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PRE-BOARD EXAM III (NURSING PRACTICE III) 1

PRE-BOARD EXAMINATION III NURSING PRACTICE III Care of Clients (Part A)

GENERAL INSTRUCTIONS:

1. This test booklet contains 100 test questions.

2. Read INSTRUCTIONS TO EXAMINEES printed on your answer sheet.

3. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.

4. AVOID ERASURES.

INSTRUCTIONS:

1. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.

2. Write the subject title Nursing Practice III on the box provided.

a) Perhaps you and I can discuss who those voices are?

b) Your mother is not there, I am a nurse.

c) You are upset now, tell me why.

d) I would like to spend time with you.

SITUATION 2: Nancy, a 40-year-old seamstress was brought to E.R. with bruises all over her body and strangulation marks on the neck and says to the nurse, I am afraid he will kill me. 6) After an assessment, the nursing diagnosis would be:

a) Ineffective individual coping

b) Impaired skin integrity

c) Potential for injury

3. Shade Set Box A on your answer sheet if your test booklet is Set A; Set Box A on your

d) Potential for violence

answer sheet if your test booklet is Set A; Set Box B if your test booklet is Set B.

7)

Which of the following statements about spouse abuse is true?

SITUATION 1: A 23-year-old married woman,

evaluation. On admission, she looked confused,

a) Battered wives grew up with violence in their home

Maricar was brought to the hospital for psychiatric

sits motionless, very pale with poor skin turgor. Her

b) The wives behavior often causes the men to assault

c) Battered wives are usually poorly educated

husband claims that she has not eaten for three days. Diagnosis: Schizophrenia, Catatonia.

d) Battered wives are machonists and like to be bitten

1) Upon admission, the nurse should prioritize this nursing intervention:

8)

The common behavioral characteristics of the

a) Make Maricar feel safe and accepted

battered wives and husband and children is:

b) Encourage Maricar to answer the questions

c) Introduce Maricar to the staff

d) Make Maricar comfortable by helping her change her clothes

2)

The

problem:

a) Ineffective individual coping

b) Impaired verbal communication

c) Impaired social interaction

d) Altered thought process

nurse

initially

identifies

this

patient

3) Nurse Iris can encourage Maricar to express herself verbally by implementing this nursing intervention:

a) Ask simple questions for her to answer

b) Use non-verbal communication

c) Stay with her and state open ended statements followed by silence

d) Use simple and clear statement in communicating Maricar

a) Low self-esteem

b) Sense of hopelessness

c) Limited tolerance for frustration

d) Poor impulse control

9) One of the secondary effects of spouse is depression. NOT CLEAR should be considered in taking care of Nancy. One important information for suicidal risk is:

a) Only mentally ill persons commit suicide

b) Persons who are psychotic have greater chance to commit suicide

c) Suicide can be an inherited trait

d) There are greater chances of suicide as the depression lessens

10) An appropriate nursing diagnosis for suicidal ideation is:

a) Potential for self-directed violence

b) Ineffective individual coping

c) Altered thought process

d) Related to anxiety

4)

An antipsychotic drug is ordered. This is:

a) Imipramine Hydrochloride (Tofranil)

b) Zyprexa (Olanzapine)

c) Flouxetine Hydrochloride (Prozac)

d) Diazepam (Valium)

SITUATION 3: Aiding, a 20-year-old woman, was admitted to the hospital for sudden onset of blindness. There was no evidence of organic pathology. Assessment data showed that she

5)

Nurse Iris orients Maricar to reality by saying one of the following statements?

witnessed the slaving of her father when she was 6 years old.

PRE-BOARD EXAM III (NURSING PRACTICE III) 2

11) She

is

manifesting

a

somatoform

known as:

a) Hypochondriasis

b) Dysmorphic disorder

c) Conversion disorder

d) Somatization disorder

disorder

12) An effective nursing intervention for a patient who are experiencing a severe anxiety would be:

a) Lower the patients level of anxiety by administering anti-anxiety medication

b) Encourage the patient to express her feelings without attempting to modify the defense behavior

c) Suggest to the patient to participate in scheduled activities

d) Establish a trusting nurse-patient relationship

13) The

nurse

identifies

this

relevant

nursing

diagnosis:

a) Self-esteem disturbance

b) Hopelessness

c) Impaired social interaction

d) Severe anxiety

14) Aiding uses this defense mechanism by being

19) Jonah, because of her washing rituals is always late for meals and does not have enough time

to finish eating. An effective nursing intervention is:

a) Give her the food after the clients have eaten

b) Allow Jonah to continue her rituals and let met non-nutritional needs

c) Interrupt the washing rituals and insists she come for meal on time

d) Notify Jonah one hour before meal time, so she can start her washing rituals

20) An appropriate short term goal for Jonah is after one week, she will:

a) Increase her self-esteem

b) Verbalize that her rituals are irrational

c) Participate in a daily exercise activity

d) Identify the reason for her rituals

SITUATION 5: Aling Cora an elderly, former laundry woman has osteoarthritis and concern

about maintaining her house. 21) Which of the following conditions is an early sign of osteoarthritis?

a) Early morning stiffness

b) Painful cartilage

blind

without

physiological cause of his

c) Locking of joints

 

symptom:

d) Nodes around arm

 

a) Sublimation

c) Suppression

b)

Projection

d) Displacement

22) When

assessing

Aling

Cora s

limitation

of

 

movement, what data is most helpful?

15) Which of the following nursing intervention

a)

Knock knee

 

would not be appropriate for a patient with

b)

Pain on movement

 

somatoform disorder?

c) Muscle atrophy

 

a) Set limits to her behavior by withdrawing attention from Aiding when she continues

d) Inability to bend

complaining about her physical symptom

23) The

main

goal

of

nursing

intervention

is

b) Encourage Aiding to express her positive as well as negative feelings

c) Decrease Aiding s attention on her physical complaint by involving her scheduled activities

d) Allow her to maintain the need for the physical symptoms to reduce anxiety

SITUATION 4: Jonah was brought to the hospital by her husband for insomnia, irritability and time consuming washing rite. 16) The nurse knows that Jonah s behavioral rituals serve the purpose of:

a) Increasing inhibitory powers of super ego

b) Blocking delusions from awareness

c) Providing temporary relief from anxiety

d) Drawing attention from others

17) The obsessive-compulsive patient is fixated at stage psychosexual development?

a)

b)

Phallic

Genital

c) Anal

d) Oral

18) The nurse allows Jonah to continue with rituals

initially to:

a) Prevent increasing level of her anxiety

osteoarthritis:

a) Adapting to the environment

b) Refer to physical problems

c) Cure of health problems

d) Limiting activities of daily living

24) The best treatment for long term back problem is:

a) Regular Physical Therapy

b) Life long care of one s back

c) Correct body alignment

d) Early and prompt treatment

25) Psychosocial response to immobility problem

may result in interpretation of patient due to:

a) Increasing awareness of limitation

b) Disability due to immobility

c) Decline in decision making abilities

d) Lack of facilities for treatment

SITUATION 6: This is about Intrapartal Nursing Care.

26) Nutrition, being vital to pregnancy requires that the diet contain food which are:

b) her

Increase

self-confidence

and

self-

a) Low in fat

c) Low carbohydrates

esteem

b) High calories

d) Rich in iron

c) Encourage independence

PRE-BOARD EXAM III (NURSING PRACTICE III) 3

27) The nurse s assessment of a patient in labor was: Contractions lasting 60 seconds 4 minutes apart, Cervix is 6 cm dilated. The nurse recognizes that this stage of labor is:

a) Active phase II

b) Active phase I

c) False labor

d) Active phase III

28) Candy is admitted to the unit in active labor. What initial action should the nurse take?

a) Take vital signs and check FHT for baseline record

b) Do Leopold s maneuver

c) Assess for ruptured membrane

d) Catheterize to empty the bladder

29) Catherine is assessing Candy who was in active labor, breech presentation, ruptured membranes, and change of location of fetal heart sounds. Katrina assesses this as:

a) A normal change in location of fetal heart sounds in breech presentation

b) A labor in progress

c) A fetal distress

d) A possible cesarean

30) When a primagravida is in labor, the patient may be taken to delivery room when the:

a) Cervix is fully dilated at 10 cm

b) Bag of water ruptures

c) Cervical effacement occurs

d) Transition phase occurs

SITUATION 7: Roda, a teacher from Bukidnon, underwent thyroidectomy. 31) Roda has to have oxygen inhalation if more

than 6 liters/minute is administered, this can lead to:

b) Deflate the cuff and maintain ventilation

c) Inflate the cuff and maintain ventilation

d) Inflate the cuff only

SITUATION 8: Miss Gina is confined in San Luis ward, with a diagnosis of epilepsy.

