Tiêu đề RECALLS 12 (NP5) - STUDENT COPY ✅

RECALLS EXAMINATION 12 NURSING PRACTICE V CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART C) NOVEMBER 2024 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 1. A client is admitted to the emergency department with drug-induced anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse should obtain initially would be which data? A. Name of the nearest relative and his or her phone number B. Name of the ingested medication and the amount ingested C. Cause of the attempt and if the client plans another attempt D. Length of time on the medication and any noted side effects 2. The nurse provides instructions to the client taking clorazepate (Tranxene) for the management of an anxiety disorder. What information related to this medication should the nurse provide to the client? A. Dizziness is a side effect. B. If drowsiness occurs, call the health care provider. C. Smoking increases the effectiveness of the medication. D. If gastrointestinal disturbances occur, discontinue the medication. 3. A client comes into the emergency department in a severe state of anxiety. What is the priority nursing intervention at this time? A. Remaining with the client. B. Placing the client in a quiet room. C. Teaching the client deep-breathing exercises. D. Encouraging the expression of feelings and concerns. 4. The nurse teaches the client with a history of anxiety and command hallucinations to harm self or others appropriate management techniques. Which client statement indicates that the client understands these techniques? A. “I can go to group and talk about my feelings to hurt myself or others.” B. “If I take my prescribed medication as I’m supposed too, I won’t be as anxious.” C. “I can call my counselor so that I can talk about my feelings and not hurt anyone.” D. “If I get enough sleep and eat well, I won’t be as likely to get anxious and hear things.” 5. Buspirone hydrochloride (BuSpar) is prescribed for a client with an anxiety disorder. The nurse instructing the client should inform the client about which characteristic of this medication? A. The medication is addicting. B. Dizziness and nausea may occur. C. Tolerance can occur with the medication. D. The medication can produce a sedating effect. 6. The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas (ABG) values are pH = 7.53, Pao2 = 72 mm Hg, Paco2 = 32 mm Hg, and HCO3 = 28 mEq/L (28 mmol/L). Which conclusion about the client would the nurse make? A. The client has acidotic blood. B. The client is probably overreacting. C. The client is uid volume overloaded. D. The client is probably hyperventilating. 7. A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action would the nurse take initially? A. Contact the client’s primary health care provider. B. Call the client’s family to arrange for transportation. C. Attempt to persuade the client to stay “for only a few more days.” D. Tell the client that leaving would likely result in an involuntary commitment. 8. Which of the following nursing interventions can help manage anxiety? (Select all that apply) A. Encourage deep breathing exercises B. Promote a quiet environment C. Educate the patient on the benefits of caffeine D. Provide reassurance and emotional support E. Instruct the patient to ignore their feelings of anxiety 9. Which of the following are potential psychological symptoms of anxiety? (Select all that apply) A. Irritability B. Excessive worrying C. Difficulty concentrating D. Fear of impending doom 10.When planning the discharge of a client with chronic anxiety, the nurse develops goals to promote a safe environment at home. Which area should the appropriate maintenance goal for the client focus on? A. Identifying anxiety-producing situations B. Maintaining contact with a crisis counselor C. Techniques for ignoring feelings of anxiety D. Eliminating all anxiety from daily situations 11. The nurse is caring for a female client who was recently admitted to the hospital with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action would be therapeutic? A. Allow the client to complete the exercise program. B. Interrupt the client and weigh the client immediately. C. Interrupt the client and offer to take the client for a walk. D. Tell the client that she is not allowed to exercise rigorously. 12. The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further assessment? A. “I check my weight every day without fail.” B. “I exercise 6 to 8 hours every day to keep my slim figure.” C. “I’ve been told that I am 10% below my ideal body weight.” D. “My best friend was in the hospital with this disorder a year ago.” 1 | Page
13. A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on? A. Providing a supportive environment B. Examining intrapsychic conflicts and past issues C. Emphasizing social interaction with clients who are withdrawn D. Helping the client identify and examine dysfunctional thoughts and beliefs 14. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client’s room. Which client would be the best choice as a roommate for the client with anorexia nervosa? A. A client with pneumonia B. A client undergoing diagnostic tests C. A client who thrives on managing others D. A client who could benet from the client’s assistance at mealtime 15. A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes, but expresses that money is limited. Group members have brought some used clothes to the client to replace the client’s old clothes. The client believes that the new clothes are much too tight and has reduced personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior? A. Normal behavior B. Evidence of the client’s disturbed body image C. Regression as the client is moving toward the community D. Indicative of the client’s ambivalence about hospital discharg 16. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply. A. Dental decay B. Moist, oily skin C. Loss of tooth enamel D. Electrolyte imbalances E. Body weight well below ideal range 17. The nurse admits a client to the hospital with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse asks questions and expects to elicit which data about bulimia? A. Binge eats, then purges B. Is accepting of body size C. Overeats for the enjoyment of eating food D. Overeats in response to losing control of diet 18. The nurse is providing care for a client with Bulimia Nervosa. Which of the following nursing interventions are appropriate? (Select all that apply) A. Monitor electrolyte levels regularly. B. Allow the patient to eat meals alone to avoid anxiety. C. Provide emotional support and encourage expression of feelings related to body image. D. Educate the patient on the effects of binge eating and purging on the body. E. Administer prescribed medications such as antidepressants if ordered. F. Weigh the patient daily and focus on their weight loss progress. 19. A nurse is planning care for a client diagnosed with Bulimia Nervosa. Which interventions should be included in the care plan? (Select all that apply) A. Provide a structured and supportive meal schedule. B. Discourage the client from talking about their feelings related to food and body image. C. Monitor the client closely for signs of purging after meals. D. Educate the client on healthy eating habits. E. Focus on the client's weight during each assessment. 20. A client with Bulimia Nervosa has been admitted to the hospital for electrolyte imbalances. Which of the following laboratory findings would the nurse expect? (Select all that apply) A. Hypokalemia (low potassium). B. Hypernatremia (high sodium). C. Metabolic acidosis. D. Hyponatremia (low sodium). E. Metabolic alkalosis. 21. The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. A. Restating B. Active listening C. Asking the client “Why?” D. Maintaining neutral responses E. Giving advice and approval or disapproval 22. A client says to the nurse, “The federal guards were sent to kill me.” Which is the best response by the nurse to the client’s concern? A. “I don’t believe this is true.” B. “The guards are not out to kill you.” C. “Do you feel afraid that people are trying to hurt you?” D. “What makes you think the guards were sent to hurt you?” 23. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care? A. Ask the client why they started taking illegal drugs. B. Ask the client about the amount of drug use and its effect. C. Ask the client how long they thought that they could take drugs without someone nding out. D. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home. 24. Which initial information gathered by the nurse is most important when assessing Erikson’s stages of development? A. The chronological age of the individual. B. The developmental age exhibited through behaviors. C. The time-frame needed to complete a successful outcome at a previous stage. D. The implementation of interventions based on developmental age. 25. According to Maslow’s hierarchy of needs, which client action would be an example of a highly evolved, mature client? A. A client discusses the need for avoiding harm and maintaining comfort. B. A client states the need for giving and receiving support from others. C. A client begins to discuss feelings of self-fulfillment. D. A client discusses the need to achieve success and recognition in work. 26. According to Maslow’s hierarchy of needs, which situation exhibits the highest level of Attainment? A. An individual demonstrates an ability to discuss objectively all points of view and possesses a strong sense of ethics. B. An individual avoids harm while maintaining comfort, order, and physical safety. C. An individual establishes meaningful interpersonal relationships and can identifymhimself or herself within a group. D. An individual desires prestige from personal accomplishments. 27. Which is an example of appropriate psychosexual development? A. An 18-month-old relieves anxiety by the use of a pacifier. B. A 5-year-old boy focuses on relationships with other boys. C. A 7-year-old girl identifies with her mother. D. A 12-month-old begins learning about independence and control. 28. Which scenario describes an individual in Erikson’s developmental stage of “old age” exhibiting a negative outcome of despair? A. A 60-year-old woman having difficulty taking care of her aged mother. B. A 50-year-old man reviewing the positive and negative aspects of his life. 2 | Page
C. A 65-year-old man openly discusses his life’s accomplishments and failures. D. A 70-year-old woman angry about where her life has ended up. 29. Which is an example of an individual successfully completing Erikson’s “school age” stage of development? A. A 14-year-old girl verbalizes that she resisted peer pressure to drink alcohol at a party. B. A 5-year-old boy is able to ask others in his class to play hide-and-seek with him. C. A 3-year-old preschool boy is able to play by himself while other family members play games. D. An 11-year-old girl is trying out for cheerleading. 30. 15. A 7-year-old boy is active in sports and has received a most-improved player award at his baseball tournament. Which outcome reflects this child’s developmental task assess- ment as described by Erikson? A. Autonomy. B. Identity. C. Industry. D. Initiative. 31. Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. A. Monitor vital signs. B. Provide a safe environment. C. Address hallucinations therapeutically. D. Provide stimulation in the environment. E. Provide reality orientation as appropriate. 