Title RECALLS 2 - NP5 - SC ✅

a. cut the dressing using sterile scissors b. cleans the incision with iodine-based antiseptic c. secure clean ties before removing soiled ones d. used clean technique 47. which of the following nursing actions should the nurse TEACH the patient’s care giver regarding tracheostomy care? a. Remove the tracheostomy tube if obstruction occurs b. Leave the tracheostomy ties in place until the physician change them c. Remove and clean the inner cannula daily d. Never put a covering over the tracheostomy stoma 48. After a tracheostomy procedure, the nurse documents important observations made during the procedures such as _______. a. response of the patient after the procedure b. vital signs of the patient during the procedure c. amount, color, and consistency of sputum and appearance of the incision d. behavior of the patient during the procedure 49. What is the purpose of a tracheostomy? To _____. a. establish an airway b. establish a pathway for nutrition c. monitor respiratory functions d. maintain the patency of the airway 50. which of the following can be a MAJOR PROBLEM for a patient with tracheostomy? a. Breathing b. Ambulating c. Swallowing d. Singing situation 11- You are staff nurse in the Psychiatric Unit of a private hospital. Lorena, a 20-year old stage actress was admitted with the chief complaints of getting angry easily and inability to tolerate being alone. She claimed that she has also the tendency to manipulate people and feels unhappy most of the time. She was diagnosed to be suffering from Borderline Personality Disorder (BPD). 51. You have observed that Lorena is manifesting “spitting”. This characteristic of BPD is BEST defined as ______. a. viewing people and objects as parts, either good or bad b. having two personalities c. talking about other people behind their back d. literally spitting in other people’s face 52. When assessing a patient with BPD which of the following information would you focus on? a. Ability to get people on his/her side b. Disruption in some aspect of his/her life c. desire for intimate relationship d. Increase acceptance from other people 53. Lorena revealed she has a tendency to manipulate others. What would be the MOST APPROPRIATE short-term goal for her? For Lorena to _____. a. have an intimate relationship b. acknowledge her own behavior c, stop arguing with other people d. express her feelings verbally 54. Patient with BPD manifest transient psychotic symptoms. What is the drug of choice to treat these symptoms? a. Mood stabilizer b. Benzodiazepines c. Lithium d. Antipsychotics 55. Lorena has a history of alcohol abuse so she was started on Antabuse. Which of the following is a COMMON side effect of this drug? a. Hypertension b. Bradycardia c. Depression d. Elation Situation 12- Angela, a 40-year old, single mom of two preschool children, aged two (2) and five (5) years old respectively was admitted to the Psychiatric Unit for attempting to kill her two children. 56. Angela says “My dead mother ordered me to kill my two children before the devil could get them”. What behavior is being manifested by Angela? a. Auditory hallucination b. Visual hallucination c. Tactile stimulation d. Olfactory hallucination 57. You ask Angela to touch a 25-centavo coin and a one-peso coin. You have observed that Angels was having difficulty differentiating one coin from the other. This is manifestation of _____. a. astereognosis b. kinesthetic c. agraphestesia d. cenesthetic 58. You have observed that Angela is manifesting persistent hallucination. What is the MOST EFFECTIVE therapy in treating patient with a condition like that of Angela’s? a. Cognitive-behavior therapy b. Crisis intervention c. Psycho-pharmacologic treatment d. Anti-psychotic drug 59. Which of the following is the GOAL of nursing intervention for a patient who is hallucination. a. To help the patient to have an increased awareness that in symptoms she is experiencing is not real b. To help the patient to identify what triggers her hallucination c. To encourage the patient to verbalized her fear, anxiety, and anger d. To help the patient to go back to her real world 60. What communication technique would be Most effective to achieve the nursing goal for patient with hallucination? a. Listening b. Facilitative communication c. One-on-one discussion d. Social interaction Situation 13- Charting is part of the professional nurse’s responsibility related to record management. The following questions refer to this statement. 61. One of the characteristics of charting is brevity. Which of the following example of charting shows this characteristics? a. Nurse brought the patient to OR via stretcher at 10:15 b. Patient left for surgery via stretcher at 10:15 am c. To surgery via stretcher at 10:15 d. patient brought by the nurse to OR via stretcher at 10:15 accompanied by the “bantay” 62.Which of the following is NOT a requirement for a late entry in charting? a. nurse’s initials above the time b. may be made if something has been forgotten c. circle it and write “late entry” d. reason for the late entry 63. There is a black space after your last entry in your charting. You will ______. a. draw a double line after your last entry b. sign your full name after your last entry c. draw a horizontal line through the center of an empty line d. draw a perpendicular line across the empty space 64. Which of the following should the nurse’s notes focus on? a. Immediate past and the present b. The present only c. The future d. The recent past 65. Which of the following sample charting would show the characteristic of ACCURACY? a. intake from 700-1000 ml: 80 ml of coffee; 240 ml of orange juice; 500ml of water b. Patient on forced fluid but refused to take it most of the time c. Patient on forced fluids observed d. Given fluid at frequent intervals but takes only a few sips Situation 14- During summer season incidence of heat stroke rises. As a community health nurse you should disseminate information on this as part of your role as a health educator. 4 | Page