Title RECALLS 1 (NP5) - STUDENT COPY ✅

RECALLS EXAMINATION 1 NURSING PRACTICE V CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART C) MAY 2025 Philippine Nurse Licensure Examination Review GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 5. Write the subject title “NURSING PRACTICE V” on the box provided Situation: Belle is a 30-year-old single mother who is dependent on her family for support. Her diagnosis is mild mental retardation withpost-traumatic disorder with depressive episodes related to her mother's death. Her current symptoms include depressed mood with irritability, difficulty tolerating frustration, difficulty falling asleep, increased appetite and weight gain, hypervigilance, and worry that something terrible will happen to her child. 1. A cognitive assessment of Belle indicated that according to Piaget's theory she was functioning at the concrete operational stage. Which of these behaviors would the nurse observe in Belle? A. Thinks logically and sees possibilities. B. Understands only her own viewpoint. C. Feels her own reasoning should agree with the reasoning of others. D. Makes and tests hypothesis. 2. Belle has difficulty tolerating frustration. The GOAL of the nurse is to assist Belle to ________. A. increase her self-esteem A. cope with anxiety B. recognize her needs C. mobilize her resources 3. Which of the following historical data MOST probably led to apost-traumatic stress disorder? A. Unstable relationship with ex-fiancé. B. Suicide of her mother. C. No gang-relationship with peers 4. Given her problems of hyper vigilance and worry that something terrible will happen to her child, nursing interventions should be aimed at addressing her needs for _________. A. love and belongingness B. biological integrity C. psychological security D. self-esteem 5. In terms of social support therapy, which of these is the MOST APPROPRIATE and therapeutic? A. with appropriate support, lives in the community, eitherIndependently or in a supervised setting. B. Individualized relationship with a caregiver. C. High structured environment with constant aid and supervision. D. Vocational training with moderate supervision but not beyond second grade academic challenges. Situation: Patrick, Charge nurse, is aware that the uses of resources are essential for patient care. 6. A safe patient environment includes following factors EXCEPT _______. A. socio-economic needs B. basic needs are met C. sanitation is maintained D. physical hazards are reduced 7. As an individual, which of the following is an INTERNAL variable affecting health status, belief, or practices? A. Genetics B. Socioeconomic status C. Family structure D. Living situation 8. Falls are one of the leading environmental hazards reported in her facilities. One of the MOST common occurrences that precipitate a patient fall is _______. A. experiencing stress, anxiety, and fatigue B. leaving the side rails down C. reaching item at the bedside D. performing activities of daily living 9. If a patient falls, the nurse FIRST responsibility is to _______. A. assess the patient's injury B. write an incident report C. report the incident to the head nurse. D. notify the physician at once 10. In healthcare facility, a planned program of loss prevention and liability control refers to _______. A. quality assurance B. critical pathways C. risk management D. peer review Situation: Quality and safety are rooted in the daily work of a health care professional. Nurses in the Orthopedic Unit attend monthly quality assurance meetings. The following questions were discussed. 11. Who should be involved in quality improvement measures? A. Everyone B. Management staff C. Professional staff D. Consumers 12. To start a nursing improvement project, what is the FIRST step that nurses most keep in mind? A. Implement plan to correct the problem B. Determine the nursing standards C. Determine findings if warrant correction D. Collect data, determine if standards are set 13. To achieve organized work flow in the unit the staff must be aware of the head nurse's role. What is the PRIMARY purpose of supervision delegation? A. Enhances the delivery of quality nursing care B. Influences organization's approach in personnel evaluations C. Improves staff attendance in seminars D. Assigns any staff to do the tasks or project. 14. To ensure quality nursing care to a patient in skin traction, what is the PRIORITY Intervention that a nurse has to assess frequently? A. Signs of infection around the pin site. B. Signs of skin breakdown C. Urinary incontinence D. Presence of bowel sounds 15. The nursing team plans to do chart audit project on post-op patients who had developed pressure sores at the 1 | Page
