same
results
d. Request the raw data from the researchers so that the nurse can analyze the
statistics again
Answer: B
Rationale: Since the primary purpose of research is to improve quality of client care,
the nurse should determine if published research results are applicable to the specific
client population.

Situation 8: A research study was undertaken in order to identify and analyze a disabled
boys coping reaction pattern during stress.
36. This study which is an in depth study of one boy is a:
a. Longitudinal study
b. Evaluative study
c. Cross-sectional study
d. Case study
Answer: D
Rationale: Case study is an in depth analysis of a person, family, community or
situation.
37. The process recording was the principal tool for data collection. Which of the
following is not a part of a process recording?
a. Audio-visual recording
b. Verbal narrative account
c. Non-verbal narrative account
d. Analysis and interpretation
Answer: A
Rationale: There is no visual recording only audio recording.

38. The investigator also provided the nursing care of the subject. The investigator is
referred to as a/an:
a. Advocate c. Observer researcher
b. Caregiver d. Participant-observer
Answer: D
Rationale: When the investigator also provided the nursing care of the subject, the
investigator is referred to as a participant-observer.

39. Which of these do not happen in a descriptive study?
a. Manipulation of variable
b. Investigation of a phenomenon in real life context
c. Explanation of relationship between two or more phenomena
d. Exploration of relationship between two or more phenomena

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Answer: A
Rationale: There is no manipulation in a descriptive study. Manipulation is done in an
experimental study.

40. To ensure reliability of the study, the investigators analysis and interpretations are:
a. Scored and compared standard criteria
b. Subjected to statistical treatment
c. Subjected to an inter-observer agreement
d. Correlated with a list of coping behaviors
Answer: A
Rationale: To ensure reliability (degree of consistency or accuracy) of the study, the
investigators analysis and interpretations should be scored and compared to standard
criteria.

Situation 9: Gladys, a nurse researcher in the community, plans to undertake a study of
Barangay A and B in terms of utilization of MCN services after organizing and training
Barangay Health Workers in Barangay A.
41. This type or research is:
a. Historical c. Basic
b. Experimental d. Pure
Answer: B
Rationale: Experimental research deals with cause and effect relationship.

42. The independent variable is:
a. Utilization of MCN services
b. Organization and training of BHW
c. Barangay A and B
d. Data gathering and instrument
Answer: B

43. The dependent variable is:
a. Utilization of MCN services
b. Organization and training of BHW
c. Barangay A and B
d. Data gathering and instrument
Answer: A

44. Which of the following is the best hypothesis for this research?
a. Barangay A is better in the performance than Barangay B
b. The presence of organized and trained BHW will increase the utilization of MCN
services by Barangay A and B
c. Organization and training of BHW
d. Barangay A and B will both improve their services
Answer: B

45. In the above number, what type of hypothesis is formulated?
1. Simple 4. Directional
2. Complex 5. Non-directional
3. Null

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a. 1 and 5 c. 1 and 4
b. 2 and 4 d. 2 and 3
Answer: B
Rationale: The formulated hypothesis is both complex (2) and directional (4).
Complex/Multivariate hypothesis involves two or more independent and/or dependent
variables. Directional hypothesis states directly the relationship between the variable.
1. Simple. It is not a simple hypothesis because there are two independent variables
(organization and training of BHW)
3. Null hypothesis is stated as There is no significant relationship between the
organization and training of BHW, and the utilization of MCN services.
5. Non-directional. It is not non-directional because the relationship between the
variables is directly stated.

Situation 10: As a professional nurse, you have certain responsibilities to your self, your
co-workers, and your clients.
46. The registered nurse arrives at work and is told to report (float) to the intensive care
unit for the day because the ICU is understaffed and needs additional nurses to care
for the clients. The nurse has never worked in the ICU. Which of the following is the
most appropriate nursing action?
a. Refuse to float to the ICU
b. Call the hospital lawyer
c. Call the nursing supervisor
d. Report to the ICU and identify tasks that can be performed safely
Answer: D
Rationale: Floating is an acceptable legal practice used by hospitals to solve their
understaffing problems. Legally, a nurse cannot refuse to float unless a union contract
guarantees that nurses can work only in a specified area or the nurse can prove the
lack of knowledge for the performance of assigned tasks. (Saunders, 3
rd
Edition)

47. A nurse who works in the night enters the medication room and finds a co-worker
with a tourniquet wrapped around the upper arm. The co-worker is about to insert a
needle attached to a syringe containing a clear liquid, into the antecubital area. The
most appropriate initial action by the nurse is which of the following?
a. Call the police
b. Call security
c. Lock the co-worker in the medication room until help is obtained
d. Call the nursing supervisor
Answer: D
Rationale: Nurse practice act require reporting impaired nurses. The BON has
jurisdiction over the practice of nursing and may develop plans for treatment and
supervision of the impaired nurse. This incident needs to be reported to the nursing
supervisor, who will then report to the BON and other authorities, such as the police, as
required.
(Saunders, 3
rd
Edition)

48. A nurse had been caring for a client whose vital signs had previously been unstable.
The nurse had not had a coffee break or lunch break all day. By 2 pm, the client had

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been stable for a number of hours. The physician in charge had seen the client and had
told the nurse that the client appeared much improved. The nurse should:
a. Leave for lunch break
b. Forego lunch break because of the clients previous unstable condition
c. Arrange to eat lunch in the clients room
d. Discuss the situation with the nurse in charge of the unit and determine who should
cover the client while the staff is at lunch
Answer: D
Rationale: The nurse would come back to the client revitalized after having a lunch
break, and the client would be covered the whole time the nurse is away. In deciding
that the nurse would not be negligent to leave such a client, the court would emphasize
that the question of liability should be determined in light of the circumstances as they
existed at the time. When the nurse left the client, it was not foreseeable that an
increased risk to the client would result. On the contrary, the client would be looked
after, and the nurses needs would also be met.
(Daviss, 2
nd
Edition)

49. In a certain hospital, whenever there are clients in the recovery room, two nurses
are usually present. The hospital policy expects the nurses to take their breaks before
clients arrive for surgery. On this particular day, there are two nurses on duty and two
clients in the recovery room who have had minor surgeries performed that morning.
One nurse had not had a coffee break that morning. The nurse should:
a. Stay because hospital policy expects there to be two nurse in attendance while
there are clients in the recovery room
b. Leave for coffee break because there are only two clients in the recovery room and
one nurse can handle two clients quite easily
c. Talk with the nursing supervisor and secure permission from him or her
d. Leave to get coffee and come right back
Answer: A
Rationale: In a court of law, hospital policy may be used to set the standard care by
which nurses actions are judged. Because the hospital policy states that two nurses
must be in attendance while clients are in the recovery room, both the nurse who left
(options B and D) and the supervisor who authorized the nurses absence (option C)
would be held liable. (Davis, 2
nd
Edition)

50. The nurse finds an unopened vial of morphine sulfate lying on the cabinet in a
patients room. What is the most appropriate action for the nurse to take first?
a. Secure the vial and return the medication to stock the future use
b. Remove the vial from the patients bedside and notify the nurse supervisor that an
unsecured vial of a controlled substance was found
c. Check with the other nurses to see if their patient have morphine orders and
administer the medication to another patient to avoid waste
d. Contact the organizations security department and have it investigate the crime
scene
Answer: B
Rationale: Morphine is a controlled substance and should be secured at all times. The
nurse should immediately remove the vial from the patients bedside and notify the
supervisor that an unsecured vial of morphine was found. The supervisor should then

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proceed to intervene and follow organizational policy. (Chernecky, NCLEX-RN Review
Guide)

Situation 11: Professional obligations of nurses are accompanied by legal responsibilities.
Nurses must be keen in observing these legalities in order to protect ones self from legal
suits, and secure the client's safety.
51. The nurse is working in a long-tem care facility and is administering medications to
assigned clients. A client refuses to take the prescribed medication, and the nurse
threatens the client and tells the client that if medication is not taken orally, the
restraints will be applied and the mediation will be given by injection. This statement
by the nurse constitutes which legal tort?
e. Invasion of privacy c. Assault
f. Negligence d. Battery
Answer: C
Rationale: An assault occurs when a person puts another person in fear of a harmful or
offensive contact. For this intentional tort to be actionable, the victim must be aware of
the threat of harmful or offensive contact.

52. A client had been receiving a drug by injection over a number of weeks. As the
clinical symptoms changed, the physician wrote an order sheet changing the mode of
administration from injection to oral. When the nurse on the unit, who had been off
duty for several days, was preparing to give the medication by injection, the client
objected and referred the nurse to the physicians new orders. The nurse should:
e. Go back to the order sheet and check for the order
f. Talk with the nurse who had taken care of this particular client while he or she had
been off duty
g. Talk with the head nurse about the advisability of using oral rather than injectable
medications
h. Check the order sheet for the changed order and then speak with the attending
physician concerning the changed order
Answer: D
Rationale: The nurse should validate the changed order and learn the physicians
rationale for the change.

53. While driving down a freeway, a nurse spots an overturned car with the driver lying
next to the car. The nurse:
a. May drive on without stopping, or stop and render emergency first aid, without
liability
b. May stop, start to render aid, and then leave, without liability
c. Must stop at the scene of an accident and render first aid
d. May stop and render aid, but if he or she performs a medical act, he or she may be
charged with illegal practice of medicine
Answer: A
Rationale: The court has stated that no one is obliged by law to assist a stranger, even
if he or she can do so by a word and without the slightest danger to himself or herself.

54. A nurse has been administered the wrong oral medication. Which action should the
nurse take first?
a. Complete a medication error

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b. Notify the prescribing physician
c. Assess the patient
d. Contact the pharmacist
Answer: C
Rationale: The first responsibility of the nurse when a medication error is discovered is
to assess the patient. The assessment should focus on the current health status of the
patient and identify whether there are any adverse effects from the medication
administered in error. The assessment also serves as a baseline for further monitoring
for adverse effects. (Chernecky, NCLEX-RN Review Guide)

55. The nurse has been working with a man who is terminally ill for weeks. The client is
lucid. His wife pleads with the nurse not to use heroic measures on her husband but to
let him die with dignity. The nurse should:
a. Tell the wife that she needs to talk with the attending physician, client (if possible),
and other significant people about her concerns
b. Act on the wifes request
c. Ignore the wifes request and proceed with the clients care
d. Tell the wife that to do as she requested would be equivalent to murdering the client
Answer: A
Rationale: Neither the nurse, the wife, nor the doctor can make that decision as long
as the client is an adult who is competent. (Davis, 2
nd
Edition)

Situation 12: When nurses undertake to practice their profession, they are held
responsible and accountable for the quality of performance of their duties.
56. A graduate nurse who was new to a unit was caring for an elderly client. The
physician on call ordered a treatment that the nurse had not heard of. The nurse
should:
e. Inform the physician of the nurses lack of education and experience and refuse to
do the treatment without supervision
f. Inform the physician of the nurses lack of education and experience and then
proceed to perform the treatment
g. Refuse to perform the treatment
h. Carry out the treatment to the best of the nurses ability
Answer: A
Rationale: If the nurse informs the physician and still carries out the treatment, both
the nurse and the physician could be held liable if the client is negligently harmed. The
nurse would be held liable for not acting as a reasonably prudent nurse, and the
physician would be liable because he or she knew of the nurses lack of knowledge and
did not step in to protect the client.

