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Situation 1 - Jimmy developed this goal for hospitalization. "To get a handle on my nervousness." The
nurse is going to collaborate with him to reach his goal. Jimmy was admitted to the hospital because he
called his therapist that he planned to asphyxiate himself with exhaust from his car but frightened instead.
He realized he needed help.
1. The nurse recognized that Jimmy had conceptualized his problem and the next priority goal in the
care plan is:
2. The nurse is guided that Jimmy is aware of his concerns of the "here and now" when he crossed out
which item from this "list of what to know"
3. While Jimmy was discussing the signs and symptoms of anxiety with his nurse, he recognized that
complete disruption of the ability to perceive occurs in:
4. Jimmy initiates independence and takes an active part in his self care with the following EXCEPT:
5. The nurse notes effectiveness of Interventions in using subjective and objective data in the:
Situation 2 - A research study was under taken in order to identify and analyze a disabled boy's coping
reaction pattern during stress.
a. case study
b. longitudinal study
c. cross-sectional study
d. evaluative study
7. The process recording was the principal tool for data collection. Which of the following is NOT a
part of a process recording?
a. Non verbal narrative account
b. Audio and interpretation
c. Audio-visual recording
d. Verbal narrative account
9. The investigator also provided the nursing care of the subject. The investigator is referred to as
a/an.
a. Participant-observer
b. Observer researcher
c. Caregiver
d. Advocate
10. To ensure reliability of the study, the investigator analysis and interpretations were:
Situation 3 - During the morning endorsement, the' outgoing nurse informed the nursing staff that Regina, 5
years old, was given Flurazepam (Dalmane) 15 mg at 10:00pm because she had trouble going to sleep.
Before approaching Regina, the nurse read the observation of the night nurse.
11. Which of the following approaches of the nurse validates the data gathered?
a. "I learned that you were up till ten last night, tell me what happened before you were finally able to sleep
and how was your sleep?"
b. "Hmm...You look like you had a very sound sleep. That pill you were given last night is effective isn't
it?"
c. "Regina, did you sleep we!!?"
d. "Regina, how are you?"
12. Regina is a high school teacher. Which of these information LE^ST communicate attention and
care for her needs for information about her medicine?
a. Guided by a medication teaching plan go over with her the purpose, indications and special instructions,
about the medication and provide her a checklist
b. Provide a drug literature
c. Have an informal conversation about the medication and its effects
d. Ask her what time she would like to watch the informative video about the medication
13. The nurse engages Regina in the process of mutual inquiry to provide an opportunity for Regina
to
14. Which of these responses indicate that Regina needs further discussion regarding special
instructions?
15. Regina commits to herself that she understood and will observe all the medicine precautions by;
a. affixing her signature to the teaching plan that she has understood the nurse
b. committing what she learned to her memory
c. verbally agreeing with the nurse
d. relying on her husband to remember the precautions
Situation 4 - The nurse-patient relationship is a modality through which the nurse meets the client's needs.
16. The nurse's most unique tool in working with the emotionally ill client is his/her:
a. theoretical knowledge
b. personality make up
c. emotional reactions
d. communication skills
17. The psychiatric nurse who is alert to both the physical and emotional needs of clients is working
from the philosophical framework that states:
18. One way to increase objectivity in dealing with one’s fears and anxieties is through the process of:
a. observation
b. intervention
c. validation
d. collaboration
19. All of the following response are non therapeutic. Which is the MOST direct violation of the
concept, congruence of behavior?
20. The rnentally ill person responds positively to the nurse who is warm and caring. This
demonstration of the nurse’s role as:
a. counselor
b. mother surrogate
c. therapist
d. socializing agent
Situation 5 - The nurse engages the client in a. nurse-patient interaction.
21. The best time to inform the client about terminating the nurse-patient relationship is
22. The client says, "I want to tell you something but can you promise that you will keep this, a
secret?" A therapeutic response of the nurse is:
a. "Yes, our interaction is confidential provided the information you tell me is not detrimental to your
safety."
b. "Of course yes, this is just between you and me. Promise!"
c. "Yes, it is my principle to uphold my client's rights."
d. "Yes, you have the right to invoke confidentiality of our interaction."
23. When the nurse respects the client's self-disclosure, this is a gauge for the nurse's:
a. trustworthiness
b. loyalty
c. integrity
d. professionalism
24. Rapport has been established in the nurse-client interaction time. I am committed to have this
time available for us while you are at the hospital and ends after your discharge."
a. "The best time to talk is during the nurse-client interaction time. I am committed to have this time
available for us while you are at the hospital and ends after your discharge."
b. "Yes, if you keep it confidential, this is part of privileged communication."
c. "I am committed for your care."
d. "I am sorry, though I would want to, it is against hospital policy."