Orthopedic unit over the past year to present. What type of audit is it? A. Retrospective B. Process C. Concurrent D. Outcome. Situation: Mark, a 25 year old student suddenly had convulsive movements with loss of consciousness during their lecture. After the episode he was rushed to the nearest hospital. 16. A nurse is conducting physical assessment, which of the following is INAPPROPRIATE action in this stage? A. Insert intravenous cannula B. Assess patient's lifestyle C. Assess patient source of stress D. Identify the patient's daily activity 17. Mark is scheduled for an EEG after having a seizure for the first time. What is the BEST patient preparation instruction before the procedure? A. "Avoid thinking and personal matters for 12 hours before thetest." B. "Do not shampoo your hair for 24 hours before the test. " C. "Do not eat anything for 12 hours before the test.” D. "Avoid stimulants and alcohol for 24 to 48 hours before the test." 18. Which of the following manifestations should the nurse APPROPRIATELY observe during generalized seizures? A. Loss of consciousness, dilated pupils, and muscular stiffening B. Jerking movements of all extremities. C. Facial grimace with patting and smacking. D. Vacant stare with a brief loss of consciousness 19. What is the FIRST Priority which the nurse must observe in caring for a patient with seizure? A. Safety B. Airway C. Nutrition D. Mobility 20. Phenytoin (Dilantin) has been prescribed for a patient. Based on an understanding of the medicine, what is the APPROPRIATE nursing instruction of the nurse? A. Give Dilantin intramuscularly B. Administer good oral hygiene C. Dilute IV Dilantin with 5% dextrose D. Maintain a Dilantin level of 30-50 ug/ml Situation: Ms. Diaz, a new Charge Nurse of EENT unit is keen on staff and professional growth of the nursing team. 21. Ms. Diaz learns that some leaders are transactional leaders. Which of the following does NOT characterize a transactional leader? A. Focuses on management tasks B. Inspires others with vision C. In a caretaker D. Uses bargaining to meet goals 22. Ms. Diaz finds out that some managers have benevolent-authoritative style of management. Which of the following behaviors will she exhibitMOST likely? A. Have condescending trust and confidence in their subordinates B. Gives economic or ego awards. C. Communicates downward to the staff. D. Allows decision making among subordinates 23. Ms. Diaz knows that there are external forces that influence changes in his unit. Which of the following is NOT an external force? A. Demands of the labor sector to increase wages B. Exacting regulatory and accreditation standard C. Low morale of staff in his unit D. Memo from the CEO to cut down on electrical consumption 24. After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to? A. Majority rule B. Dominance C. Collaboration D. Compromise 25. The nurse asks the aide to weigh a patient. Later, the nurse discovered that a patient had been weighed who was supposed to be on rest. This situation violates which of the following rights of delegation? A. Right person B. Right direction and communication C. Right supervision and evaluation. D. Right task Situation: The following scenarios are potential routines that could checkwork ethics of a professional nurse. 26. A patient asks to be discharged from the health care facility against medical advice(AMA). What should the nurse do? A. Notify the physician. B. Prevent the patient from leaving. C. Have the patient sign an AMA form. D. Call a security guard to help detain the patient. 27. A nursing assistant in assigned to provide morning care to a patient. How should the nurse document care given by the nursing attendant? A. "Morning care rendered". B. "Morning care rendered by Grace Go, NA" C. "Morning care provided by G.G., nursing assistant". D. "Morning care refused to be given by nursing assistant. 28. A nurse administers the wrong intravenous fluid to a patient. She shouldaccomplish which of the following documents to be submitted to herimmediate supervisor? A. Patient Kardex B. Incident report C. Progress report D. Endorsement record 29. When developing a care plan for a patient with a do-not-resuscitateorder, the nurse should NOT Include which intervention on the care plan? A. Allow access to individuals who can provide spiritual care. B. Administer pain medications as ordered by physician. C. Provide usual routine nursing care as ordered by physician. D. Administer lethal doses of medication as patient request. 