57. The day nurse tells the night nurse that the suction equipment in a clients room is
not working properly. The night nurse, who will be working with this client, should:
a. Follow the day nurses suggestions on how to get the malfunctioning equipment to
work
b. Continue to use the malfunctioning machine, hoping that it will function for the
night shift
c. Ask the supervisor how to work with the malfunctioning equipment
d. Replace the equipment or report it to whomever is responsible for maintaining
equipment in proper working condition

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Answer: D
Rationale: As a nurse, you should not plan to use equipment that you know is
malfunctioning. You could be held liable because you were on notice and could
reasonably foresee that properly functioning equipment could be needed by your client.
(Davis, 2
nd
Edition)

58. A client who is terminally ill tells the nurse during a home health-care visit that he
does not want CPR when the time comes. What should be the nurses next action?
a. Document the request in the health care plan
b. Talk to the family about this request
c. Obtain an order from the MD
d. Share this information with other members of the home health care team
Answer: C
Rationale: A DNR order is required.

59. Which situation would be an example of professional malpractice by a nurse?
a. An infant is injured as a result of incorrect information provided to the parents by
the nurse on the use of a child safety restraint in the car
b. The nurse inadvertently throws away the container holding the clients dentures
c. A client is ambulating in the hall and slips on a recently mopped floor, causing
injury to the leg
d. A visitor who is sitting by the clients bed is hit by a falling IV pole while the nurse is
changing the IV tubing, and require stitches for a laceration
Answer: A
Rationale: The definition of malpractice is the incorrect or negligent treatment of a
client. Included would be incorrect instructions that resulted in injury.

60. When checking the IV solution at the beginning of the shift, it was discovered that
an incorrect solution was running. After changing the solution to the correct order, an
appropriate nursing action would be to:
a. Report the discovery of the error to the supervisor
b. Document the error and correction in the medical record
c. Fill out an incident report according to hospital policy
d. Assure the client that the error had no adverse effects
Answer: C
Rationale: A quality assurance report of incident report should be completed and
submitted according to hospital policy. The report would indicate that the MD was
notified and the status of the client, and any other as a result of the error.

Situation 13: Nursing ethics involves rules and principles to guide right conduct in terms
of moral duties and obligations to protect the rights of human beings.
61. In caring for a 15-year-old client in the terminal stages of cancer who is refusing any
more treatment, the nurse should provide ethical care that:
21. Ensures a cure and benefits the clients parents
22. Allows the client to determine his or her care
23. Requires treatment to be continued
24. Promotes equity and prevents litigation
Answer: B

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Rationale: A persons autonomy and ability to make decisions affect his or her care
need to be considered and honored if the decision is the most beneficial and least
harmful. (Chernecky, NCLEX-RN Review Guide)

62. The clients physician informs him that he must receive chemotherapy or the client
will die within 6 weeks. The client expresses to the nurse that he does not want the
treatment. As the clients advocate the nurse should recognize that the client:
a. Has the right to refuse treatment to the extent permitted by law
b. Must recognize the physicians expertise and agree to the treatment
c. Has the right to ask for an early death
d. Has an obligation to himself and his family to accept the life-saving treatment
Answer: A
Rationale: Clients have the right to be autonomous and make their own choices.
(Chernecky, NCLEX-RN Review Guide)

63. The client tells the nurse to not inform family members about the medical diagnosis
or to share other details of the medical record. In meeting this request, the nurse
would be upholding which of the following?
a. Informed consent c. Living will
b. Confidentiality d. Advance directive
Answer: B
Rationale: Confidentiality protects the privacy of clients and their records.

64. A nurse sees a motor vehicle accident and stops to provide first aid. The nurse
knows that this action is protected by the Good Samaritan Law. Which of the following
items should the nurse recall about the Good Samaritan Law?
a. It was created specifically for RNs
b. It differs in places
c. It does not provide liability for the nurse responding to an emergency
d. It hinders nurses for providing help during an accident
Answer: B
Rationale: Good Samaritan laws are designed to protect healthcare professionals who
offer assistance during an emergency and may apply to various licensed personnel.
The laws vary from state to state and should be reviewed by the practicing RN. (Hogan,
Reviews and Rationales Series for Nursing: Fundamentals of Nursing)

65. A client with rheumatoid arthritis does not want cortisone even if it is prescribed
and informs the nurse of this. Later, the nurse attempts to administer the cortisone
that has been ordered by the physician. When the client asks what the medication is,
the nurse gives an evasive answer. The client takes the medication and later finds that
it was cortisone. The client states intent to sue. The decision in this suit would take into
consideration the fact that:
a. The nurse should have notified the physician
b. The nurse is required to answer the client truthfully
c. The client has insufficient knowledge to make such a decision
d. The physician's order takes precedence over a client's preference
Answer: B
Rationale: The client has the right to know what medication is being administered
(informed consent).

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Situation 14: In nursing, ethical codes provide professional standards and formal
guidelines for nursing activities to protect both the nurse and the client.
66. An ethical conflict about a patients care has developed, and the nurse is unable to
resolve the conflict. Which hospital resource would be most appropriate for the nurse
to consult about the ethical dilemma?
a. Hospital ethics committee
b. Quality improvement committee
c. Chaplain
d. Nursing supervisor
Answer: A
Rationale: The most appropriate resource for the nurse to consult regarding the ethical
dilemma would be the hospital ethics committees. The scope of an ethics committees
responsibilities may vary form organization to organization. Common functions of such
a committee include evaluation of institutional polices, provision of educational
programs, and consultation on cases with ethical issues. (Hogan, Reviews and
Rationales Series for Nursing: Fundamentals of Nursing)

67. Four student nurses are discussing the Code of Ethics. The student who correctly
understands the purpose of the document is the one who states that the purpose of
the code is to do which of the following?
a. Assure the public that nurses will display ethical behaviors when providing client
care
b. Compare the expected behavior of nurses with other healthcare providers such as
physicians
c. Provide guidelines with respect to the care of individuals, and for accountability to
the profession and society
d. Prevent certain individuals from practicing nursing by enforcing regulations that
prohibit attainment of licensure
Answer: C
Rationale: The Code of Ethics provides guidelines with respect to the care of
individuals, and for accountability to the profession and society. (Hogan, Reviews and
Rationales Series for Nursing: Fundamentals of Nursing)

68. The client is to undergo an invasive procedure. While providing information about
the procedure, the nurse provides legal protection of a clients right to autonomy with
which of the following?
a. Informed consent
b. Beneficence
c. Good Samaritan Law
d. Advance directives
Answer: A
Rationale: Informed consent provides legal protection of a client's right to personal
autonomy and to choose medical treatment.

69. A nurse is concerned about maintaining the standards for client confidentiality. The
nurse can perform the duties of the position and still maintain client confidentiality by
doing which of the following?

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a. Reading the records of clients not assigned to the nurse to become more familiar
with disease processes
b. Sharing information about an interesting client with nurses from another unit that
may eventually care for the individual
c. Allowing the clients family to review the medical record in order to provide answers
to questions
d. Sharing information about the client with those involved in care for the purpose of
planning nursing care
Answer: D
Rationale: The client has the right to confidentiality.

70. The Code of Ethics for Nurses provides information that's necessary for the
practicing nurse to:
a. Document her nursing care appropriately
b. Make ethical decisions about patient care
c. Use her professional skills in providing the most effective holistic care possible
d. Strengthen and protect patient privacy
Answer: C
Rationale: The Code of Ethics for Nurses provides information that's necessary for the
practicing nurse to use her professional skills in providing the most effective holistic
care possible. (Lippincotts Fundamentals of Nursing Made Incredibly Easy)

Situation 15: Records contain comprehensive descriptions of patients health conditions
and needs and at the same serve as evidences of every nurses accountability in the care
giving process. Nursing records normally differ from institution to institution nonetheless
they follow similar patterns of meeting needs for specific types of information.
71. This special form is used when the patient is admitted to the unit. The nurse
completes the information in this record particularly his/her basic personal data,
current illness, previous health history, health history of the family, emotional profile,
environmental history as well as physical assessment together with nursing diagnosis
on admission. What do you call this record?
a. Nursing Kardex
b. Nursing Health History and Assessment Worksheet
c. Medicine and Treatment Record
d. Discharge Summary
Answer: B

72. These are sheets/forms provide an efficient and time saving way to record
information that must be obtained repeatedly at regular and/or short intervals of time.
This does not replace the progress notes. This records information on vital signs, intake
and output, treatment, postoperative care, post partum care, and diabetic regimen,
etc. What is this?
a. Nursing Kardex
b. Graphic Flow Sheets
c. Discharge Summary
d. Medicine and Treatment Record
Answer: B

73. These records show all medications and treatment provided on a repeated basis.

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What do you call this record?
a. Nursing Health History and Assessment Worksheet
b. Discharge Summary
c. Nursing Kardex
d. Medicine and Treatment Record
Answer: D

74. This flip-over card is usually kept in a portable file at the Nurses Station. It has 2-
parts: the activity and treatment section and a nursing care plan section. This carries
information about basic demographic data, primary medical diagnosis, current orders
of the physician to be carried out by the nurse, written nursing care plan, nursing
orders, scheduled tests and procedures, safety precautions in patient care and factors
related to daily living activities. This record is used in the charge-of-shift reports or
during the bedside rounds or walking rounds. What record is this?
a. Discharge Summary
b. Medicine and Treatment Record
c. Nursing Health History and Assessment Worksheet
d. Nursing Kardex

Answer: D

75. Most nurses regard this conventional recording of the date, time, and mode by
which the patient leaves a health care unit but this record includes importantly, directs
of planning for discharge that starts soon after the person is admitted to a health care
institution. It is accepted that collaboration or multidisciplinary involvement (of all
members of the health team) in discharge results in comprehensive care. What do you
call this?
a. Discharge Summary
b. Nursing Kardex
c. Medicine and Treatment Record
d. Nursing Health History and Assessment Worksheet
Answer: A

Situation 16: Nurses must be aware of the legal and ethical responsibilities related to
informed consent.
76. In relation to obtaining informed consent from a 17-year-old adolescent, the nurse
should remember that the adolescent:
a. Does not have the legal capacity to give consent
b. Is not able to make an acceptable or intelligent choice
c. Is able to give voluntary consent when parents are not available
d. Will most likely be unable to choose between alternatives when asked to consent
Answer: A
Rationale: An individual is legally unable to sign consent until the age 18 years. The
only exception is the emancipated minor, a minor who is self-sufficient, or married.

