Title RECALLS 12 - NP5 - SC ✅

2 | Page 11. Nurse Rico is aware that the major advantage of observation over interview is that _____________. A. Observation may be recorded and scrutinized later B. Observations enable the recording of actual behaviors, rather than subjects' interpretations C. Observation is scientific, unlike interviews which necessary involve personal interactions D. Observations are unbiased and do not elicit reactions in human subjects. 12. Participant observation may be defined as: A. The observation of participants in the study B. The observation of the researcher’s input to a study C. Participation in a group while studying it D. The study of observational and clinical techniques 13. One of the major problems associated with the use of participant observation as a research strategy is that: A. It is more expensive than experimental approaches to implement. B. It does not allow "in-depth" study of any phenomena C. The results cannot be replicated D. May cause unrest among samples Situation: Two weeks ago, Alice began to exhibit manic behavior. She appears to be jumping from one topic to another and is very talkative. Excited as she was, she has not eaten or slept for 3 days. Nurse Queenie was assigned in the psychiatric ward when an incident occurred involving Alice and another patient.  14. While inside the psychiatric ward, Alice threatens to hit another patient. The most appropriate response from Nurse Queenie would be? A. "Stop that. No one did anything to provoke an attack by you." B. "If you do that one more time, you will be secluded immediately." C. "Do not hit anyone. If you are unable to control yourself, we will help you." D. "You know we will not let you hit anyone. Why do you continue this behavior?" 15. Nurse Queenie plans to establish a nursing diagnosis which applies to Alice. With the nursing diagnosis of imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days, the most appropriate outcome for the patient will be to: A. Ask staff for assistance with feeding within 4 days B. Drink six servings of a high-calorie, high-protein drink each day C. Consistently sit with others for at least 30 minutes at mealtime within 1 week D. Consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit 16. Alice develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). Nurse Queenie understands that the addition of Olanzapine to the medication regimen will: A. Minimize the side effects of lithium B. Bring hyperactivity under rapid control C. Enhance the antimanic actions of lithium D. Provide long-term control of hyperactivity 17. During a manic episode, Nurse Queenie will initiate what initial nursing intervention as a priority? A. Allow the patient to act out his or her feelings. B. Set limits on the patient’s behavior as necessary. C. Provide verbal instructions to the patient to remain calm. D. Restrain the patient to reduce hyperactivity and aggression. 18. Desmond, diagnosed with bipolar disorder, has been hospitalized for 7 days. He has taken lithium 6 times daily. Throughout confinement, Nurse Sky observed increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the Nurse Sky’s best intervention? A. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. B. Continue to monitor and document the patient's speech patterns and motor activity. C. Ask the health care provider to prescribe an increased dose and frequency of lithium. D. Consider the need to check the lithium level. The patient may not be swallowing medications. Situation: Mila is set undergo cataract removal of the left eye. Nurse Kiara is assigned to assist her in the process. The following question applies.  19. Which drug should Nurse Kiara anticipate from the surgeon to administer given the situation? A. Atropine Sulfate (Tropin) B. Glycopyrrolate (Robinul) C. Acetazolamide (Diamox) D. Pralidoxime (Protopam) 20. Nurse Kiara should instruct Mila on activities that can impact her intraocular pressure. After an eye surgery all of the following activities greatly increases the client's intraocular pressure, EXCEPT? A. Sneezing, coughing and blowing the nose B. Straining to have a bowel movement C. Wearing tight shirt collars D. Sexual intercourse 21. On one hand, Nurse Kiara also knows that increased intracranial pressure (ICP) is manifested by which earliest sign? A. Abnormal respiratory pattern B. Rising systolic and widening pulse pressure C. Contralateral hemiparesis and ipsilateral dilation of the pupils D. Progression from restlessness to confusion and disorientation to lethargy Situation: Nurse Coraline is tasked to manage the case of Mr. Tirso, a 62-year-old patient, who was brought to the hospital due to right sided weakness and slurring of speech. 22. Nurse Coraline takes the pharmacologic regimen into consideration for the Mr. Tirso. Which statement is incorrect in the management of a client with cerebrovascular accident (CVA)? A. Osmotic diuretics and corticosteroids are given to decrease cerebral edema B. Anticonvulsants are given to prevent seizures C. Thrombolytics are most useful within three hours of an occlusive CVA D. Aspirin is used in the acute management of a complete ischemic stroke. Situation: Kendrick, a 20-year-old fine arts student thinks that his roommate is trying to poison him. He was admitted in the psychiatric ward because this has affected his performance in school and his classmates were afraid that he might hurt them. Nurse Maya is assigned during his stay. The following questions apply. 23. Kendrick refused all hospital meals for 3 days already. Nurse Maya is planning on ways in order to feed him. Which intervention is most likely to be acceptable to the patient? A. Allow Evan to have supervised access to food vending machines B. Allow Evan to telephone a local restaurant to deliver meals C. Offer to taste each portion on the tray for Evan D. Begin tube feedings or total parenteral nutrition for Evan 24. Kendrick blurted out "The voices are bothering me. They yell and tell me I'm bad. I have got to get away from them." The most appropriate response from Nurse Maya would be _____________. A. "Do you hear the voices often?" B. "Do you have a plan for getting, away from the voices?" C. "I will stay with you. Focus on what we are talking about, not the voices."