32. The nurse determines that the spouse of an alcoholic client is beneting from attending an Al-Anon group if the nurse hears the spouse make which statement? A. “I no longer feel that I deserve the beatings my partner inflicts on me.” B. “My attendance at the meetings has helped me to see that I provoke my partner’s violence.” C. “I enjoy attending the meetings because they get me out of the house and away from my partner.” D. “I can tolerate my partner’s destructive behaviors now that I know they are common among alcoholics.” 33. The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypotension, coarse hand tremors, lethargy D. Hypertension, changes in level of consciousness, hallucinations 34. A female client who is in a manic state emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. Which intervention should the nurse initiate first? A. Quietly approach the client, escort her to her room, and offer help to get dressed. B. Confront the client on the inappropriateness of her behavior and offer her a time out. C. Approach the client in the hallway and insist that she go to her own room immediately. D. Ask the other clients to ignore her behavior; eventually she will return to her own room 35. A patient who is manic has been monopolizing the group time. The nurse has been setting limits on this behavior. If the patient is benefiting from this intervention, the nurse should expect the patient to A. Correct arrive on time for group. B. dress appropriately. C. raise a hand before speaking. D. remain seated throughout the session 36. The nurse should asses a patient who has bipolar disorder, manic episode for which of the following manifestations? A. Waxy flexibility B. Flat affect C. Flight of ideas D. Hypersomnia 37. Which of the following food selections during lunch would be MOST APPROPRIATE for a patient with bipolar disorder, manic episode? A. Cheese sandwich banana and milk shake B. Vegetables soup, applesauce and tea C. Rice and beans, custard and carbonated water D. Beef stew, peas and milk 38. A patient who is taking lithium carbonate (Eskalith) for the treatment of bipolar disorder, manic type comes to the outpatient clinic reporting insomnia, hyperactivity and pressured speech. Which of the following questions should a nurse ask the patient FIRST? A. “Have you been taking your medication?” B. “How much caffeine have you had today?” C. “How much sleep did you have last night?” D. “Is there something that has been upsetting you?” 39. When considering the nutritional needs of a patient who has a diagnosis of bipolar point disorder, manic type, a nurse should plan to: A. offer finger foods. B. serve food in sealed containers. C. engage the patient in food preparation. D. seat the patient with other lively patient in the dining room. 40. Which of the following patient outcomes would indicate that the manic phase of a point bipolar disorder is subsiding? A. The patient participates in group activity without disruption. B. The patient has an increased ability to verbalize. C. The patient assumes leadership in social activities. D. The patient initiates multiple projects in art therapy. Abuse can affect your sense of self and leave emotional scars that may take a long time to recover. As a nurse, it is your role to deal with different clients according to their physical, emotional and social needs. 41. Nurse Patricia is caring for an 11-year-old child who has been abused. Which therapeutic action should the nurse include in the plan of care? A. Encourage the child to fear the abuser. B. Provide a care environment that allows for the development of trust. C. Teach the child to make wise choices when confronted with an abusive situation. D. Have the child point out the abuser if he or she should visit while the child is hospitalised 42. Which psychosocial factor obtained during an assessment of an old places the client at risk for abuse? A. The client resides in an apartment in a lowincome neighborhood. B. The client shows several signs and symptoms of clinical depression. C. The client is completely dependent on family members for both food and medicine. D. The client has been diagnosed with and is receiving treatment for several chronic illnesses. 43. The nurse is caring for a 12-year-old client who has been physically and sexually abused by her father. The father angrily approaches the nurse and says, “I’m taking my daughter home. She’s told me what you people are up to, and we’re out of here!” Which therapeutic response should the nurse make? A. “Your daughter will remain here until the doctor discharges her. I’ll call hospital security and the police if you attempt to take her.” B. “Try to listen to me, please. If you are insistent and do take your daughter from this unit, the police will most certainly order you to bring her back again.” C. “Your daughter is ill and needs to be here. I know you want to help her to recover and that you will work to help everyone straighten out the circumstances that caused this.” D. “You seem very upset. Let’s talk at the nurse’s station. I know you’re very concerned and that you want to help your daughter. It will be best if you agree to let your daughter stay here for now.” 44. A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 3 PM. The nurse making rounds at 3:45 PM finds that the client is complaining of a pounding headache and is dyspneic, is experiencing chills, and is apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action FIRST A. Call the physician. B. Slow the IV infusion. 3 | Page