36) Epilepsy

Paroxysmal Neurologic disorder

is

causing the least recurring episode of:

a) Loss of consciousness

b) Sensory phenomena

c) Behavioral abnormalities

d) Hysteria

37) The nurse informed the physician regarding Miss Gina altered unconsciousness lasting from two to three minutes and has complete amnesia for the seizure episodes, this is a typical:

a) Partial seizures

b) Petit mal seizure

c) Minor motor seizures

d) Grand mal seizures

38) This neurologic disorder may be diagnosed by any of the diagnostic tests, EXCEPT:

a) Cerebral angiogram

b)

CT scan

c) EEG

d) ECG

39) Which of this should the nurse refrain from doing if Gina is having seizure?

a) Suction her PRN

b) Raise the bedside rails

c) Apply restraint to both arm

d) Put the mouth gag in her mouth

40) Ms. Gina is taking Primidone tablet per orem, BID. You carefully observe the side-effect of:

a) Mental change

c) Nystagmus

a) Nystagmus

c) Tinnitus

b) Mental dullness

d) Transient nausea

b) Pleurisy

d) Tympanism

32) In making safety rounds in your ward, you keep in mind that SMOKING is restricted in the presence of oxygen tank, it is because:

a) Oxygen is explosive when open to heat

b) Smoking would increase the carbon dioxide in the air

c) Smoking can lead to cancer of the lung

d) Oxygen support combustion

33) Tracheostomy

must be at her bedside

postoperatively, because of this possible post- operative complication:

a) Cardiac arrest

b) Cardiac standstill

c) Ventricular fibrillation

d) Atelectasis

set

34) Following tracheostomy, the immediate nursing care are, EXCEPT:

a) Give DAT

b) Watch for signs of shock and hemorrhage

c) Assess and clean stoma to prevent infection

d) Monitor vital signs

35) Roda s tracheostomy tube is cupped. There is a need to do emergency resuscitation. What will you do?

a) Deflate the cuff only

SITUATION 9: Jingle, 33-years-old, single, has a history of multiple psychiatric admissions with a diagnosis of schizophrenia undifferentiated.

41) While giving medications to the patients in the unit, the nurse observed Jingle standing at the window of the room touching the glass and muttering to herself. By asking on of the following questions, nurse Mila validates her knowledge of the behavior.

a) What can you see at the window, Jingle?

b) Why are you looking at the window and touching the glass?

c) Do you see yourself in the glass, Jingle?

d) Are you hearing voices again?

42) Initially nurse Mila identifies this patient s problem:

a) Self-esteem disturbance

b) Ineffective individual coping

c) Body image disturbance

d) Altered though process

statements about

dopamine hypothesis is not true?

a) Symptoms of schizophrenia such as delusion and hallucination are primarily due to hyperdopamine activity

following

43) Which

of

the

b) Amphetamine produce an excess of dopamine in the brain and it exacerbates the symptoms of psychosis

PRE-BOARD EXAM III (NURSING PRACTICE III) 4

c) Antipsychotic drugs limit the activity of dopamine thus reducing the symptoms of schizophrenia

d) Cocaine decreases the level of dopamine in the brain

44) During the interaction, Jingle becomes restless and appeared nervous. Nurse Mila therapeutically asked this question:

a) Do you feel uncomfortable talking to me?

b) Can you tell me what part of our conversation did you begin to feel uncomfortable?

c) Do you sometime feel uneasy talking about yourself?

d) Did I say something wrong that made yourself?