3 | Page D. "Forget the voices. Ask some other patients to sit and talk with you. 25. Kendrick has taken fluphenazine (Prolixin) 5 mg orally twice daily for 3 weeks. Suddenly, Nurse Maya observes a shuffling, propulsive gait, mask-like face, and drooling. This is collectively termed as _____________.  A. Neuroleptic malignant syndrome B. Hepatocellular effects C. Pseudo-Parkinsonism D. Akathisia 26. Kendrick began showing violent tendencies. He received several doses of haloperidol (Haldol). Two hours later the nurse notices the patient's head rotated to one side in a stiffly fixed position while the lower jaw is thrust forward, and the patient is drooling. Which intervention by the nurse is indicated? A. Administer diphenhydramine (Benadryl) 50 mg IM from the PRN medication administration record. B. Reassure the patient that the symptoms will subside. Practice relaxation exercises with the patient. C. Give trihexyphenidyl (Artane) 5 mg orally at the next regularly scheduled medication administration time. D. Administer atropine sulfate 2 mg subcutaneously from the PRN medication administration record. 27. Kendrick is receiving an antipsychotic, risperidone (Risperdal). He reports severe muscle stiffness at 10:30 AM. By noon, he is diaphoretic, drooling, and has difficulty swallowing. By 4:00 PM, vital signs are body temperature, 39°C; pulse, 110 beats per minute; respirations, 26 breaths per minute; and blood pressure, 150/90 mm Hg. Nurse Maya can best interpret this as ____________________ and will take action by _____________________. A. Agranulocytosis. Institute reverse isolation. B. Tardive dyskinesia. Withhold the next dose of medication. C. Cholestatic jaundice. Begin a high-protein, low fat diet. D. Neuroleptic malignant syndrome. Immediately notify the health care provider. Situation: Juliet, 42 years old, began developing weakness of the facial muscles and extremities as well as drooping of eyelids. Diagnostics were done and it confirmed the presence of Myasthenia Gravis.  28. Nurse Paula chooses which nursing diagnosis considered as the highest priority when caring for a client with Myasthenia Gravis? A. Pain related to neuromuscular dysfunction B. High risk for injury related to muscle weakness C. Ineffective coping related to illness D. Ineffective airway clearance related to muscle weakness 29. Pyridostigmine bromide (Mestinon) therapy is started for Juliet. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s intervention is to: A. Administer the medication exactly on time. B. Administer the medication with food. C. Evaluate the clients muscle strength an hour after medication. D. Evaluate the clients emotional side effect between doses. Situation: Leo and Sean are best friends. Their friendship dates back to elementary school days. While Sean was bullied, Leo is always ready to defend him. Even in periodic tests, Leo will make a cheat sheet for both of them to help Sean get a passing rate. When the parents of Sean separated, Leo was there to support him. But things changed when Leo had a romantic affair with Ysavelle. Sean felt his best friend left him. He felt alone but not for long, for he found what he considered to be his new best friend - a friend that will never leave him, a friend through thick and thin, who will stick with him for better or worse.  30. After all this, Sean engaged in habits such as consuming “shabu”. He also drank alcohol. Nurse Jess receives him at 02AM in the morning. She would expect alcohol withdrawal symptoms to begin at what time? A. Between 0800 and 1000 today (6 to 8 hours after drinking stopped) B. Between 0200 tomorrow and hospital day 2 (24 to 48 hours after drinking stopped) C. About 0200 on hospital day 3 (72 hours after drinking stopped) D. About 0200 on hospital day 4 (96 hours after drinking stopped) 31. When working with Sean who is beginning treatment for alcohol abuse, the most therapeutic approach by Nurse Jess would be? A. Empathetic, supportive B. Strong, confrontational C. Skeptical, guarded D. Cool; distant 32. Nurse Jess will prioritize which nursing intervention when giving care to Sean who is withdrawing from a central nervous system (CNS) stimulant such as amphetamine (shabu)? A. Make physical contact by frequently touching Sean B. Offer intellectual activities requiring concentration C. Avoid manipulation by denying the Sean’s requests D. Observe for depression and suicidal ideation 33. Leo has impregnated Ysavelle. During her pregnancy, she drinks 8 to 12 ounces of alcohol daily. Nurse Jess will plan for the delivery of an infant who is likely to be ________________. A. Jaundiced B. Dependent on alcohol C. Healthy but underweight D. Microcephalic and cognitively impaired 34. Leo has been having marital problems. He began to abuse heroin. Which assessment findings will the nurse expect in an individual who has just injected heroin? A. Anxiety, restlessness, paranoid delusions B. Heightened sexuality, insomnia, euphoria C. Muscle aching, dilated pupils, tachycardia D. Drowsiness, constricted pupils, slurred speech Situation: Clara, a 30-year-old female social worker has had a variety of vague complaints for the past 6 months. The physician suspects multiple sclerosis and plans to complete neurologic assessment. Nurse Willy assists the physician throughout the process. 35. When testing the trigeminal nerve, Nurse Willy should expect the physician to evaluate which assessment finding? A. Ocular muscle movement B. Shrugging of the shoulders C. Smiling and frowning D. Corneal sensation 36. Clara is suspected of having multiple sclerosis. Nurse Willy anticipates her to complain about the common initial symptom associated with multiple sclerosis. Which of the following is considered as the earliest sign of MS? A. Diarrhea B. Headaches C. Skin infection D. Visual disturbances 37. Nora has been admitted with relapsing-remitting multiple sclerosis (MS). Which of the following should be the focus of the nursing assessment and history? A. Level of consciousness B. Evoked potentials of the optic pathways C. Bladder function D. Rate of ascending paralysis 38. Which intervention or rationale should Nurse Willy suggest to help the client with MS to avoid episodes of urinary incontinence? A. Limit fluid intake to 1,000 mL/day B. Administer prophylactic antibiotics as ordered C. Provides the precursor of dopamine D. Inhibit the activity of acetylcholine Situation: Rose, 54-years old, has had menopause 8 years ago. Lately, she has been prone to injuries and fractures which led her to consult the doctor.