30. A patient is to undergo a laminectomy in the morning. The physician asksthe nurse to witness the patient's signing of the consent form. What isthe BEST action the nurse? A. Provide emotional support for the patient while the patient signs the consent. B. Make sure the physician explains the risks of undergoing the procedure. C. Make sure the physician thoroughly describes the procedure. D. Make sure the patient is competent, awake and alert before he/she signs the consent form. Situation: Gloria is a nurse researcher in the Department of Health. She is assigned to conduct research on patient's safety practices of nurses in the psychiatric unit. She is given 6 months to conduct the study. 31. After formulating and delimiting the research problem, which following will be a PRIORITY action of Gloria? A. Develop the theoretical framework of the study B. Formulate the hypothesis C. Plan the research design of the study D. Conduct a literature search on the topic 32. Gloria decides to include only nurses who have a minimum three year’s experience as psychiatric nurses. Which of the following terms refer to this? A. Concept B. Variable C. Limitation D. Delimitation 33. The statement “The length of service is not associated with the degree of patient safety practices of staff nurses" is an example of a/an ________. A. Variable B. Assumption C. Hypothesis 2 | Page
D. Theory 34. Which of the following research designs is MOST APPROPRIATE for this study if the aim is to find a relationship between two variables in thestudy? A. Phenomenological study B. Experimental C. Exploratory D. Correlational 35. She plans to interview the Psyche Nurse Manager about the patient safety practices of the nurses. What type of sampling includes those who happen to be in the conference room where the activity is scheduled? A. Random B. Purposive C. Convenience D. Quota Situation: Sandro 8 years old, 1st grader child has always been the subject of her mother's prompting and care. He always test his mom's rule in preparing for school. Although this has been for five months now , Sandro still has to be reminded in getting dress completely and dilly dally eating his breakfast. He still plays with his toys and interferes with her sister in playing blocks. The mother is so anxious in reminding Sandro that his school bus will be arriving in 10 minutes every day. 36. Attention deficit hyperactivity disorder (ADHD) is characterized by NOTof the following? A. Mental retardation B. Overactivity C. Inattentiveness D. Impulsiveness 37. Which of the following would the nurse expect to see as symptoms in with ADHD,except: A. Moody, sullen and pouting behavior B. Interrupts others and can’t take turns C. Excessive running, climbing and fidgeting D. Easily distracted and forgetful 38. Sandro is taking pemoline(Cylert) for ADHD. The nurse must be aware which of the following side effects? A. Decreased thyroid stimulating hormones B. Decreased red blood cell count C. Elevated white blood cell count D. Elevated liver function test results 39. An effective nursing intervention for the impulsive and aggressive behaviors that accompany conduct disorder is _______. A. open expression of feelings B. assertiveness training C. negotiation of rules D. consistent limit setting 40. Nursing diagnosis commonly used when working with Sandro is __________. A. ineffective role performance B. impaired social interaction C. compromised family coping D. risk for injury Situation: Peter, a 19-year-old college student, has been in excellent health until developing a flu-like illness a couple of weeks ago. He was admitted with a diagnosis of Guillain-Barr syndrome ago. 41. Which of the following clinical manifestations would the nurse expect to find when performing admission assessment? A. Rapid progressive muscular atrophy. B. Ascending paralysis with ataxia. C. Hyperactive deep tendon reflexes D. Paresthesia and muscle weakness of the upper body. 42. What is the MOSTAPPROPRIATEnursingdiagnosis for this patient? A. Self-care deficit related to neuromuscular impairment. B. Alteration in nutritional status related to possible choking C. Alteration in nutritional status related to anorexia. D. Alteration in urinary elimination related to sensory motor impairment. 