45) An element critical to a therapeutic relationship with a psychotic patient is:

52) When you commit error in IV therapy, under the new law you are:

a) Liable for negligence due to imprudence

b) Accountable for your action

c) Liable for malpractice due to carelessness

d) Liable under the penal provisions

53) With special IV training, a registered nurse can now administer the injection.

a) As an independent function

b) In the presence of a physician

c) With IV order of a doctor

d) As assigned by the head nurse

54) The ultimate purpose of the IV special training as mandated by nursing law:

a) Protection of standards of IV

b) Protection of nurse and patient

c) Protection of nurse and hospital

a) Trust

c) Limit setting

d) Protection of doctor and nurse who

b) Empathy

d) Honesty

prescribed IV

SITUATION 10: In your study, you examined the age characteristic of the identity using descriptive statistics. 46) Descriptive statistics are useful measures in:

a) Calculating standard deviation

b) Summarizing

c) Determining frequency of data

55) This is a serious complication of IV therapy:

a) Sudden drop in BP

b) Prolonged chills of medication

c) Incompatible drug and medication

d) Out of vein with swelling in the area

SITUATION 12: Gemmy was rushed to the ER for

d) Estimating central tendency

burns. Diagnosis by factor was 2 nd degree burns around the abdominal area and in both limbs.

47) The one which occur most frequency is the:

a) Median

c) Proportion

56) Approximately what percent of the body surface area is affected in 2 nd degree burns?

b) Mode

d) Mean

a) 42%

c) 10%

 

b) 35%

d) 15%

48) When the mean age of your subjects is 54 which statement is correct?

a) 50% subjects are skewed

b) Ages of subjects are skewed

c) Ages of subject are normal

d) 50% of subjects are below 54 years old

49) When you divide the frequency of each age by the total size of sample and multiple the result by 100 the value obtained is:

57) You know that in burns cases, the relationship of body surface area of fluid is:

a) Inversely proportional

b) Unrelated

c) Directly proportional

d) Equal

58) Fluid loss due to burns is best evaluated by monitoring the:

a) Percentile

c) Ratio

a) Blood Ph

c) BUN

b) Proportion

d) Percentage

b) Hematocrit

d) Sedimentation rate

50) Fifty seven (57) subjects in your study ranged in

59) You will expect the doctor to order IV, designed to provide:

age 21 to 40 of the median age of your sample is:

a) Plasma

c) Potassium

a) 30.5

c) 30

b) Dextrose

d) Minerals

b) 30.1

d) 31.1

SITUATION 11: Under RA 9173, intravenous injection, administering a medication without the doctors order is not a legal function of the nurse. 51) To guarantee safe IV practice, a registered nurse must undergo:

a) Special training based on protocol

b) Advanced skills in therapy

c) Special training under PNA program

d) Competence as certified by the school

60) Which among the symptoms would you be least concerned?

a) Leukopenia

c) Pain

b) Laryngeal edema

d) Hypovolemia

SITUATION 13: Mrs. Lagdameo was referred to you for follow-up. She has kidney operation wherein her left kidney was removed.

61) In your plan of care for Mrs. Lagdameo, which of the following is an appropriate objective/s?

a) To prevent an infection of the surgical wound

b) To provide for the comfort of Mrs. Lagdameo

PRE-BOARD EXAM III (NURSING PRACTICE III) 5

c) To promote healing tissue

d) All these objectives are appropriate

62) One of your home visits you encouraged Mrs.

around obtained the

advantages of ambulation. Except:

a) Muscle tone is improved

b) It is psychologically stimulating

c) Infection is prevented

d) Blood circulation to the extremities is improved

Lagdameo

to

walk

63) Mrs. Lagdameo refuses to perform her deep

breathing exercise as advice as it increase pain over the operating area. Your nursing intervention would be:

a) Advise her to inform her physician about this

b) Explain the importance of the exercise and convince her to cooperate

c) Allow her to disregard the exercise

d) Allow her to perform the exercise whenever she wants

64) In order to facilitate the healing of the surgical

wound,

Lagdameo s diet with additional foods rich in:

a) Protein and Iron

b) Vitamin B complex

c) Protein and Vitamin C

d) Carbohydrates

advice

the

family

to

enrich

Mrs.