77. When obtaining consent for surgery, the nurse should initially:
a. Explain the risks involved in the surgery
b. Explain that obtaining the signature is routine for any surgery
c. Evaluate whether the client's knowledge level is sufficient to give consent

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d. Witness the signature because this is what the nurse's signature documents
Answer: C
Rationale: It is the physician's responsibility to obtain the consent and to ensure that
the signer is competent. A medicated client generally is not deemed competent and
the surgery may have to be postponed.

78. While conducting the study, one of the participants told the nurse that she wants to
withdraw from the study. The nurse should perform which of the following actions?
a. Convince the participant not to withdraw
b. Give her the permission to withdraw
c. Sue her since she already signed a contract
d. Allow her to withdraw from the study
Answer: D
Rationale: The patient can withdraw anytime his/her participation in the study.

79. In any research study where individual persons are involved, it is important that an
informed consent of the study is obtained. The following are essential information
about the consent that you should disclose to the prospective subjects except:
a. Consent to incomplete disclosure
b. Benefits, risks and discomforts
c. Explanation of procedure
d. Assurance of anonymity and confidentiality
Answer: A
Rationale: The patient as a subject of the study has to right to complete disclosure. The
following should be considered before an informed consent can be obtained: Benefits,
Risks, and Alternatives are presented; Inquiries of the patient are answered; Decision
is made voluntarily; Explanation of the procedure is done; and Documentation
(BRAIDED).

80. Mr. R has been medicated for surgery. The OR nurse, when going through the
client's chart realizes that the consent form has not been signed. Which of the
following is the best action for the nurse to take?
a. Assume it is emergency surgery and the consent is implied
b. Get the consent form and have the client sign it
c. Tell the physician that the consent form is not signed
d. Have a family member sign the consent form
Answer: C
Rationale: It is the physician's responsibility to obtain the consent and to ensure that
the signer is competent. A medicated client generally is not deemed competent and
the surgery may have to be postponed.

Situation 17: The use of massage and meditation to help decrease stress and pain have
been strongly recommended based on documented testimonials.
81. Marjorie wants to do a study on this topic: Effects of massage and meditation on
stress and pain. What type of research best suits this topic?
a. Applied research
b. Qualitative research
c. Basic research
d. Quantitative research

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Answer: D
Rationale: Quantitative research includes cause-and-effect relationships, in this case,
the effect of massage and meditation on stress and pain.

82. Which type of research design does not manipulate the independent variable?
a. Experimental design
b. Quasi-experimental design
c. Non-experimental design
d. Quantitative design
Answer: C
Rationale: Non-experimental designs, such as historical and descriptive research
designs, do not involve manipulation of variables.

83. This research topic has the potential to contribute to nursing because it seeks to:
a. Include modalities of care
b. Resolve a clinical problem
c. Clarify an ambiguous modality of care
d. Enhance client care
Answer: D
Rationale: Studying the effects of massage and meditation on stress and pain
enhances client care, since it offers alternative ways in relieving stress and pain.

84. Marjorie does review of related literature for the purpose of:
a. Determining statistical treatment of data research
b. Gathering data about what is already known or unknown about the problem
c. Identifying if problem can be replicated
d. Answering the research question
Answer: B
Rationale: The review of related literature helps the researcher in gathering data about
what is already known or unknown about the problem for better understanding of
his/her research topic.

85. Marjorie knows that the client's rights should be protected when doing research
using human subjects. These include the following except:
a. Right to self-determination
b. Right to compensation
c. Right of privacy
d. Right not to be harmed
Answer: B
Rationale: There are five basic human rights of research subjects, which include
choices A, C and D. The other two are the right to informed consent, and the right to
confidentiality or anonymity of data.
Situation 18: Research design is a blue print or plan of action for meeting all the object of
the study. Appropriateness is the main concern. There is no best or versatile design, its
importance is its applicability to the study.
86. A systematic critical inquiry of the whole truth of past event using critical method in
the understanding and interpretation of facts which are applicable to the current issues
and problem is:
a. Experimental design c. Case study

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b. Descriptive design d. Historical design
Answer: D
Rationale: Historical design is a systematic critical inquiry of the whole truth of past
event using critical method in the understanding and interpretation of facts which are
applicable to the current issues and problem.

87. A researcher wants to investigate the relationship between student's licensure
examination score and their pursuit of a graduate degree. The appropriate research
design is:
a. Correlational c. Basic research
b. Causal-comparative d. Applied research
Answer: A
Rationale: Correlational study is a quantitative research design that describes the
relationship of the variables under the phenomenon being investigated.

88. Which of the following must be present in a quasi-experimental design?
1. Control 2. Randomization 3. Manipulation

a. 1 only c. 3 only
b. 2 only d. All of the above
Answer: C
Rationale: In a quasi-experimental design, the investigator manipulates (C) the
independent variable but without either the randomization (option B) or control (option
A) that characterizes true experiments.
D. Either control or randomization is not included in a quasi-experimental design.

89. A study was conducted on a client living in a nursing home with multiple sclerosis.
The appropriate research design is:
a. Phenomenological c. Historical
b. Ethnographic d. Grounded-theory
Answer: A
Rationale: Phenomenological is a study conducted to investigate and gain insight
about human life experience.

90. A researcher wants to study the cultural practices of the Muslims. Which research
design is appropriate?
a. Case study c. Ethnographic
b. Action Research d. Grounded-theory
Answer: C
Rationale: Ethnographic is a study to investigate the beliefs, cultures, and practices of
the cultural minorities.

Situation 19: Sampling is an essential element of the research process.
91. This type of sampling chooses subjects without using random sampling method.
This is called:
a. Systematic sampling
b. Convenience sampling
c. Probability sampling
d. Non-probability sampling

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Answer: D
Rationale: Non-probability or non-scientific sampling chooses subjects without using
random sampling method (randomization).

92. This type of sampling uses the techniques whereby the population is subdivided into
areas or sections and then taking a random sample from each section is called:
a. Stratified sampling
b. Purposive sampling
c. Simple random sampling
d. Multistage sampling
Answer: A
Rationale: Stratified random sampling is a probability sampling wherein the population
is divided into 2 or more strata.

93. In this type of sampling, data are collected from anyone available such as those
who are present in the theater lobby or those who are present in the CR at one time or
another. This is called:
a. Systematic sampling c .Incidental sampling
b. Quota sampling d. Purposive sampling
Answer: C
Rationale: Incidental, Convenience or Accidental sampling study subjects that are
accessible and readily available. It is a non-probability sampling.

94. In this type of sampling, selection of units in the sample is done by some sort of
chance. This is called:
a. Purposive sampling
b. Simple random sampling
c. Accidental sampling
d. Cluster sampling
Answer: B
Rationale: Simple random sampling is a probability sampling wherein each subject or
unit has equal chance to be chosen.

95. A new staff nurse would like to collect data on common problems encountered by
renal patients in the hospital. In this survey, she selects only the kidney patients in the
hospital. This is an example of what type of sampling?
a. Judgmental sampling c. Sequential sampling
b. Snowball sampling d. Accidental sampling
Answer: A
Rationale: Purposive or Judgmental sampling is a non-probability sampling wherein
samples are chosen deliberately because they are representative of the target
population.

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Situation 20: As a nurse researcher, you must have a very good understanding of the
common terms and concepts used in research.

96. Patient's level of anxiety and pain tolerance are an example of which level of
measurement?
a. Nominal c. Interval
b. Ordinal d. Ratio
Answer: B
Rationale: In ordinal measurement, the attributes can be rank-ordered (1
st
, 2
nd
, 3
rd
,
etc.). The patient's level of anxiety (mild, moderate, severe, and panic) and pain
tolerance (pain scale) uses the ordinal measurements.

97. Hawthorne effect in observation means that:
a. The subjects will refuse to join the study because they will be watched by the
researcher
b. The observer will be influenced by his own biases and prejudices
c. The subjects behavior will be unnatural because they are being observed
d. The observer may become subjective in his observations
Answer: C
Rationale: Hawthorne effect occurs when study participants respond in a certain
manner because hey are aware that they are being observed. (Asperas, Introduction to
Basic Nursing Research)

98. An interview schedule that is read to a respondent is what kind of interview?
a. Standardized c. Semi-standardized
b. Non-standardized d. Unstructured
Answer: A
Rationale: A standardized/structured interview utilizes specific questions that are read
to the respondent.

99. Which of the following is the building block of theory?
a. Conceptual framework c. Construct
b. Theoretical framework d. Concept
Answer: D
Rationale:
A. Conceptual framework general explanation that relates the study to an existing
theory.
B. Theoretical framework specific or well-defined concepts that are used to explain
the relationships between concepts.
D. Model representation of a phenomenon.

100. Leadership styles of chief nurses are an example of which level of measurement?
a. Nominal c. Interval
b. Ordinal d. Ratio
Answer: A
Rationale: In nominal measurement, the numerical values just name the attribute
uniquely. No ordering of the cases is implied. The leadership styles (autocratic,
democratic, laissez-faire, multicratic, bureaucratic, or parental) are measures at
nominal level.

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PSYCHIATRIC NURSING

Situation 1. Psychiatric Nursing, as a profession, makes use of a theoretical body of
knowledge. A competent psychiatric nurse must be knowledgeable of the different
concepts in Psychiatric Nursing.
126. A nurse is aware that extremely depressed patients seem to do best in settings
where they have:
a. Multiple stimuli
b. Varied Activities
c. Minimal decision making
d. Routine Activities
Answer: D
Rationale: Depression usually is both emotional & physical. A simple daily routine is
the best, least stressful and least anxiety producing.