25. The client has not been visited by relatives for months. He gives a, telephone number and requests
the nurse to call. An appropriate action of the nurse would be:
Situation 6 - Camila, 25 years old, was reported to be gradually withdrawing and isolating herself from
friends and family members. She became neglectful of her personal hygiene. She was observed to be
talking irrelevantly and incoherently. She was diagnosed as schizophrenia
26. The past history of Camila would most probably reveal that her premorbid personality is:
a. schizoid
b. extrovert
c. ambivert
d. cycloid
28. Which of the following disturbances in interpersonal relationships MOST often predispose, to the
development of schizophrenia?
a. Guilt feelings
b. Ambivalence
c. Narcissistic behavior
d. Insecurity feelings
a. anxiety disorder
b. neurosis
c. psychosis
d. personality/disorder
Situation 7 - Salome, 80 year old widow, has been observed to be irritable, demanding and speaking louder
than usual. She would prefer to be alone and take her meals by herself, minimized receiving visitors al
home and no longer bothers to answer telephone calls because of deterioration of her hearing. 'She was
brought by her daughter to, the Geriatic clinic for assessment and treatment.
31. The nurse counsels Salome's daughter that Salome's becoming very loud and tendency to become
aggressive is a/an:
a. sensory deprivation
b. social isolation
c. cognitive impairment
d. ego despair
33. The nurse will assist Salome and her daughter to plan a goal which is:
34. The daughter understood, the following ways to assist Salome meet her needs and avoiding which
of the following:
a. Using short simple sentences
b. Speaking distinctly and slowly
c. Speaking at eye level and having the client's attention
d. Allowing her to take her meals alone
35. Salome was fitted a hearing aid. She understood the proper .use and wear of this device when she
ways that the battery should be functional, the device is turned on and adjusted to a:
a. therapeutic level
b. comfortable level
c. prescribed level
d. audible level
Situation 8 - For more than a month now, Cecilia is persistently feeling restless, worried and feeling as if
something dreadful is going to happen. She fears being alone in places and situations where she thinks that
no one might come to rescue her just in case something happens to her.
a. acrophobia
b. claustrophobia
c. agoraphobia
d. xenophobia
37. Cecilia's problem is that she always sees and thinks negative hence she is always fearful Phobia is
a symptom described as:
a. organic
b. psychosomatic
c. psychotic
d. neurotic
38. Cecilia has a lot of irrational thoughts: The goal of therapy is to modify her:
a. communication
b. cognition
c. observation
d. perception
39. Cognitive therapy is indicated for Cecilia when she is already able to handle anxiety reactions.
Which of the following should the nurse implement?
40. After discharge, which of these behaviors indicate a positive result of being able to overcome her
phobia?
41. It is unethical to tell one's friends and family member’s data bout patients because doing so is
violation of patients’ rights to:
a. Informed consent
b. Confidentiality
c. Least restrictive environment
d. Civil liberty
42. The nurse must see to it that the written consent of mentally ill patients must be taken from:
a. Doctor
b. Social worker
c. Parents or legal guardian
d. Law enforcement authorities
43. In an extreme situation and when no other resident or intern is available, should a nurse receive,
telephone orders, the order has to be correctly written and signed by the physician within.
a. 24 hours
b. 36 hours
c. 48 hours
d. 12 hours
44. The following are SOAP (Subjective - Objective - Analysis - Plan) statements on a problem:
Anxiety about diagnosis. What is the objective data?
a. Relate patient's feelings to physician initiate and encourage her to verbalize her fears give emotional
support by spending more time with patient, continue to make necessary explanations regarding diagnostic
test.
b. Has periods of crying, frequently verbalizes fear of what diagnostic tests will reveal
c. Anxiety due to the unknown
d. "I’m so worried about what else they'll find wrong with me"
45. Nursing care plans provide very meaningful data for the patient profile and initial plan because
the focus is on the:
Situation 10 - Marie is 5 ½ years old and described by the mother as bedwetting at night.
46. Which of the following is the MOST common physiological cause of night bedwetting?
47. All of the following, EXCEPT one comprise the concepts of behavior therapy program:
48. The help Marie who bed wets at night practice acceptable and appropriate behavior, it is
important for the parents to be consistent with the following approaches EXCEPT:
a. You are supposed to get up and go in the toilet when you feel you have to go and did not. The next time
you bed wet, I’ll tell your friends and hand your sheets out the window for them to see."
b. "You are supposed to get up and go in the toilet when you feel you have to go and you did not. I expect
you to from now on without fail."
c. "If you bed wet, you will change your bed linen and wash the sheets."
d. "If you don't make an effort to control your bedwetting, I'd be upset and disappointed."