65) In response to the family s fear of inability to recognize signs of post operative hemorrhage you discuss with them these signs as, except:

a) Drop in body temperature

b) Rise in BP

c) Pallor of lips

d) Restlessness and anxiety

SITUATION 14: Mr. Suarez is experiencing chronic cough and dyspnea on moderate exertion. His physician made a diagnosis of acute pulmonary emphysema. 66) His dyspnea on moderate exertion was probably the result of:

a) Thrombic obstruction of capillaries and pulmonary arterioles

b) Reduced O 2 carrying capacity of his RBC

c) Impaired diffusion between the blood and alveolar air

d) Reduced tone of the diaphragm and intercostals muscle

67) The increased antero-posterior diameter of Mr. Suarez s is the result of the:

a) Fixation of the ribs and sternum in the inspiratory position

b) Inflammatory condition of the mediastinal lymph nodes

c) Distention of pleural and pericardial sacs by transudate

d) Obstruction of pulmonary circulation due to cardiac hypertrophy

a) Explain to him not to be afraid because a highly trained technician will give you the treatment through a mechanical respirator

b) This is a non-painful 20 minutes procedure in which you will breath oxygen and air through a mouth piece to relieve your discomfort and improve your breathing

c) For the duration of the treatment, the breathing machine will take control of your respiration, regulate the rate and depth thus improving O 2 delivery to the blood

d) Part of your lung sacs had been collapsed, you will be attach to a machine which will blow pressured air into your lungs to re- expand them

69) While waiting for the doctor for examination, he would have been comfortable by one of the following position:

a) Sitting on the edge of the bed

b) Reclining on his right side

c) Supine with his head slightly lowered

d) Lying flat on bed

70) Diet management for Mr. Suarez:

a) Low caloric, small frequent meals

b) Low carbohydrates, small frequent meals

c) High calorie, small frequent meals

d) Full diet

SITUATION 15: Marina, a mother of 8 children, a known diabetic, complains of dizziness upon awakening at 6:30am.

71) Her skin is cold, clammy and feels weak. This is typically:

a) Hypertension

b) Hypochondriac

c) Hypoglycemia

d) Hyperglycemia

72) She had early dinner, the following morning about 6:00 am, she experienced dizziness and

clammy skin. The appropriate nursing

cold

intervention is:

a) Give her plain hot tea

b) Give her Milo and candy

c) Give insulin injection

d) Give her warm shower and hot tea

73) Your instruction, the night before FBS is to avoid stress, because this will:

a) Alter glucose metabolism

b) Cortisone increase the blood sugar and at the same time it alters glucose metabolism

c) Release glucose metabolism thus altering the increase of blood sugar.

d) Release the epinephrine and cortisone increase blood sugar by promoting gluconeogenesis

74) The following are the basis of the prescription of a diabetic diet, except:

a) Age

b)

Occupation

c) Sleeping pattern

d) Size

75) Marina loves gardening, you should discourage her of handling:

68) Which of the following explanation would best

a) Roses

c) Orchid

prepare Mr. Suarez for IPPB treatment:

b) Chrysanthemum

d) Dahlia

PRE-BOARD EXAM III (NURSING PRACTICE III) 6

SITUATION 16: During the past 2 years, Aling Dugong, age 70, manifested aggressive memory impairment and confusion. 76) Initial nursing diagnosis would be:

a) Impaired social interaction

b) Altered though process

c) Impaired adjustment

d) Increases her feeling of security

77) Aling Dugong makes up stories about events she cannot recall. The nurse should:

a) Reduce feeling of interaction

b) Reduce her feeling of frustration

c) Maintains her self-esteem

d) Increases her feeling of security

85) Associated with low birth weight infants and intrauterine growth retardation in the second and third trimester results from a gain of:

a) 3 Ibs or less/month

b) 1 Ibs or less/month

c) 2 Ibs or less/month

d) 4 Ibs or less/month

SITUATION 18: Nurse Luna, a psychiatric nurse specialist was invited to talk to third year nursing students on psychopharmacological therapy. 86) An example of an Antianxiety drug is:

a) Monoamine Oxidase inhibitors

b) Biperiden (Akineton)

c) Torazepan (Ativan)

d) Lithium Carbonate

78) She is observed to be repeating the same word over and over again. This symptom is known as:

repeating the same word over and over again. This symptom is known as: 87) When Lithium

87) When Lithium levels are schedules to be done,

a) Perseveration

b) Confabulation

c) Aphasia

d) Comfort

the nurse should remember that a patient s serum lithium concentration is more stable:

a) 2 to 4 hours after the last dose

79) Dementia is characterized by:

a) Slurring of speech

b) Fluctuating levels of consciousness

c) Visual or tactile hallucination

d) Progressive aphasia

80) Discharge plan is being prepare. The family should be instructed what plan has the highest

priority to his needs in caring for Aling Dugong.

