Title RECALLS 11 - NP5 - SC ✅

3 | Page B. Care for the wounds in a matter-of-fact manner C. Allow the client to express angry feelings D. Problem-solve the situation with the client 29. Which of the following is a necessary initial step in determining interventions for Nina? A. Explore her coping behaviors B. Determine the meaning of her personal crisis C. Assess her developmental level and experience D. Let her identify current stressors 30. The nurses involved in the care of Nina feel caught in a bind because there is a need to rescue in the event that she cuts herself again and a need not to be manipulated by her. It is MOST therapeutic for the nursing team to recognize: A. Being strict regarding imposition of external controls B. Writing a “no cutting on self” contract C. Developing of a trust relationship D. Taking self- responsibility by signing a waiver Situation: Children are unique requiring specialize nursing care. To nurse a child, health care professional need to be aware that children are physically smaller and their bones grow and mature at different rates. 31. A 10-month-old infant has developmental dysplasia of the hip following confirmation of the diagnosis by ultrasonography. She is placed in Pavlik Harness. Which of the following should you expect the infant to be positioned? A. Supine B. Trendelenburg C. Flexed abduction D. Flexed adduction 32. With the application of the harness, the nurse should keep in mind the following EXCEPT? A. Assess skin daily. B. The baby should wear the harness at all times except while bathing C. Harness should be worn above the clothing continually. D. Instructing the parents on the practicalities of daily care and continuous support 33. The infant did not respond to treatment with Pavlik Harness. A surgical program is undertaken. She was admitted into hospital for a 1-week period of gallows traction. The mother asks the nurse what Gallows traction is. The nurse responds correctly if she states: A. It is a skin traction applied to the legs which are flexed at a 90-degree angle at the hips. B. The child’s head provides counter traction. C. Type of traction with the legs in an extended position D. Uses skin traction on the lower leg and a padded sling under the knee 34. The nurse should pay particular attention to which part of the body of the infant in gallows traction? A. Back B. Hips C. Lower extremities D. Skin 35. The tractions is removed after 1 week and the infant is bathed prior to surgery. Which of the following constitute this intervention? A. Bathing is necessary for hygienic measures B. Cleanse the skin and allows for the gentle removal of the adhesive traction C. Allows for adequate physical preparation D. A routine procedure prior to surgery to prevent complications Situation: Nurse Liza functions as a team leader and coordinates a small group of nurses in the psychiatric unit to provide care to a small group of patients. 36. As coordinator of the team her main function is to: A. Allow team members to practice high degree of authority B. Encourage the growth and training of each member C. Know the condition and needs of all the patients assigned to the team D. Assume responsibility of the team for planning, directing and evaluating the patient’s care 37. As team leader, Nurse Liza assumes which of the following duties? A. Assessing patients and planning care B. Directing and assisting team members C. Giving direct patient care D. Coordinating patient activities 38. Nurse Liza’s team is using a team nursing model. Weighing things, this model has advantages and also disadvantages. Of the following choices, which one is the ADVANTAGE: A. Use of each team member special expertise in caring for patients B. Direct patient care provided by a few nurses C. Team leader direct the team for effective care D. Provide total patient care 39. To make team nursing succeed, nurse Liza as coordinator of the team MUST possess which of the following? 1. Good communication skills 2. Delegation ability 3. Strong clinical skills 4. Create a cooperative working environment A. 2,3,and 4 B. 1 and 3 C. all except 4 D. all 40. Nurse Liza brings together the members to work as a group. She has successfully accomplished teamwork by means of: A. Expertise of each member B. Well define goals and objectives of the team C. Clinical skills of team members D. Adequate planning and control Situation: Romina, age 19, was admitted with acute pyelonephritis and has elevated temperature. The nurse on duty reported that she refused acetaminophen and has had only sips of fluid to supplement her IV therapy. The patient appears sad and has remained in bed with the covers over her head most of the day. Her history includes a psychiatric hospitalization two years ago for major depressive disorder. She was started on antidepressant medication. 41. Depressed mood or loss of interest in pleasure and activities in depressive disorder is with duration of at least: A. A month B. Two weeks C. 2-3 days D. one week 42. Romina has been withdrawn and appears sad. Which of the following approaches validate your initial impression? A. “I noticed that you've been withdrawn. Describe your mood for me” B. “what happened that brought your sadness?” C. “in a scale of 1 - 10, 10 being the highest, what level is your feeling sad?” D. “how long have you been feeling sad?” 43. Romina describes feeling like her body is “numb” and feels “helpless to do anything to feel better”. The nursing diagnosis is: A. Anxiety B. Risk for injury C. Acute confusion D. Powerlessness 44. Structuring a therapeutic environment places urgency in providing: A. Cheerful environment to counteract depression B. Access to security personnel C. Adequate fluids and nutrition D. Precautions regarding self-harm 45. Romina is being treated with SSRI; /selective serotonin reuptake inhibitor. The nurse watches for serotonin syndrome characterized by: A. Tremors, seizures, nausea, vomiting, and confusion B. Robot like inflexible movements C. Bizarre behavior like hallucinations and delusions