C. Sit the client up in bed. D. Remove the IV catheter 45. A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client’s blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 mL/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client’s room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is MOST likely experiencing which complication of IV therapy? A. Hematoma B. Air embolism C. Systemic infection D. Circulatory overload 46. A client who has a history of depression has been prescribed nadolol (Corgard) for the management of angina pectoris. Which item is most important when the nurse plans to counsel this client about the effects of this medication? A. Risk of tachycardia B. Probability of fatigue C. High incidence of hypoglycemia D. Possible exacerbation of depression 47. The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has occurred? A. Infection B. Phlebitis C. Infiltration D. Thrombosis 48. The nurse is inserting an intravenous line into a client’s vein. After the initial stick, the nurse continues to advance the catheter if A. the catheter advances easily. B. the vein is distended under the needle. C. the client does not complain of discomfort. D. blood return shows in the backflash chamber of the catheter. 49. The nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client experienced: A. phlebitis. B. infiltration. C. hypersensitivity to the IV solution. D. allergic reaction to the IV catheter material. 50. The nurse should teach clients to watch for which common adverse effect of phenytoin (Dilantin)? A. Alopecia B. Edema C. Gingival hyperplasia D. Hallucinations 51. The nurse is caring for a client with terminal cancer of the throat. The family approaches the nurse and tells the nurse that they have spoken to the health care provider regarding taking their loved one home. The nurse plans to coordinate discharge planning. Which service would be most supportive to the client and the family? A. Hospice care B. The American Cancer Society C. The American Lung Association D. Local religious and social organizations 52. The home care nurse is caring for a client with acute cancer pain. What is the most appropriate way to assess the client’s pain? A. The client’s pain rating B. The nurse’s impression of the client’s pain C. Verbal and nonverbal clues from the client D. Pain relief after appropriate nursing intervention 53. The nurse is caring for a client admitted to the surgical nursing unit following right radical mastectomy to treat breast cancer. The nurse includes which intervention in the nursing plan of care for this client? A. Take blood pressures in the right arm only. B. Draw serum laboratory samples from the right arm only. C. Position the client supine and flat with the right arm elevated on a pillow. D. Check the right posterior axilla area when assessing the surgical dressing. 54. Two months after a right mastectomy for breast cancer, a client comes to the office for a follow-up appointment. After being diagnosed with cancer in the right breast, the client was told that the risk for cancer in the left breast existed. When asked about her breast self-examination (BSE) practices since the surgery, the client replied, “I don’t need to do that anymore.” The nurse interprets this response as which coping mechanism? A. Denial B. Grief and mourning C. Change in body image D. Change in role pattern 55. When planning for the care of the client who is dying of cancer, one of the goals is that the client verbalizes his or her acceptance of impending death. Which client statement indicates to the nurse that this goal has been reached? A. “I just want to live until my 100th birthday.” B. “I would like to have my family here when I die.” C. “I’ll be ready to die when my children finish school.” D. “I want to go to my daughter’s wedding. Then I’ll be ready to die.” 56. A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care if the client states to do which activity? A. Use gloves when working in the garden. B. Use a straight razor to shave under the arms. C. Carry a handbag and heavy objects on the left arm. D. Allow blood pressures to be taken only on the left arm. 57. A postmastectomy client has been found to have an estrogen receptor–positive tumor. The nurse interprets after reading this information in the pathology report that the client will most likely have which common follow-up treatment prescribed? A. Removal of the ovaries B. Administration of estrogen C. Administration of progesterone D. Administration of tamoxifen (Soltamox) 58. A client has undergone mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast if which behavior is observed? A. Performs arm exercises B. Refuses to look at the dressing C. Reads the postoperative care booklet D. Requests pain medication when needed 59. The nurse is caring for a client who has just had a mastectomy. Which exercise should the nurse assist the client in doing during the first 24 hours after surgery? A. Hand wall climbing B. Pendulum arm swings C. Elbow flexion and extension D. Shoulder abduction and external rotation 60. The nurse is caring for a client after a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? A. Placing cool compresses on the affected arm B. Elevating the affected arm on a pillow above heart level C. Avoiding arm exercises in the immediate postoperative period D. Maintaining an intravenous site below the antecubital area on the affected side 61. The nurse obtains a finger-stick glucose reading of 425 mg/dL on a client who was recently started on total parenteral nutrition (TPN). Which action should the nurse take at this time? A. Stop the TPN. B. Administer insulin. C. Notify the health care provider. D. Decrease the flow rate of the TPN. 62. A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an 4 | Page