b) 4 to 6 hours after the last dose

c) 6 to 8 hours after the last dose

d) 8 to 12 hours after the last dose

88) The nurse is aware that Haloperidol (Haldol) is most effective for clients who exhibit:

a) Manic-assaultive behavior

b) Excited-overactive behavior

c) Excited-depressed behavior

d) Withdrawn-secretive behavior

a) Nutrition

c) Hygiene

b) Safety

d) Comfort

89) A patient with a diagnosis of schizophrenia is

a) Akathisia

SITUATION 17: Baby is admitted to the emergency

given one of the antipsychotic drugs. The nurse is aware that all of the extrapyramidal effects

room. Cervical dilatation is 6 cm, fully efface; cephalic presentation and 36 weeks gestation. 81) The nurse observes Baby abdomen with

associated with these drugs. The one causing the most concern would be:

irregular lines due to abdominal stretches. This

b) Tardive dyskinesia

is known as:

c) Parkinsonian syndrome

a) Linea nigra

c) Strae gravidarum

d) Acute dystonic reaction

b) Choalasma

d) Melasma

 

90) The nurse should continually assess a client

is

82) The

obstetrician

remarks

that

the

fetus

receiving lithium for an early sign of lithium

dipping which means, the fetus is:

toxicity would be:

a) Reached the ischial spine

 

a) Tinnitus

c) Akathisia

b) Still floating

 

b) Diarrhea

d) Torticolis

c) but

Descending ischial spine

does

not

reached

the

SITUATION 19: Prenatal care is geared towards

d) In station +1

 

83) The following are signs of impending delivery, except:

the delivery of healthy baby and the maintenance of maternal health. Physical exam is visit in assessing the patient s condition.

a) Increasing bloody show

 

91) The characteristic posture of the fetus or the relationship of the fetal structures to one

b) Rectal pressure

 

another determine the:

c) Contractions become regular and shorter in

a) Lie

c) Variety

duration

b) Position

d) Attitude

d) Rupture of membrane

84) When a fetal head is determined the nurse should:

a) Cut the cord

b) Apply abdominal pressure

c) Use bulb syringe to clear mouth and nose secretion

d) Use Ritgens maneuver

92) Which best describes interval rotation:

a) There is turning of the head in a manner the

occiput gradually moves from its original transverse oblique position

b) It is the first requisite for birth

c) The delivered head then undergoes restitution

d) Known as couple of force

PRE-BOARD EXAM III (NURSING PRACTICE III) 7

93) Which of the following is the diagnostic test for fertility?

a) Comb s test

b) Hysterosalpingography

c) Pap s smear

d) Culdocentesis

94) The diameter: measuring 10 cm or more at the midpelvis is usually the smallest diameter of the pelvis

a) Diagonal conjugate

b) Oblique diameter

c) Interspinous diameter

d) Obstetrical conjugate

95) The nurse would estimate the age of gestation through the fundal height of the uterus. At the level of the umbilicus, the AOG is estimated to be:

a) 25 weeks

c) 20 weeks

b) 15 weeks

d) 10 weeks

SITUATION 20: Understanding the Growth and Development of the child is one of the vital role of a pediatric nurse. 96) Baby Mariluna, 6-month-old, most appropriate toy would be:

a) Pull-push toys

b) Wooden blocks

c) Soft stuffed animals

d) Shape matching toys

97) The nurse is aware that the kind of play for 2- year-old Angelu is:

a) Group play

b) Parallel play

c) Dramatic play

d) Cooperative play

98) The most reliable indicator of pain in a 4-year- old chills is:

a) Crying and sobbing

b) Changes in behavior

c) Decrease heart rate

d) Verbal report of pain

99) Julie,

at

psychosexual development?

12-year-old,

is

what

stage

of

a) Genital

c) Latency

b) Anal

d) Phallic

100)

Preparation for surgery on a 4-year-old

Tala, must include consideration of the child s age-related fear of:

a) Strangers

b) Intrusive procedure

c) Disruption of routines

d) Intrusive of routines

***END***