50. During your conference, the parent inquires how to motivate Marie to be dry in the morning.
Your response which is an immediate intervention would be:
a. Give a star each time she wakes up dry and every set of five stars, give a prize
b. Tokens make her materialistic at an early age. Give praise and hugs occasionally
c. What does you child want that you can give every time he/she wakes up dray in the morning
d. Promise him/her a long awaited vacation after school is over.
Situation 11 - The nurse is often met with t-he following situations when clients become angry and hostile.
51. To maintain a therapeutic eye contact and body posture while interacting with angry and
aggressive individual, the nurse should:
52. During the pre-interaction phase of the N-P relationship/the nurse recognizes this normal
INITIAL reaction to an assaultive or potentially assaultive person.
53. Which of the following is an accurate way of reporting and recording an incident?
a. "When asked about his relationship with his father, client became anxious."
b. "When asked about his relationship with his father, client clenched his jaw/teeth made a fist and turned
away from the nurse."
c. "When asked about his relationship with his father, client was resistant to respond."
d. "When asked about his relationship with his father, his anger was suppressed."
55. A patient grabs a chair and about to throw it. The nurse best responds saying.
56. In planning care for a patient with Parkinson's disease, which of these nursing diagnoses should
have priority?
a. Number of accomplishments
b. Ability to avoid interpersonal conflict
c. Physical health throughout life
d. Personality development in his life span
58. The frequent use of the older client's name by the nurse is MOST effective in alleviating which of
the following responses to old age?
a. Loneliness
b. Suspicion
c. Grief
d. Confusion
59. An elderly confused client gets out of bed at night to go to the bathroom and tries to go to another
bed when she returns. The MOST appropriate action the nurse would take is to:
60. An elderly who has lots of regrets, unhappy and miserable1 is experiencing:
a. Crisis
b. Despair
c. Loss
d. Ambivalence
Situation 13 - Graciela 1 ½ year old is admitted the hospital from the emergency room with a fracture of the
left femur due to a Tall down a flight of stairs. Graciela is placed oh Bryant's traction.
61. While on Bryant's traction, which of these observations of Graciela and her traction apparatus
would indicate a decrease in the effectiveness of her traction?
62. The nurse notes that the fall might also cause a possible head injury. She will be observed for
signs of increased intracranial pressure which include:
63. Graciela is assessed to have no head injury. The Bryant's traction is removed. A plaster of Paris
his spica is applied. Which of these finding as a concern of immediate attention that must be reported
to the physician immediately?
64. Part of discharge plan is for the nurse to give instructions about the care of Graciela's cast to the
mother. Which of these statements indicate that the mother understood an important aspect of case
care?
65. The nurse counsels Graciela's mother ways to safeguard safety white providing opportunities of
Graciela to develop a sense of:
a. Trust
b. Initiative
c. Industry
d. Autonomy
Situation 14 - Jolina is an 18 year old beginning college student. Her mother observed that she is having
problems relating with her friends. She is undecided about her future. She has lost insight, lost interest in
anything and complained and complained of constant tiredness.
66. Jolina is out on antidepressant drugs. These drugs act on the brain chemistry, therefore they
would be useful in which type of depression?
a. exogenous depression
b. neurotic depression
c. endogenous depression
d. psychotic depression
68. After one week of antidepressant medication, Jolina still manifests depression. The nurse
evaluates this as;
69. Jolina continues to verbalize feeling sad and hopeless. She is not mixing well with other clients.
One of the nurse's important consideration for Jolina Initially is to:
70. During the predischarge conference, the nurse suggests vocational guidance because it should
help Jolina to:
72. Which of the following questions illustrates the group role of encourager?
a. Insight
b. Productivity
c. Socialization
d. Intimacy
74. The treatment of the family as a unit is based on the belief that the family:
a. is a social system and all the members are interrelated components of that system
b. as a unit of society needs the opportunity to change its own destiny
c. who has therapy together will tend to remain together
d. is "contaminated" by the presence of deviant member and all members need treatment
75. The working phase in therapy group is usually characterized by which of the following?
a. Caution
b. Cohesiveness
c. Confusion
d. Competition
Situation 16 - The mental health - psychiatric nurse functions in a variety of setting with different types of
clients.
76. Poverty as reflected in prevalence of communicable diseases, malnutrition and social ills such as
street children, homeless and prostitution is a predisposing factor to mental illness. A community
approach to cope with this problem is for the nurse to support:
77. The MOST cost effective way to meet the mental health needs of the public is through programs
with a priority goal of:
a. treatment
b. prevention
c. rehabilitation
d. research
78. Lorelle upon discharge was referred to a volunteer group where she has learned to read patterns,
cut out fabric and use a sewing machine to make simple outfits that will help her earn in the future.