4 | Page D. Agranulocytosis, jaundice, signs of infection Situation: It is important for a psychiatric nurse to be knowledgeable about the different psychiatric medications administered to patients. The following questions will test you about psychopharmacology: 46. Patient Santino is being treated for his bipolar disorder. He is prescribed with Eskalith. As a nurse, which of the following should you exclude from your health teachings? A. Medication can be administered with food. B. He is allowed to drink coffee every morning. C. Notify the physician if fever occurs. D. He can take the missed dose within 2 hours of the scheduled time. 47. While reviewing about Eskalith, you know that severe lithium toxicity is manifested by: A. Anuria B. Severe diarrhea C. Apathy D. Muscle twitching 48. Patient Cleo’s chart states that dystonia is noted on her while taking antipsychotic medications. Which manifestations do you expect to see? A. Dysphagia, facial grimacing B. Oculogyric crisis, increased heart rate, drooling C. Twisting of the torso D. Drowsiness, restlessness 49. Fluoxetine is prescribed to Patient Mark Lee. How should it be administered? A. On full stomach B. On an empty stomach C. At the same time each morning D. At the same time each evening 50. A mother of a child with ADHD asked you the most effective medication in controlling the disorder. Your answer would be: A. CNS stimulants B. CNS depressants C. Donepezil D. Rivastigmine Situation: A client is brought to the Emergency Department complaining of generalized weakness of all extremities and facial muscles and drooping of the eyelids since a week ago His condition fluctuates from day to day. The examining physician tested the client with an acetylcholinesterase inhibitor test to diagnose myasthenia gravis. 51. Nurse Liza is assigned to care for the client. Which of the following medications prescribed by the physician should nurse Liza prepare to diagnose myasthenia gravis? A. Atropjne sulfate B. Tensilon C. Mestinon D. lsuprel 52. Thirty minutes after injection, nurse Liza noted an immediate Improvement in the muscle strength. This can be interpreted as a: A. Autoimmune disorder B. Positive test confirming the diagnosis C. Negative failure D. Negative for myasthenia gravis 53. The client asked if he will take Tensilon for MG treatment. Nurse Liza answered “NO” because: A. It is toxic to the body B. It is only short-acting C. It causes adverse effects D. It crosses the blood-brain barrier 54. Nurse Liza noticed the client suddenly developed cramps and sweating. In a situation like this, which of the following drugs must be made available to control the side effects of he tested drug? A. Prednisone B. Mestinon C. Atropine sulfate D. Potassium supplement 55. Nurse Liza is administering pyridostigmine (Mestinon) orally to the client. Which of the following nursing intervention indicates safety measure before administering the medication? A. Instructing the client to be in bed when taking the medication B. Determining client’s ability to swallow C. Positioning the client to lie down on his left side D. Requiring the client to lei still in bed Situation: Abbey is a 40-year-old wife who was brought by neighbors to the emergency room confused and crying with body bruises and swollen eyes. She claimed that she was physically abused by her husband who was intoxicated with alcohol. She is admitted for brief hospitalization for further observation and crisis intervention. 56. The admitting nurse is aware that the following should be carefully documented EXCEPT: A. Quote of Abbey’s account of the incident that led to the injuries B. Specific and factual assessment of physical injuries incurred by Abbey C. Photographs of Abbey’s physical injuries D. Neighbors claim regarding estranged relationship of Abbey and husband 57. The nurse did a process recording of an interaction with Abbey. The following descriptions about process recording are true EXCEPT: A. Recording of the verbatim account of the entire interaction, including verbal and non-verbal B. Tool to improve interpersonal communication techniques C. A form of documentation for professional development D. Helps the nurse in analyzing content of interaction 58. Which of the following information about Abbey is LEAST ESSENTIAL FOR CRISIS ITNERVENTION? A. Abbey perception of the event B. Longitudinal life history C. How Abbey is coping with the present situation D. Availability of friends or family for support 59. Abbey asked the nurse if she may have a photocopy of her records. The nurse is aware that client records belong to the: A. Health facility B. Health team members C. Family of the client D. Client 60. Potential benefits of the use of computers in documentation have been recognized, however clients are MOST concerned about: A. Validity B. Accuracy C. Reliability D. Confidentiality Situation: A 67 year old female client is diagnosed with Senile Nuclear Cataract OU (both eyes) H25.1; Dry Eye Syndrome. 61. The nurse is conducting nursing assessment and preparing a nursing history. Which of the following clinical manifestations of the client gathered by the nurse is characteristic of cataracts? A. Narrow anterior chamber B. Optic nerve damage C. Painless blurry vision D. Age factor 62. Based from the information gathered the nursing diagnosis is: A. Self-care deficit related to impaired vision B. Disturbed sensory perception related to visual impairment C. Acute pain related to eye dysfunction D. Anxiety related to possible vision loss 63. The physician scheduled the client for Phacoemulsification with intraocular lens implantation surgery. The physician informed the client of the nature of the procedure and what to