127. A nurse is caring for a patient with delirium and states Look at the spiders on the
wall. What should the nurse respond to the patient?
a. Youre having a hallucination, there are no spiders in this room at all
b. I can see the spiders on the wall, but they are not going to hurt you
c. Would you like me to kill the spiders
d. I know you are frightened, but I do not see spiders on the wall
Answer: D
Rationale: When hallucination is present, the nurse should reinforce reality with the
patient.

128. A nurse recognizes that the focus of environmental (milieu) therapy is to:
a. Role play life events to meet individual needs
b. Allow the clients freedom to determine whether or not they will be involved in
activities
c. Manipulate the environment to bring about positive changes in behavior
d. Use natural remedies rather than drugs to control behavior
Answer: C
Rationale: Environmental (milieu) therapy aims at having everything in the clients
surrounding area toward helping the client.

129. A man is confronted by a situation in which a decision must be made about future
behavior. The man is at Kohlberg's conventional stage of moral development when
before acting, the man asks himself, If I take this course of action, will I:
a. Get into trouble?
b. Do what is right?
c. Receive a reward?
d. Obtain acceptance from others?
Answer: D
Rationale: Kohlberg's second stage of moral development is called conventional moral
development. In conventional morality the person seeks conformity and loyalty. It is
based on the personal concordance in that it deals with the reciprocal nature of
helping others and receiving approval from others.

130. A patient is using a self-report scale in which she assigns a number to the frequency

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of dissociative experiences. The nurse correctly identifies this as which type of
diagnostic tool?
a. Dissociative Disorders Interview Schedule
b. Dissociative Experiences Scale
c. SCID-D
d. Diagnostic Drawing Series
Answer: B
Rationale: Dissociative Experiences Scale is a brief, self-report scale that measures the
frequency of dissociative experiences. The patient quantifies her experience by
assigning a number for each item in the scale.

Situation 2. Implementing the art of psychiatric-mental health nursing is an important way
to convey to patients the caring aspect of nursing.
131. The statement that would best describe the practice of psychiatric nursing would be:
a. Ensuring patients legal and ethical rights by acting as a patient advocate
b. Helping people with present or potential mental health problems
c. Focusing interpersonal skills on people with physical or emotional problems
d. Acting in a therapeutic way with people who are diagnosed as having a mental
disorder
Answer: B
Rationale: An important aspect of the role of the psychiatric nurse is primary,
secondary, and tertiary interventions to promote emotional equilibrium. (Mosby, 18
th

Edition)

132. A female patient on the psychiatric unit remains aloof from the other patients. A
nurse with whom she has developed a friendly relationship may help her participate in
some activity by:
a. Finding solitary pursuits that the patient can enjoy
b. Speaking to the patient about the importance of entering into activities
c. Asking the physician to speak to the patient about participating in activities
d. Inviting another patient to take part in a joint activity with the nurse and the patient
Answer: D
Rationale: Bringing another patient into a set situation would be the most therapeutic,
least-threatening approach. (Mosby, 18
th
Edition)

133. A nurse is assigned to care for a regressed 19-year-old college student recently
admitted to the psychiatric unit with a 1-month history of talking to unseen people and
refusing to get out of bed, go to class, or get involved in daily grooming activities. The
nurses initial efforts should be directed toward helping the patient by:
a. Providing frequent rest periods to avoid exhaustion
b. Facilitating the patients social relationships with a peer group
c. Reducing environmental stimuli and maintaining dietary intake
d. Attempting to establish a meaningful relationship with the patient
Answer: D
Rationale: The first step in a plan of care should be the establishment of a meaningful
relationship because it is through this relationship that the patient can be helped.
(Mosby, 18
th
Edition)

134. A nurse should plan to explain to the adult daughters of a dying patient whose

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mood changes and apparent anger at them is causing them concern that their mother
is:
a. Frightened by her impending death
b. Working through acceptance of her situation
c. Attempting to reduce her familys dependence on her
d. Hurt that the family will not take her home to die in her own bed
Answer: B
Rationale: Understanding the stages leading to the acceptance of death may help the
family to understand the patients moods and anger. (Mosby, 18
th
Edition)

135. A 45-year-old physician is admitted to the psychiatric unit. The patient is restless,
loud, aggressive, and resistive during the admission procedure and states, I will take
my own blood pressure. The most therapeutic response by the nurse would be:
a. Right now, doctor, you are just another patient.
b. I am sorry, but I cannot allow that. I must take your BP.
c. If you would rather, doctor, Im sure you will do it OK.
d. If you do not cooperate, I will get the attendants to hold you down.
Answer: B
Rationale: This simply states facts without getting involved in role conflict. (Mosby, 18
th

Edition)

Situation 3. Defense mechanisms are mental mechanisms (largely unconscious) that
provide initial protection for the personality. They are most helpful in dealing with mild
and moderate levels of anxiety.
136. When teaching about child abuse, the nurse includes the fact that the defense
mechanism most often used by the physically abusive individual is:
a. Manipulation c. Displacement
b. Transference d. Reaction formation
Answer: C
Rationale: Displacement is a defense mechanism in which ones pent-up feelings
toward threatening others are discharged on less-threatening others. (Mosby, 18
th

Edition)

137. A patient being treated in a chemical dependency unit tells a nurse that he only
uses drugs when under stress and therefore does not have a substance problem.
Which of the following defense mechanism is the patient using?
a. Compensation c. Suppression
b. Undoing d. Denial
Answer: D
Rationale: Denial is commonly used by individuals who have substance problems.
(Lippincotts Review Series: Mental Health and Psychiatric Nursing, 3
rd
Edition)

138. One day a male patient with the diagnosis of borderline personality disorder
describes a situation that happened at work when his immediate supervisor
reprimanded him for not completing an assignment. He explains that it was not his
fault and states, people get angry and take it out on me. The nurse recognizes that
the patient is using the defense mechanism called:
a. Denial c. Displacement
b. Projection d. Intellectualization

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Answer: B
Rationale: Attributing unacceptable feelings or attributes to others is the mechanism
known as projection; the data demonstrate use of this defense mechanism. (Mosby,
18
th
Edition)

139. A patient with diabetes is able to discuss in great detail the metabolic process in
diabetes while eating a piece of chocolate cake topped with butter frosting. This is an
example of the defense mechanism known as:
a. Intellectualization c. Displacement
b. Dissociation d. Projection
Answer: A
Rationale: Intellectualization occurs when a painful emotion is avoided by means of a
rational explanation that removes the event from any personal significance. (Mosby,
18
th
Edition)

140. A person released from prison for selling narcotics has been rehabilitated and now
works for a youth drug prevention agency. This persons current behavior reflects which
of the following defense mechanisms?
a. Denial c. Identification
b. Displacement d. Sublimation
Answer: D
Rationale: Sublimation is the defense mechanism whereby an individual substitutes
constructive, socially acceptable behavior for strong impulses that are unacceptable.
rd
Edition)

Situation 4. Concha, a 35-year-old patient with major depression, has been hospitalized
for treatment after taking a leave of absence from work. The patients employer expects
the patient to return to work following inpatient treatment.
141. During the initial assessment, Nurse Melai would expect the patient to display:
a. Elated affect related to reaction formation
b. Loose associations related to thought disorder
c. Physical exhaustion resulting from decreased physical activity
d. Paucity of verbal expression related to slowed thought processes
Answer: D

Rationale: As depression increases, thought processes become more slowed and
verbal expression decreases. (Mosby, 18
th
Edition)

142. Concha has not verbalized problem areas to staff or peers since admission to the
psychiatric unit. Which activity should the nurse recommend to help this patient
express herself?
a. Art therapy in a small group
b. Basketball game with peers on the unit
c. Reading a self-help book on depression
d. Watching movie with the peer group
Answer: A
Rationale: Art therapy provides a nonthreatening vehicle for the expression of feelings,
and use of a small group will help the patient become comfortable with peers in a
group setting.

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143. Concha is given prescribed medications and talks with her therapist about her belief
that she is worthless and unable to cope with life. Psychiatric care in this treatment
plan is based on which framework?
a. Cognitive framework
b. Behavioral framework
c. Interpersonal framework
d. Psychodynamic framework
Answer: A
Rationale: Cognitive thinking therapy focuses on the patients misperceptions about
self, others and the world that impact functioning and contribute to symptoms.

144. During the morning rounds, Concha tells the nurse, Im no good. Im a failure. The
statement that would be most appropriate for Nurse Melai to use in interviewing the
patient whose thoughts focus on feelings of unworthiness and failure would be:
a. Tell me how you feel about yourself.
b. Tell me what has been bothering you.
c. Why do you feel so bad about yourself?
d. What can we do to help you during your stay with us?
Answer: A
Rationale: Since major depression is due to the patients feelings of self-rejection, it is
important for the nurse to have the patient identify these feelings before a plan of
action can be taken. (Mosby, 18
th
Edition)

Nurse Melai who is caring for Concha knows that the priority nursing intervention is to
assess the patient's:
a. Response to medication administration
c. Current mood and activity level
d. Risk of suicide
e. Appetite and weight
Answer: C
Rationale: While it is important for the nurse to assess the patient's areas of
functioning, current mood, and fluid/electrolyte balance, assessing the suicide risk of
the patient with major depression takes priority.