What type of activity therapy is this?
a. Recreational therapy
b. Art therapy
c. Vocational therapy
d. Educational therapy
79. In a residential treatment home for adolescent girl's the clients were becoming increasingly tense
and upset because of shortening of their recreation time. To die escalate possible anger and
aggression among the clients it is BEST to play:
a. religious music
b. relaxation music
c. dance music
d. rock music
80. The parents of special children who are behaviorally disturbed need mental health education.
Which of these topics would the school nurse consider as priority for their parents’ class?
a. Drug education
b. Child abuse
c. Effective parenting
d. Sex education
Situation 17 - Nurse's in all practice areas are likely to come in contact with clients suffering from acute or
chronic drug abuse.
81. The psychodynamic therapy of substance abuse is based upon the premise that drug abuse is:
82. Being in contact with reality and the environment is a function of the:
a. conscience
b. ego
c. id
d. super ego
83. Substance abuse is different from substance dependence is than, substance dependence:
84. During the detoxification stage, it is a priority for the nurse to:
a. Cannabis Sativa
b. Lysergic add diethylamide
c. Methylenedioxy, methamphetamine
d. Methamphetamine hydrochloride
86. Anticipation of personal questions is given adequate attention during which phase of the nurse
patient relationship?
a. Orientation phase
b. Working phase
c. Pre-interaction phase
d. Termination phase
87. The client asks for the nurse's telephone number, which of these responses is NOT appropriate?
89. When the nurse is asked a personal question, which of these reactions indicate a need her to
introspect?
90. It is 10 o'clock of your watch. The client asks, "What time is it?" The nurse's appropriate
response is:
Situation 19 - Ricky is a 12 year old-boy with Down’s syndrome. He stands 5' ½" and weight 100 lbs. He is
slim and walks sluggishly with a limp. He wears a neck brace as support for his neck. X - ray of cervical
spine showed "subluxation of CI in relation to C2 with cord compression." He attends a school for special
education.
91. The classroom teacher consults the school for guidance on how to take care of Ricky while inside
the, classroom. The nurse considers as priority, Ricky's:
a. Physiological needs
b. Need for self-esteem
c. Needs for safety and Security
d. Needs for belonging
92. Ricky's mother visited the school nurse. She asked, " What should I do when Ricky fond his
genitalia?" Appropriate response of the nurse is for the mother to:
93. The nurse has one on one health education sessions with Ricky's mother. The mother understood
that for her son to learn to cope and be independent, she should constantly provide activities for
Ricky to be able to:
94. All of the following activities are appropriate for Ricky EXCEPT:
95. Ricky's IQ falls within the range of 50-55. He can be expected to:
Situation 20 - The abuse of dangerous drug is a serious public health concern that nurses need to address,
96. The nurse should recognize that the unit primarily responsible for education and awareness of the
members of the family on the ill effects of dangerous drugs is the:
97. A drug dependent utilizes this defense mechanism and enables him to forget shame and pain.
a. repression
b. rationalization
c. projection
d. sublimation
98. This drug produces mirthfulness, fantasies, flight of ideas, loss of train of thought, distortion of
size, distance and time, and "bloodshot eyes", due to dilated pupils.
a. Opiates
b. LSD
c. Marijuana
d. Heroin
99. The nurse evaluates that-.her health teaching to a group of high school boys is effective if these
students recognize which of the following dangers of inhalant abuse.
100. The mother of a drug dependent would never consider referring her son to a drug rehabilitation
agency because she fears her son might just becomes worse while relating with other drugs users. The
mother's behavior can be described as:
a. Unhelpful
b. Codependent
c. Caretaking
d. Supportive
ANSWER KEY:
1. C
2. C
3. B
4. A
5. D
6. A
7. C
8. D
9. D
10. A
11. A
12. D
13. D
14. D
15. A
16. D
17. C
18. B
19.
20.
21.
22.
23.
24.
25. A
26. A
27. A
28. B
29. C
30. C
31. A
32. A
33. A
34. D
35. D
36. C
37. D
38. B
39. A
40. A
41. B
42. C
43. A
44. B
45. C
46.
47.
48.
49.
50.
51. D
52. B
53. B
54. A
55. A
56. A
57. C
58. D
59. A
60. B
61. A
62. B
63. D
64. D
65. D
66. B
67. D
68. C
69. C
70. C
71. C
72. B
73. B
74. A
75. B
76. B
77. B
78. C
79. B
80. C
81. B
82. B
83. D
84. D
85. D
86. B
87. A
88. B
89. D
90. B
91. C
92.
93. D
94. B
95. C
96. D
97. A
98. B
99. A
100. A