43. What is the priority of a care patient diagnosed with Guillain- Barre syndrome? A. Maintenance of respiratory function B. Control of urinary tract infection C. Prevent of decubitus D. Replacement of fluid and electrolytes 44. In planning the nursing care for this patient, what is the most important nursing intervention a nurse must do? A. Encourage patient to release anxiety by crying B. Reassure family that complete recovery is probable. C. Assess patients for respiratory distress. D. Have patient assist with care 45. What symptom is an indicator of cranial nerve involvement? A. Difficulty of speaking and chewing B. Spastic paralysis of the extremities C. Loss of pain sensation D. Forgetfulness and syncope Situation: Incidence of drug abuse has greatly increased over time. Korino has been using drugs for the past three years. 46. You are a Drug Abuse Treatment and Rehabilitation Center Nurse. During the assessment of a newly admitted Person Who Uses Drugs(RWUDS) named Korino, which of the following is the MOST APPROPRIATE question to ask? A. Ask Korino how long he thought that he could take drugs without someone finding it. B. Ask Korino why he started taking illegal drugs. C. Do not ask any questions for fear Korino will deny and may become assaultive. D. Ask Korino about the amount of drug used and its effect and how long he had been using. 47. Upon data collection he had been falling three times in his math class and Korino was known for substance dependent for three years. What is the MOST APPROPRIATE nursing diagnosis for him? A. Alteration in perception. B. Alteration in social interaction. C. Ineffective individual coping. D. Impaired judgement. 48. Korino has been using meperidine and codeine for personal consumption.Which of the following does the nurse understand as the effect of these drugs? A. Increases sexual stimulation. B. Relieves pain by increasing pain threshold. C. Decrease craving for alcoholic intake. D. Heightens concentration and alertness 49. Which assessment by the nurse would cause a concern for Meperidine overdose? A. Respiration rate of 12 bpm. B. Hypercapnia C. Dryness of the skin. D. Pinpoint pupils. 50. What drug should the nurse prepare for administration to reverse all signs of toxicity? A. Digibind (Digoxin) B. Naloxone (Narcan) C. Atropine sulfate D. Diazpam (Valium) Situation: Charge Nurse Tessie works at the surgical ward. She ensures g record management is implemented in her unit at all times. 51. A patient is having elective surgery under general anesthesia. Who is responsible for obtaining informed consent? A. Surgeon B. Nurse C. Nurse anesthetist D. Anesthesiologist 52. Which statement by the patient indicates that he understands the explanation of the surgeon? A. "I refuse to sign the consent form; another family member can sign for me." B. “Now I know what alternative treatments and procedures are.” C. "If I refuse to sign the consent form, other treatment will be withdrawn.” D. "I can't refuse the procedure after the consent is signed." 53. The wait secretary who transcribes the physicians order asks them to interpret an order because she cannot read the writing. The nurseBEST action is to _______. A. Clarify the order with the pharmacies 3 | Page
B. clarify the order by calling the physician C. interpret the order according to the patient’s previous medication record D. clarify the order with junior staff 54. The physician orders to transfuse 500ml packed RBC blood postoperatively. The nurse must check the name on the label of the blood with the name on the patient’s _____. A. Medication administration record B. Wristband in the presence of another nurse C. Medical Chart D. Wristband 55. The patient's wife is so anxious about the condition of her husband. The MOST appropriate INITIAL intervention for the nurse to make is to _____. A. Describe her husband's medical treatment since admission B. reassure her that the important fact is her presence C. explain the nature of the injury and reassure her that husband's condition is stable D. allow her to verbalize her feelings and concern Situation: Effective communication is a core skill for nurses that a professional nurse must apply in their daily routine for patient care, colleagues and family. 56. The nurse asks the patient, "What do you fear MOST about your surgery tomorrow? This is an example of which communication technique? A. Providing general leads B. Summarizing C. Seeking clarification D. Presenting reality 57. The patient made the following statement to the nurse, “My doctor just told me that he cannot save my leg and that I need to have an above-the-knee-amputation." Which response by the nurse is MOST APPROPRIATE? A. "Tell me more." B. “Dr. Benito is an excellent surgeon." C. "If I were you, I will get a second opinion. " D. "Are you in pain?" 58. A nurse is communicating with the attending physician about medical intervention prescribed for a patient-post spine surgery. Which statement is INDICATIVE of a collaborative relationship? A. "Can we talk about Mrs. Santos?" B. "I am worried about Mrs. Santos' blood pressure. It is not decreasing even with the new antihypertensive medication." C. "That new medication you prescribed for Mrs. Santos is ineffective." D. "We do not need to talk about Mrs. Santos' blood pressure." 