Situation 5. Nurse Agua is working with Mr. Jayson Ivlearn, age 37, who has
schizophrenia, paranoid type.
101. Prominent symptoms lasting for at least 1 month that are diagnostic for
paranoid schizophrenia are:
a. Delusions and hallucinations
b. Poverty of speech and apathy
c. Disturbed relationships and poor grooming
d. Bizarre behaviors associated with drug use
Answer: A
Rationale: Diagnostic criteria for paranoid schizophrenia include two or more
symptoms such as delusions and hallucinations; other less prominent criteria are
disorganized behavior and negative symptoms. (Mosby, 18
th
Edition)

102. As Nurse Agua enters the room and approaches Mr. Ivlearn, the patient

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states, Get out of here before I hit you! Go away! The nurse recognizes that this
patients aggressive behavior was probably related to the fact that he:
a. Was hallucinating and the voices were directing his response
b. Was afraid that he might harm the nurse if the nurse came nearer
c. Was reminded of someone who was frightening and threatening to him
d. Felt hemmed in and trapped when the nurse came around the bed toward him
Answer: D
Rationale: Patients acutely ill with schizophrenia frequently do not trust others; feeling
hemmed in would be frightening, causing them to lash out. (Mosby, 18
th
Edition)

103. Mr. Ivlearn often directs brief, hostile verbal outbursts toward the nursing
staff. Which of the following nursing actions is the most therapeutic way to address
this problem?
a. Administer antipsychotic medications as needed when verbal outburst occur
b. Set limits and provide a structured, predictable environment
c. Place the client in seclusion when these episodes occur
d. Minimize the outbursts by walking away when they occur
Answer: B
Rationale: Firm, non-punitive limit setting and a structured environment are the best
approach to a verbally hostile patient. (Lippincotts Review Series: Mental Health and
Psychiatric Nursing, 3
rd
Edition)

104. Which of the following outcomes related to Mr. Ivlearns delusional
perceptions would Nurse Agua establish?
a. The patient will demonstrate realistic interpretation of daily events in the unit
b. The patient will perform daily hygiene and grooming without assistance
c. The patient will take prescribed medications without difficulty
d. The patient will participate in unit activities
Answer: A

Rationale: A patient with schizophrenia, paranoid type, will distort perceptions and
view events in the environment as related to people or institutions plotting against him.
The outcome related to a realistic interpretation of daily events would establish
improvement in the patients perceptual ability. (Lippincotts Review Series: Mental
Health and Psychiatric Nursing, 3
rd
Edition)

105. A week after the admission of Mr. Ivlearn, the patient stands up in the lounge
and throws a chair across the room and starts yelling at the other patients. Several
of the other patients have frightened expressions, one starts to cry, and another
begins to pace. After removing Mr. Ivlearn from the room, Nurse Agua should:
a. Arrange a unit meeting to discuss what just happened
b. Continue the units activities as if nothing has happened
c. Refocus patients negative comments to more positive topics
d. Have a private talk with the patients who cried and started to pace
Answer: A
Rationale: This provides an opportunity for the other patients to voice and share
feelings and to identify and separate real from imaginary fears; an open expression of
feelings allows the nurse to deal with clients fears and provide reassurance. (Mosby,
18
th
Edition)

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Situation 6. Ms. Mytililing Aguila, age 40, is admitted to the psychiatric unit with the DSM-
IV diagnosis of bipolar I disorder, manic episode.
106. Which of the following behaviors in Ms. Aguila would be assessed by Nurse
Bhoy?
a. Apathy, poor insight, poverty of ideas
b. Anxiety, somatic complaints, insomnia
c. Elation, hyperactivity, impaired judgment
d. Social isolation, delusional thinking, clang association
Answer: C
Rationale: A client with bipolar I disorder, manic episode, would demonstrate
symptoms, such as flight of ideas and hyperactivity, as part of the increased
psychomotor activity. The mood is one of elation and the feeling is that one is
invincible; therefore, judgment may be quite impaired. (Isaacs, Lippincotts Review
Series: Mental Health and Psychiatric Nursing, 3
rd
Edition)

107. When the language of Ms. Aguila becomes vulgar and profane, Nurse Bhoy
should:
a. State, We do not like that kind of talk around here.
b. Ignore it, since the client is using it only to get attention
c. Recognize the language as part of the illness, but set limits on it
d. State, When you can talk in an acceptable way, we will talk to you.
Answer: C
Rationale: Recognizing the language as part of the illness makes it easier to tolerate,
but limits must be set for the benefit of the staff and other patients. Setting limits also
shows the client that the nurse cares enough to stop the behavior. (Mosby, 18
th
Edition)

108. Ms. Aguila has a superior, authoritative manner and is constantly instructing
the other patients on the unit about how to dress, what to eat, and where to sit.
These behaviors will eventually make the other patients feel:
a. Ambivalent c. Dependent
b. Inadequate d. Angry
Answer: D
Rationale: When people are imposed on by a person with a condescending, bossy
attitude they react frequently with feelings of anger in an attempt to decrease their
anxiety. (Mosby, 18
th
Edition)

109. Ms. Aguila is extremely active, talks constantly, and tends to badger the other
patients, some of whom are now becoming agitated. The best strategy to use with
this patient is:
a. Distraction c. Assertiveness
b. Sympathy d. Confrontation
Answer: A
Rationale: During periods of hyperactivity, the patient has a short attention span and
can be distracted easily; this is a therapeutic intervention for all the clients. (Mosby,
18
th
Edition)

110. A nursing diagnosis of Altered thought processes related to difficulty
concentrating, secondary to flight of ideas was made. Which of the following

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outcome criteria would indicate improvement in Ms. Aguila?
a. The patient verbalizes feelings directly during treatment
b. The patient speaks in coherent sentences
c. The patient verbalizes positive self-statements
d. The patient reports increased feelings of clam
Answer: B
Rationale: Flight of ideas occurs when the clients speech flow is continuous and the
client jumps from one topic to another. The client who can speak in coherent
sentences shows that concentration has improved and thoughts are no longer racing.
(Isaacs, Lippincotts Review Series: Mental Health and Psychiatric Nursing, 3
rd
Edition)

Situation 7. Kevin Kosme, age 81, is admitted to a psychiatric hospital with the diagnosis
of dementia, Alzheimers type.
111. Nurse Azon recognizes that dementia of the Alzheimers type is characterized
by:
a. Hypoxia of selected areas of brain tissue
b. Areas of brain destruction called senile plaques
c. Aggressive acting-out behavior
d. Periodic remissions and exacerbation
Answer: B
Rationale: When an older persons brain atrophies, some unusual deposits of iron are
scattered on nerve cells. Throughout the brain, areas of deeply staining amyloid, called
senile plaques, can be found; these plaques are end stages in the destruction of brain
tissue. (Mosby, 18
th
Edition)

112. When answering questions from the family of Mr. Kosme with Alzheimers
disease, Nurse Azon explains that this disease is:
a. A slow, relentless deterioration of the mind
b. A functional disorder that occurs in the later years
c. A disease that first emerges in the fourth decade of life
d. Easily diagnosed through laboratory and psychologic tests
Answer: A
Rationale: This is a true statement; patients become progressively worse over time.
(Mosby, 18
th
Edition)

113. Mr. Kosme confabulates. Nurse Azon understands that the patient:
a. Denies confusion by being jovial
b. Pretends to be someone else
c. Rationalizes various behaviors
d. Fills in memory gaps with fantasy
Answer: D
Rationale: Confabulation is a communication device used by clients with dementia to
compensate for memory gaps. (Lippincotts Review Series: Mental Health and
Psychiatric Nursing, 3
rd
Edition)

114. Mr. Kosme becomes agitated and combative when Nurse Azon approaches to
help with morning care. The most appropriate nursing intervention would be:
a. To tell the patient firmly that it is time to get dressed
b. To obtain assistance to restrain the patient for safety

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c. To remain calm and talk quietly to the patient
d. To call the physician and request order for sedation
Answer: C
Rationale: It is important to maintain a calm approach when intervening with an
agitated client. (Lippincotts Review Series: Mental Health and Psychiatric Nursing, 3
rd

Edition)

115. Which of the following would Nurse Azon implement for Mr. Kosme who has
frequent episodes of emotional lability?
a. Attempt humor to alter mood
b. Explore reasons for altered mood
c. Reduce environmental stimuli to redirect attention
d. Use logic in order to point out reality aspects
Answer: C
Rationale: The client with Alzheimers disease can have frequent episodes of labile
mood, which can best be handled by decreasing a stimulating environment and
redirecting the clients attention. An over-stimulating environment may cause the labile
mood, which will be difficult for the client to understand. (Lippincotts Review Series:
Mental Health and Psychiatric Nursing, 3
rd
Edition)

Situation 8. Charice Pipino, a 10-year-old girl, who was diagnosed with autism at the age
of 3, attends a school for developmentally disabled children and lives with her parents.
116. When assessing Charice, Nurse Raph should expect which of the following?
i. Imitates others
ii. Seeks physical contact
iii. Avoids eye-to-eye contact
iv. Engages in cooperative play
v. Performs repetitive activities
vi. Displays interest in children rather than adults
a. 3 and 5 only c. 2 and 6 only
b. 1 and 4 only d. 3 only
Answer: A
Rationale: Qualitative impairments in social interaction are manifested by a lack of eye
contact (3), a lack of facial responses, and a lack of responsiveness to and interest in
others. In addition, children with autism display obsessive ritualistic behaviors (5), such
as rocking, spinning, dipping, swaying, walking on toes, head banging, or hand biting
because of their self-absorption and need to stimulate themselves. (Mosby, 18
th

Edition)

117. When planning activities for Charice, Nurse Raph must remember that
autistic children respond best to:
a. Large-group activity
b. Loud, cheerful music
c. Individuals in small groups
d. Their own self-stimulating acts
Answer: D
Rationale: Autistic behavior turns inward. These children do not respond to the
environment but attempt to maintain emotional equilibrium by rubbing and

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manipulating themselves and displaying a compulsive need for behavioral repetition.
(Mosby, 18
th
Edition)

118. Charice is nonverbal and has limited eye contact. To promote social
interaction, Nurse Raph initially should:
a. Engage in parallel play while sitting next to the child
b. Encourage the child to vocalize through sound games and songs
c. Provide play opportunities for the child to play with other children
d. Use therapeutic holding when the child does not respond to verbal interactions
Answer: A
Rationale: Entering the childs world in a nonthreatening way helps to promote trust
and eventual interaction with the nurse. (Mosby, 18
th
Edition)

119. Charice has frequent episodes of biting her arms and banging her head and
needs help with feeding and toileting. The priority goal for this child would be, The
child will:
a. Be able to feed herself.
b. Control repetitive behaviors.
c. Remain safe from self-inflicted injury.
d. Develop control of fecal and urinary elimination.
Answer: C
Rationale: The priority is safety; the child must be protected from self-harm. (Mosby,
18
th
Edition)

120. Nurse Raph visits the home of Charice. The parents express feelings of shame
and guilt about having somehow caused this problem. Which of the following
statements by the nurse would be best to help alleviate parental guilt?
a. Autism is a rare disorder. Your other children shouldnt be affected.
b. The specific cause of autism is unknown. However, it is known to be associated
with problems in the structure of and chemicals in the brain.
c. Sometimes a lack of prenatal care can be the cause of autism.
d. Although autism is inherited from the genes, if you didnt have testing you could
not have known this.
Answer: B
Rationale: This statement is factual and does not cast blame on anything the parents
did or did not do. (Lippincotts Review Series: Mental Health and Psychiatric Nursing,
3
rd
Edition)

Situation 9. Mental Retardation is an increasingly common childhood disorder that
impairs learning.
121. Mental retardation is:
a. A delay in normal growth and development caused by an inadequate environment
b. A lack of development of sensory abilities
c. A severe lag in neuromuscular development and motor abilities
d. A condition of sub-average intellectual functioning that originates during the
developmental period and is associated with impairment in adaptive behavior
Answer: D

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Rationale: Mental retardation refers to below-average general intellectual functioning
with associated deficits in communication, social skills, self-care, and adaptive
behavior. (Straight As in Psychiatric and Mental Health Nursing)

122. Which of the following is true with regards to mental retardation?
a. Mental retardation is always accompanied by physical features
b. Hereditary and prenatal factors do not result to mental retardation
c. Mental retardation is a mental illness
d. Hereditary and prenatal factors are known to result to impaired intellectual
functioning
Answer: D
Rationale: In mental retardation, hereditary and prenatal factors are known to result to
impaired intellectual functioning, which includes:
i. Chromosomal disorders: trisomy 21 (Down syndrome), fragile X syndrome, or
Klinefelters syndrome.
ii. Single dominant gene problems: neurofibromatosis or tuberous sclerosis.
iii. Inborn errors of metabolism: phenylketonuria (PKU) or hyperglycinemia.
iv. Problems during embryonic development: mental illness (such as diabetes or
toxemia) or maternal infection (such as rubella, herpes simplex, or human
immunodeficiency virus).
v. Pregnancy and perinatal factors: prematurity, maternal-neonate blood group
incompatibility, brain trauma or oxygen deprivation.
(Mosby, 18
th
Edition) and (Straight As in Psychiatric and Mental Health Nursing)

123. An important principle for the nurse to follow in interacting with retarded
children is:
a. Seen that if the child appears contented, his needs are being met
b. Provide an environment appropriate to their developmental task as scheduled
c. Treat the child according to his developmental age
d. Treat the child according to his chronological age
Answer: C
Rationale: The nurse should monitor the childs developmental levels and initiate
supportive interventions, such as speech, language, or occupational skills, as needed.
(Mosby, 18
th
Edition) and (Straight As in Psychiatric and Mental Health Nursing)

124. The onset of mental retardation is before the child reaches what particular
age?
a. 18 years old c. 16 years old
b. 17 years old d. 15 years old
Answer: A
Rationale: Mental retardation affects roughly 1% to 3% of the population that occurs
before age 18. If mild, it may not be recognized until school age or later. (Straight As
in Psychiatric and Mental Health Nursing)

125. Which of the following is true with regards to Mild Mental Retardation?
a. Trainable; can reach up to grade 2 and can reach the maturity of a 7-year-old
b. Custodial and barely trainable
c. Requires total care throughout life, mental age of a young infant
d. Educable; can reach up to grade 6 and has a maturity of a 12-year-old

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Answer: D
Rationale: In mild mental retardation, the child may be able to live somewhat
independently with monitoring or assistance with life changes, challenges or stressors
(such as personal illness or the death of a loved one). They are educable; the child can
achieve fourth- to sixth-grade reading skills and may master vocational training. They
can achieve a mental age (maturity) of 8 to 12 years old. (Mosby, 18
th
Edition) and
(Straight As in Psychiatric and Mental Health Nursing)

Situation 10. A personality disorder exists when personality traits become rigid,
maladaptive and fixed. The disorder affects the person's cognition, behavior, and style of
interacting with others.
126. A male patient
is diagnosed with schizotypal personality disorder. Which signs would this patient
exhibit during social situation?
a. Emotional affect
b. Paranoid thoughts
c. Aggressive behavior
d. Independence need
Answer: B
Rationale: Patients with schizotypal personality disorder are paranoid about other's
motivations, which cause them to experience excessive social anxiety.

127. Which of the
following approaches would be most appropriate to use with a patient suffering
from narcissistic personality disorder when discrepancies exist between what the
patient states and what actually exist?
a. Consistency
b. Limit setting
c. Rationalization
d. Supportive confrontation
Answer: D
Rationale: The nurse would specifically use supportive confrontation with the patient to
point out discrepancies between what the patient states and what actually exists to
increase responsibility for self.

128. A female
patient is admitted to the psychiatric unit with a diagnosis of borderline personality
disorder. The nurse should expect the assessment to reveal:
a. Coldness, detachment and lack of tender feelings
b. Somatic symptoms
c. Inability to function as responsible parent
d. Unpredictable behavior and intense interpersonal relationships
Answer: D
Rationale: A patient with borderline personality displays a pervasive pattern of
unpredictable behavior, mood and self image. Interpersonal relationships may be
intense and unstable and behavior may be inappropriate and impulsive.

129. The patient with borderline personality disorder who is to be discharged soon
threatens to do something to herself if discharged. Which of the following actions

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by the nurse would be most important?
a. Ask a family member to stay with the patient at home temporarily
b. Discuss the meaning of the patients statement with her
c. Request an immediate extension for the patient
d. Ignore the patients statement because its a sign of manipulation
Answer: B
Rationale: Any suicidal statement must be assessed by the nurse. The nurse should
discuss the patients statement with her to determine its meaning in terms of suicide.

130. A 20-year-old
client was diagnosed with dependent personality disorder. Which behavior is most
likely to be evidence of ineffective individual coping?
a. Recurrent self-destructive behavior
b. Avoiding relationship
c. Showing interest in solitary activities
d. Inability to make choices and decision without advice
Answer: D
Rationale: Individual with dependent personality disorder typically shows
indecisiveness submissiveness and clinging behavior so that others will make
decisions with them.

Situation 11. Somatoform Disorders are groups of psychiatric disorders in which the
patient has persistent physical complaints that cannot be explained by a physical
disorder, substance use, or another mental disorder.
131. A somatoform disorder is:
a. A physiologic response to stress
b. An unconscious means to reduce stress
c. A conscious defense against anxiety
d. An intentional attempt to gain attention
Answer: B
Rationale: When emotional stress overwhelms an individuals ability to cope, the
unconscious seeks to reduce stress. A conversion reaction removes the client from the
stressful situation and the conversion reactions physical/sensory manifestation
causes little or no anxiety in the individual. This lack of concern is called la belle
indifference. (Mosby, 18
th
Edition)

132. A patients family brought the patient into the hospital because of his many
somatic complaints. He has been seen by many medical specialists in the past
without discovery of organic pathology. The nurse assesses that the patient is
experiencing which of the following problems?
a. Conversion disorder
b. Body dysmorphic disorder
c. Hypochondriasis
d. Malingering
Answer: C
Rationale: Hypochondriasis is excessive preoccupation with ones physical health,
without organic pathology. (NSNA NCLEX-RN Review, 4
th
Edition)

133. The nurse finds, during the initial assessment of the star player on the

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basketball team, that he is not concerned about the sudden paralysis of his
shooting arm. This behavior is known as:
a. Secondary gain c. Malingering
b. La belle indifference d. Hypochondriasis
Answer: B
Rationale: This lack of concern is identified as la belle indifference and is often a clue
that the problem may be psychological rather than physical. (NSNA NCLEX-RN Review,
4
th
Edition)

134. A patient who works as a receptionist in a physicians office has been an
inpatient on a medical unit for over 6 days. The patient continues to complain of
severe abdominal symptoms, is febrile, and has the primary care providers deeply
concerned because there has been no response to treatment. All tests are negative.
The patient finally is diagnosed with Munchausen syndrome. The primary care
providers would probably experience feelings of:
a. Anger c. Annoyance
b. Pity d. Indifference
Answer: A
Rationale: Anger is the expected response of staff at having been duped by a client
with a fictitious disorder; they feel both used and abused. (Mosby, 18
th
Edition)

135. A patient with a history of stabbing pain in the eyes and blurring and gradual
loss of vision is examined by an ophthalmologist, neurologist, and an internist, all of
whom have found no organic cause. The patient is admitted to the psychiatric unit
when eye complaints increase. Nursing intervention should include:
a. Requesting a description of the eye discomfort
b. Encouraging becoming involved with unit activities
c. Exploring feelings about a possible impending blindness
d. Focusing on activities while avoiding discussion of the eye discomfort
Answer: D
Rationale: The patients eye problems are a conversion reaction. Avoiding discussion of
the physical problems prevents the patient from using this topic to avoid an exploration
of feelings. Focusing on the safe topic of activities may eventually progress to the
discussion of emotion-laden topics such as feelings. (Mosby, 18
th
Edition)

Situation 12. Dissociative disorders are a group of disorders characterized by
disturbances in normal waking state. It affects fundamental aspects of consciousness,
memory, identity, self-perception and perception of the environment.
When would the nurse expect the signs and symptoms of dissociative fugue to be
most pronounced?
a. After the fugue episode
b. During the fugue episode
c. Hours before the fugue episode
d. Weeks before the fugue episode
Answer: A
Rationale: After the fugue, the person may experiences depression, grief, shame,
intense conflict, confusion, terror, or suicidal or aggressive impulses. In contrast a
fugue in progress is rarely recognized. There are no warning signs of an impending
fugue episode.

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136.
Assessment reveals that a patient with dissociative amnesia has had amnesia from
a specific time through the present. Then nurse documents that the patient is
experiencing:
a. Selective amnesia
b. Generalized amnesia
c. Continuous amnesia
d. Systematized amnesia
Answer: C
Rationale: In continuous amnesia, the patient forgets all events from a given time
forward to the present.

137.
After teaching a group of students about dissociative disorders, the instructor
determines that teaching has been successful when the students correctly identify
multiple personality disorder as:
a. Dissociative fugue
b. Depersonalization disorder
c. Dissociative amnesia
d. Dissociative identity disorder
Answer: D
Rationale: Dissociative Identity Disorder (DID), formerly known as multiple personality
disorder, is characterized by emergence of two or more distinct identities or
subpersonalities that recurrently take control of the patient's consciousness and
behavior on a recurring basis.

138.
The nurse would expect a patient to report feelings of a dreamlike state or being a
detached observer when assessing for which disorder?
a. Dissociative fugue
b. Dissociative amnesia
c. Depersonalization disorder
d. Dissociative identity disorder
Answer: C
Rationale: Depersonalization disorder is characterized by a sense of being in a
dreamlike state or being a detached observer.

139.
When assessing a patient with Dissociative Identity Disorder, which factor would the
nurse identify as least likely to contribute to its development?
a. History of seizures
b. Emotional, physical or sexual abuse
c. Genetic predisposition
d. Extreme stress and trauma
Answer: A
Rationale: A history of seizures has not been linked to the development of DID.
Contributing factors may include severe trauma; emotional, physical or sexual abuse;

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genetic predisposition; lack of nurturing experiences to recover from abuse; and low
self-esteem.