59. An 80-years-old male, admitted for emergency suturing of the foreheads sustained from accident tall while gardening under local sedation. He was just received in the ward. Which nursing intervention is APPROPRIATE to facilitate effective communication with this patient? A. Talk to the patient when fully awake and inform him and family events which may occur post-surgery. B. Provide the patient with instructional materials about discharge. C. Tell the patient, "You are fine, nothing to worry." D. Ask the patient, "Do you know where you are?" 60. The nurse who uses appropriate therapeutic listening skills will which BESTbehavior? A. Presume an understanding of the patient's needs. B. React quickly to the message. C. Reassure the patient that everything will be fine. D. Absorb both the content, and the feeling which patient is conveying. Situation: Annie is a 38-year-old-woman with three children. She has a history of otosclerosis. She is admitted for ear surgery. 61. While taking nursing history on Annie, what will be the response of the patient that indicates her present condition? A. She frequently experiences vertigo, nausea and nystagmus when sitting. B. She has ear pain and discharge from the left ear when travelling. C. She has had impaired hearing since birth. D. Her hearing loss has become worse with each succeeding pregnancy. 62. Annie states. "I'm afraid to let my children out of my sight now that I can't hear them. What is the nurse's BEST response? A. “Tell me about your fears of losing contact with your children now that you can’t hear them.” B. “Children need some freedom, and the mother has to learn to trust them”. C. “Do the children usually misbehave when they cannot be seen or heard by you?” D. “What can the children do the make you feel more comfortable?” 63. What should be APPROPRIATE the nursing care plan for Annie having otosclerosis? A. Substitute meaningful sensory input by the use of other senses. B. Orient Annie to the staff, the unit and all treatments C. Give nursing care that will meet her psychological needs. D. Make frequent calls to prevent isolation and loneliness. 64. The day after surgery, Annie expresses concern that hearing is not good as it was before admission. What is the BEST nurse action? A. Encourage Annie to divert her attention by reading B. Encourage Annie to blow her nose more to clear the eustachian tubes. C. Reassure Annie that it is temporary loss due to post op edema and ear packing D. Check the external ear for blood clots and remove them 65. What post-operative teaching will the patient strictly follow? A. Reinforce that fact that airplane travel is no longer permitted. B. Show patient how to gently irrigate the external auditory canal C. Inform physicians of any dizziness that develops after she is discharged. D. Stress that hair washing should be avoided immediately after surgery. Situation: Effective teamwork and collaboration in nursing is achieved when individuals work together in harmony, processes and goals arealigned towards achieving safe quality patient care. 66. Which of the following actions is INAPPROPRIATE for a nurse leader to apply in a work setting? A. Ask staff members for their opinion on the matter. B. Modifies his own behavior favoring the needs of individual staff. C. Gives equal consideration to each staff members D. Plans and organizes group activities of staff members. 67. In problem solving, the head nurse must know what is the MAJOR characteristic of negotiation? A. Be positive in your approach since optimism gives further favorable results. B. Harmony is possible even when strategies are not well planned. C. It is not important to get anything in writing since the truth will prevail. D. Resources tend to involve too many individuals in the decision-making process. 68. Applying multidisciplinary approach of patient care, which among the members of the multidisciplinary team that the nurse would MOST likely collaborate with when the patient is at risk of fall due to an impaired gait? A. Podiatrist B. Physical therapist C. Speech therapist D. Nutritionist 69. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. Nursing is resistant to change and is not taking an active part in facilitating the process of change. Which is the BEST approach in dealing with the nurse? A. Exert coercion on the nurse 4 | Page