Situation 13. Flo Angeles, a 16-year-old female patient, is admitted to the psychiatric unit
with the diagnosis of anorexia nervosa.
140. Ms. Angeles has lost 20 pounds in 6 weeks. She is very thin but excessively
concerned about being overweight. Her daily intake is 10 cups of coffee. The most
important initial nursing intervention would be to:
a. Compliment her on her lovely figure
b. Try to establish a relationship of trust
c. Explain the value of adequate nutrition
d. Explore the reasons why she does not eat
Answer: B
Rationale: The problem is psychologic. Therefore the initial approach by the nurse
should be directed toward establishing trust. (Mosby, 18
th
Edition)

141. Nurse Adel is assessing Ms. Angeles. In addition to weight loss, which of the
following would the nurse expect to find?
a. Irregular menses, diarrhea, dental carries
b. Fluid retention, tachycardia, hypertension
c. Bradycardia, lanugo, amenorrhea
d. Tachycardia, intolerance to heat, skin rashes
Answer: C
Rationale: The client with anorexia nervosa will demonstrate decreased heart rate due
to decreased metabolic rate, as well as possible loss of heart muscle due to starvation.
Lanugo occurs as a result of loss of subcutaneous tissue. Amenorrhea occurs as a
result of losing fatty tissue in which estrogen is stored. Weight less than 85% of the
norm for age and height is also important to establish diagnosis. (Lippincotts Review
Series: Mental Health and Psychiatric Nursing, 3
rd
Edition)

142. The psychoanalytic theory regarding etiology of anorexia nervosa includes
which of the following concepts?
a. Achievement of secondary gain through control of eating
b. Conflict between mother and child over separation and individualization
c. Family dynamics that lead to enmeshment of members
d. Incorporation of body image ideal of thinness
Answer: B
Rationale: According to psychoanalytic theory, early mother-child dynamics lead to
difficulty with a child establishing a sense of separateness from the mother. Control of
eating becomes one area in which the child establishes a sense of independence.
rd
Edition)

143. An important behavior modification goal for Ms. Angeles would be:
a. The patient will eat every meal for a week
b. The patient will gain a pound of weight a week
c. The patient will attend group therapy every day
d. The patient will talk about food for 1 hour a day
Answer: B

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Rationale: A goal focuses on where the patient should be after certain actions are
taken; these patients need to gain weight. (Mosby, 18
th
Edition)

144. Evaluation of Ms. Angeles requires reassessment of behaviors after
admission. The assessment that indicates that the therapy is beginning to become
effective is when the patient:
a. Is hiding food in pockets of clothing
b. States that the admission has been helpful
c. Has gained 6 pounds since admission 3 weeks ago
d. Is the first to sit down and the last to leave the dining room table
Answer: C
Rationale: This is objective proof that eating behaviors have improved. (Mosby, 18
th

Edition)

Situation 14. Nurse Jason is assigned to take care of Mr. Paring Roy, 28 years old, who is
diagnosed with a severe anxiety disorder.
145.
Which of the following statements about anxiety is true?
a. Anxiety is usually pathological
b. Anxiety is a response to a threat
c. Anxiety is usually harmful
d. Anxiety is directly observable
Answer: B
Rationale: Anxiety is a response to a threat arising from internal or external stimuli.

146. Mr. Roy is experiencing an anxiety attack. The most appropriate nursing
intervention should include?
a. Turning on the television
b. Leaving the patient alone
c. Staying with the patient and speaking in short sentences
d. Ask the patient to play with other patients
Answer: C
Rationale: Appropriate nursing interventions for an anxiety attack include using short
sentences, staying with the patient, decreasing stimuli, remaining calm and
medicating as needed.

147. To establish open and trusting relationship with Mr. Roy, Nurse Jason should?
a. Respect patients need for personal space
b. Share an activity with the patient
c. Give patient feedback about behavior
d. Encourage the staff to have frequent interaction with the patient
Answer: A
Rationale: Moving to a patients personal space increases the feeling of threat, which
increases anxiety.

148. Mr. Roy is pacing the floor and appears anxious. Nurse Jason approaches in
an attempt to alleviate the patients anxiety. The most therapeutic question by the
nurse would be?
a. Would you like to watch TV?

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b. Would you like me to talk with you?
c. Are you feeling upset now?
d. Ignore the patient
Answer: B
Rationale: The nurses presence may provide the patient with support & feeling of
control.

149.
When planning the discharge of Mr. Roy, Nurse Jason evaluates achievement of the
discharge maintenance goals. Which goal should be most appropriately included in
the plan of care requiring evaluation?
a. The patient eliminates all anxiety from daily situations
b. The patient ignores feelings of anxiety
c. The patient maintains contact with a crisis counselor
d. The patient identifies anxiety producing situations
Answer: D
Rationale: Recognizing situations that produce anxiety allows the patient to prepare to
cope with anxiety or avoid specific stimulus.

Situation 15. Nurse Kokey is working in a psychiatric facility where he encounters multiple
patients admitted due to substance abuse.
150. With a tentative diagnosis
of opiate addiction, Nurse Kokey should assess a recently hospitalized patient for
signs of opiate withdrawal. These signs would include:
a. Rhinorrhea, convulsions and subnormal temperature
b. Nausea, constricted pupils and constipation
c. Drowsiness and decreased level of consciousness
d. Muscle aches, pupillary dilation and yawning
Answer: D
Rationale: Muscle aches, pupillary dilation, and yawning are adaptations associated
with opiate withdrawal which occurs after cessation or reduction of prolonged
moderate or heavy use of opiates.

151. Which of the following
would Nurse Kokey eliminate from the diet of a patient in alcohol withdrawal?
a. Milk c. Soda
b. Orange Juice d. Regular Coffee
Answer: D
Rationale: Regular coffee contains caffeine which acts as psychomotor stimulants,
which aggravates the signs and symptoms of alcohol withdrawal. It leads to feelings of
anxiety and agitation, and may add to tremors or wakefulness.

152. Nurse Kokey is caring for a patient with a diagnosis of cocaine addiction. He is
aware that a serious effect of inhaling cocaine is?
a. Deterioration of nasal septum
b. Acute fluid and electrolyte imbalances
c. Extra pyramidal tract symptoms
d. Esophageal varices
Answer: A

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Rationale: Cocaine is a chemical that when inhaled, causes destruction of the mucous
membranes of the nose. Regular cocaine snorting can lead to the loss of sense of
smell and to nosebleed, swallowing difficulty, hoarseness, and nasal septum irritation.

153. A patient, who is experiencing alcohol withdrawal, exhibits tremors,
diaphoresis and hyperactivity. Blood pressure is 190/87 mm Hg and pulse rate of
92 beats per minute. Which of these medications would Nurse Kokey expect to
administer?
a. Naloxone (Narcan)
b. Benztropine (Cogentin)
c. Lorazepam (Ativan)
d. Haloperidol (Haldol)
Answer: C
Rationale: The nurse would most likely administer a benzodiazepine, such as
lorazepam (Ativan) to the client who experience symptoms of alcohol withdrawal. The
symptoms of withdrawal are caused by rebound phenomenon when the sedative effect
of alcohol to the CNS begins to decrease.

154. Which of the following would Nurse Kokey expect to assess to a patient who is
exhibiting late signs of heroin withdrawal?
a. Yawning and diaphoresis
b. Restlessness and irritability
c. Constipation and steatorrhea
d. Vomiting and diarrhea
Answer: D
Rationale: Vomiting and diarrhea are usually the late signs of heroin withdrawal, along
with muscle spasm, fever, nausea, repetitive, abdominal cramps and backache.

Situation 16. Alcohol abuse is a psychiatric diagnosis describing the use of alcoholic
beverages despite negative consequences. Appropriate management and nursing
interventions must be considered.
155. To determine the potential an individual has for a drinking problem, the nurse
uses the CAGE Screening Test for Alcoholism. One of the four questions included in
this test is:
a. Do you feel you are a normal drinker?
b. Are you always able to stop drinking when you want to?
c. Have you ever felt bad or guilty about your drinking?
d. How often did you have a drink containing alcohol in the past year?
Answer: C
Rationale: The CAGE screening test for alcoholism contains four questions,
corresponding to the letters CAGE;
C Have you ever felt you ought to Cut down on your drinking?;
A Have people Annoyed you by criticizing your drinking?;
G Have you ever felt bad or Guilty about your drinking?; and
E Have you ever had a drink first thing in the morning (as an Eye-opener) to steady
your nerves or get rid of a hangover?
Options A and B are incorrect because these questions are 2 of the 26 questions that
are included on the Michigan Alcohol Screening Test (MAST).

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Option D is incorrect because this question is 1 of the 10 questions that is included on
the Alcohol Use Disorders Identification Test (AUDIT). (Mosby, 18
th
Edition)

156. The most important factor in rehabilitation of a patient addicted to alcohol is:
a. The availability of community resources
b. The accepting attitude of the clients family
c. The qualitative level of the clients physical state
d. The clients emotional or motivational readiness
Answer: D
Rationale: Intrinsic motivation, stimulated from within the learner, is essential if
rehabilitation is to be successful. Often clients are most emotionally ready for help
when they have hit bottom. Only then are clients motivationally ready to face reality
and put forth the necessary energy and effort to change behavior. (Mosby, 18
th
Edition)

157. A patient who has just begun attending Alcoholics Anonymous asks the nurse
whether it is really necessary to go to meetings. The nurses best response would
be:
a. Yes, if you really want to get well.
b. Its your decision about whether or not you want to attend.
c. You think that attending these meetings may not be helpful.
d. It sounds like you think attending meetings is too much effort.
Answer: C
Rationale: This statement reflects the underlying theme in the patients statement and
non-judgmentally encourages the patient to verbalize further. (Mosby, 18
th
Edition)

158. A patient is attending Alcoholics Anonymous after withdrawing from alcohol.
The nurse recognizes that the ultimate purpose of self-help group such as AA is to
help members:
a. Develop functional relationships
b. Change destructive behavior
c. Identify how they present themselves to others
d. Understand their patterns of interacting within the group
Answer: B
Rationale: The purpose of a self-help group is for individuals to develop their strengths
and new individual patterns of coping. (Mosby, 18
th
Edition)

159. Patients addicted to alcohol use denial as one of their prime defense
mechanisms. The nurse further understands that these patients use denial to:
a. Reduce their feelings of guilt
b. Live up to others expectation
c. Make them seem more independent
d. Make them look better in the eyes of others
Answer: A
Rationale: The patient is using denial as a defense against feelings of guilt, which will
reduce anxiety and protect the self. (Mosby, 18
th
Edition)

Situation 17. Nurse Pharma is assigned as the medicating nurse for the morning shift. It is
essential that she knows the modes of action, side effects, adverse reactions, and nursing

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responsibilities of the different drugs for psychiatric patients in order to ensure patient
safety.
160. A patient receiving lithium has a serum drug level of 2.3 mEq/L. What would
Nurse Pharma most likely assess given this serum drug level?
a. Urinary incontinence
b. Seizures
c. Muscle weakness
d. Hyperactive deep tendon reflexes
Answer: D
Rationale: With a serum level between 2 and 2.5 mEq/L, assessment findings include
hyperactive deep tendon reflexes, persistent nausea and vomiting, blurred vision, and
muscle twitching.
Option A is incorrect because urinary incontinence is associated with drug levels of 2.5
to 3 mEq/L.
Option B is incorrect because seizures are associated with drug levels above 3 mEq/L.
Option C is incorrect because muscle weakness is seen with lithium levels ranging
from 1.5 to 2 mEq/L. (Straight As in Psychiatric & Mental Health Nursing, A Review
Series)

161. Which information would Nurse Pharma include when teaching the parents of
a child who is receiving methylphenidate (Ritalin)?
a. Monitor the childs blood glucose level because the drug increases the risk of
diabetes
b. Have the child undergo IQ testing because the drug may decrease intelligence
c. Monitor the childs growth closely because the drug may interfere with growth and
development
d. Have the child's hearing tested because the drug can cause hearing loss
Answer: C
Rationale: The childs physical growth should be monitored because methylphenidate
(Ritalin) may cause weight loss and temporary interference with growth and
development. (Straight As in Psychiatric & Mental Health Nursing, A Review Series)

162. Which medication would Nurse Pharma expect the physician to prescribe for
a patient with depersonalization disorder?
a. Clomipramine (Anafranil)
b. Lithium (Eskalith)
c. Chlorpromazine (Thorazine)
d. Fluphenazine (Prolixin)
Answer: A
Rationale: Clomipramine (Anafranil), a tricyclic antidepressant (TCA), has been
moderately successful in treating clients with depersonalization disorders. (Straight As
in Psychiatric & Mental Health Nursing, A Review Series)

163. Which of the following behaviors indicates to Nurse Pharma that the patients
antipsychotic medication is having a desired effect?
a. The patient states that her voices are not as threatening
b. The patient reports having inner feelings of restlessness
c. The patient sleeps all day
d. The patient reports muscular stiffening in her face and arms

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Answer: A
Rationale: A desired effect of the antipsychotics is to reduce the disturbing quality of
hallucinations and delusions. (NSNA, NCLEX-RN Review, 4
th
Edition)

164. A patient is to receive conventional antipsychotic drug therapy. Which drug
would Nurse Pharma expect to administer?
a. Prolixin c. Seroquel
b. Olanzapine d. Risperidone
Answer: A
Rationale: Fluphenazine (Prolixin) is a conventional (typical) antipsychotic. (Straight As
in Psychiatric & Mental Health Nursing, A Review Series)

Situation 18. Electroconvulsive Therapy is used as a treatment modality for severe
depression when psychotherapy and pharmacotherapy are not effective.
165.
Which patient would the nurse expect to prepare for ECT?
a. A female patient with dysthymic disorder
b. An elderly male with a major depressive disorder with a history of stroke
c. A female patient with depression and hypomania due to a cyclothymic disorder
d. A middle-age, female patient with major depression and an immediate risk of
suicide
Answer: D
Rationale: Electroconvulsive Therapy (ECT) may be used to treat major depression as
well as certain psychotic disorders particularly in situations of severe depression when
psychotherapy and medications have been ineffective, when ECT poses a lower risk
than other treatments.

166.
A patient is scheduled for ECT at 10 am. Which action of the nurse would be most
appropriate?
a. Giving the patient a clear liquid breakfast
b. Catheterizing the patient for a morning urine sample
c. Administering prescribed medications to reduce secretions
d. Allowing the patient to keep his dentures in his mouth
Answer: C
Rationale: In this situation, the nurse should administer the prescribed medication
(such as atropine or glycopyrrolate) to reduce secretions, prevent aspiration, and
reduce the risk of bradycardia.

167.
A neuromuscular blocking agent is administered to a patient before ECT therapy.
The nurse should carefully observe the patient for?
a. Respiratory difficulties
b. Nausea and vomiting
c. Dizziness
d. Seizures
Answer: A
Rationale: A neuromuscular blocker, such as succinylcholine (Anectine) produces
respiratory depression because it inhibits contractions of respiratory muscles.

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168.
During electroconvulsive therapy (ECT) the patient receives oxygen by mask via
positive pressure ventilation. The nurse assisting with this procedure knows that
positive pressure ventilation is necessary because?
a. Muscle relaxations given to prevent injury during seizure activity depress
respirations
b. Decrease oxygen to the brain increases confusion and disorientation
c. Grand mal seizure activity depresses respirations
d. Anesthesia is administered during the procedure
Answer: A
Rationale: A short acting skeletal muscle relaxant such as succinylcholine (Anectine) is
administered during this procedure to prevent injuries during seizure.

169.
When assessing the patient immediately after ECT, the nurse expects to find:
a. Permanent short-term memory loss and hypertension
b. Transitory short and long term memory loss and confusion
c. Transitory short-term memory loss and permanent long-term memory loss
d. Permanent long-term memory loss and hypomania
Answer: B
Rationale: ECT commonly causes transitory short and long term memory loss and
confusion, especially in geriatric clients. It rarely results in permanent short and long
term memory loss.

Situation 19. Sexuality is expressed not just in a person's appearance but also in his
attitude, behaviors and relationships.
170.
The multidisciplinary care team would suspect gender identity disorder if a patient:
a. Has a strong desire to be of the same sex
b. Insists that he or she is of the opposite sex
c. Prefers the opposite sex
d. Engages in sexual activities with the same sex
Answer: B
Rationale: Gender identity disorder is marked by a repeatedly stated desire to be of the
opposite sex or insistence that one is of the opposite sex.
Option C is incorrect because Heterosexual individuals prefer members of the opposite
sex.
Option D is incorrect because Homosexual individual engages in sexual activities with
members of the same sex.

A student is reviewing content for a test on the phases of the sexual response cycle.
The student demonstrates understanding of the material by identifying which phase
as the one involving fantasy and expectation?
a. Desire phase c. Orgasm phase
b. Excitement phase d. Resolution phase
Answer: A
Rationale: Desire phase involves fantasy and expectation.

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Option B is incorrect because Excitement phase is the arousal phase that prepares
both partners for intercourse.
Option C is incorrect because Orgasm phase is the peak of sexual excitement.
Option D is incorrect because in the Resolution phase, the body returns to its normal
unexcited state.

When developing the care plan for a patient diagnosed with premature ejaculati on,
which intervention would the nurse expect to include?
e. Administration of sildenafil (Viagra)
f. Preparation for insertion of a penile prosthesis
g. Instructions in the squeeze technique
h. Sex therapy to reduce performance anxiety
Answer: C
Rationale: For the patient with premature ejaculation, treatment may include squeeze
technique to help the patient control of ejaculatory tension.
How it is done:
When the patient feels the urge to ejaculate, place the thumb on the frenulum of the
penis; and place the index and middle fingers above and below the coronal ridge.
Squeeze penis from front to back. Apply and release pressure during a touching
exercise.

Which behavior or disorder would the nurse identify as a possible cause of or
contributing factor to sexual dysfunction?
i. Exercise
j. Drug use
k. Supplemental vitamin use
l. Dissociative disorders
Answer: B
Rationale: Sexual dysfunctions sometimes stem from transient conditions such as
drug or alcohol use.

171.
Which treatment would the nurse expect to include in the care plan for a woman
with orgasmic dysfunction?
a. Use of soothing bubble baths
b. Exercises involving touching her partner
c. More frequent sexual intercourse
d. Increased in the degree of sexual arousal
Answer: B
Rationale: Sensate focus exercises are recommended for female orgasmic disorder.
These exercises emphasize touching and awareness of sensual feelings throughout the
entire body while minimizing the importance of intercourse and orgasm. The couple
takes turns giving and receiving touch.

Situation 20. Crisis is temporary state of severe emotional disorganization resulting from
failure of coping mechanisms and/or lack of support. Treatment must be immediate,
supportive and directly responsive to the immediate crisis.
The most critical factor for a nurse to determine during crisis intervention would be
the patients:

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e. Developmental theory
f. Willingness to restructure the personality
g. Available situational supports
h. Underlying unconscious conflict
Answer: C
Rationale: Personal internal strength and supportive individuals are critical factors that
can be employed to assist the individual to cope with a crisis.

172. A nurse is
assisting in panning care for a patient being admitted to the nursing unit who
attempted suicide. Which of the following priority nursing interventions will the
nurse include in the plan of care?
a. Check the whereabouts of the patient every 15 minutes
b. Suicide precautions with 30 minute checks
c. One-to-one suicide precautions
d. Ask that the patient report suicidal thoughts immediately
Answer: C
Rationale: One-to-one suicide precautions are required for the client who has
attempted suicide.

173. A nurse
suggests a crisis intervention group to a patient experiencing a developmental
crisis. These groups are successful because the:
a. Crisis intervention worker is a psychologist and understands behavior patterns
b. Crisis group supplies a workable solution to the patients problem
c. Patient is encouraged to talk about personal problems
d. Patient is assisted to investigate alternative approaches to solving the identified
problem
Answer: D
Rationale: Crisis intervention group helps client reestablish psychologic equilibrium by
assisting them to explore new alternatives for coping. It considers realistic situations
using rational and flexible problem solving methods.

174. A patient who is
unable to cope with the sudden loss of a job and who is feeling confused and
unable to make decisions is said to be experiencing which of the following?
a. Adventitious crisis
b. Maturational crisis
c. Situational crisis
d. Cultural crisis
Answer: C
Rationale: A situational crisis is one that is often sudden and unavoidable, such as
losses and death of a loved one.

100. A nurse is caring for a young woman who was sexually assaulted. Which of the
following is indicative of successful adjustment to the trauma?
a. She moves to another city
b. She resumes her work and activities
c. She takes classes in the martial arts

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d. She remains silent about the assault
Answer: B
Rationale: The goal of adjustment is to have the women return to her precrisis level of
functioning.

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