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RECALLS EXAMINATION 7 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 SITUATION: You are a mental health nurse dealing with patients currently experiencing a crisis. You use your knowledge on crisis management to help these patients. The following questions apply. 1. In the rape crisis center, a woman is being seen a few days after she was raped. She reports that she has not had any appetite, she is experiencing anxiety and depression, and that she has been having nightmares. You as the nurse make an assessment on the woman to determine if it is appropriate for her to be admitted to the hospital. Which of the following priority questions should the nurse ask the woman? A. The client’s reaction to the event, including any suicidal thoughts. B. The client’s perceptions of her current skills for coping with the event. C. The availability of the client’s personal support systems. D. The effect of the event on other aspects of the client’s life. 2. An anxious, sobbing 19 year old is brought to the crisis shelter for an interview. She says, “I think I am pregnant but I don’t know what to do!” Which of the following nursing interventions is most appropriate for her situation at this time? A. Ask the client about the type of things that she had thought of doing. B. Give the client some ideas about what to expect to happen next. C. Recommend a pregnancy test after acknowledging the client’s distress. D. Question the client about her feelings and possible parental reactions. 3. You’re the nurse on duty when you saw an anxious 41-year-old client say that she would “rather die than be pregnant.” Which of the following responses by the nurse is most helpful? A. “Try not to worry until after the pregnancy test.” B. “You know, pregnancy is a normal event.” C. “You’re only 40 years old and not too old to have a baby.” D. “I see you’re upset. Take some deep breaths to relax a little.” 4. You were doing some charts when a client comes to the crisis center in a very distressed state. He tells you that he just cannot get over being fired from his job last week. He says that he already asked for help and talked to friends. He says, “I’ve tried everything to get through this, but nothing is working. Please, help me!” Which of the following should you, as the nurse, use as the initial crisis intervention strategy? A. Referral for counseling. B. Support system assessment. C. Emotion management. D. Unemployment assistance. 5. Getting the client’s significant others involved in helping with the immediate crisis as soon as possible is one of the major roles in crisis intervention. You as the nurse determine that the support persons are prepared to help when they verbalize which of the following? A. The name and phone number of the client’s physician. B. Emergency resources and when to use them. C. The coping strategies they are using. D. Long-term solutions they plan to tell the client to use. SITUATION: You are a nurse tasked to work with patients coping with their illnesses. 6. A client was diagnosed with an acute cardiac illness. The nurse should determine that the client lacks understanding of her illness and her ability to make changes in her lifestyle when they verbalize which of the following statements? A. “I already have my airline ticket, so I won’t miss my meeting tomorrow.” B. “These relaxation tapes sound okay; I’ll see if they help me.” C. “No more working 10 hours a day for me unless it’s an emergency.” D. “I talked with my husband yesterday about working on a new budget together.” 7. You just admitted a 19-year-old client who was recently diagnosed with leukemia. What is the most appropriate short term goal for the nurse and the client to establish? A. Accepting his death as imminent. B. Expressing his angry feelings to the nurse. C. Decreasing interaction with peers to conserve energy. D. Gaining an intellectual understanding of the illness. 8. The client hospitalized for diagnosis and treatment of atrial fibrillation states to the nurse, “Please hand me the telephone. I need to check on my stocks and bonds.” Which of the following responses by the nurse is most therapeutic? A. “You will get more upset if you make that call.” B. “You have atrial fi brillations. Let’s talk about what that means.” C. “You really don’t care about the fact that you’re sick, do you?” D. “Do you realize you have a life-threatening condition?” 9. The colostomy club made arrangements to meet with a client who will undergo a bowel surgery. Which of the following is accomplished when a representative of the colostomy club visits the client preoperatively? A. Letting the client know that he has resources in the community to help him. B. Providing support for the physician’s plan of therapy for the client. C. Providing the client with support and realistic information on the colostomy. D. Convincing the client that he will not be disfigured and can lead a full life. 10. One of your patients in the ward directs profanities at you, the nurse, then abruptly hangs his head and pleads to you, “Please forgive me. Something came over me. Ugh, why do I say those things?” As a knowledgeable nurse, you interpret this as which of the following? 1 | Page
A. Neologism B. Confabulation C. Flight of ideas D. Emotional lability SITUATION: You are a nurse tasked to care for patients experiencing stress and anxiety. You are to apply the nursing concepts you’ve learned about this topic to effectively care for these patients. 11. You notice that Nami, a young adult about to undergo a surgery is experiencing moderate anxiety regarding her upcoming procedure. As a competent nurse, you help to reduce the patient’s anxiety by: A. Telling her to distract himself with games and television B. Reassure her that she will come through the surgery without incident C. Explaining to her what happens before and after surgery D. Asking the surgeon to refer her to a psychiatrist who can work with her to diminish her anxiety 12. You are discussing the concept of anxiety to the student nurses in your unit. You explain that anxiety occurs in degrees, from a level that stimulates productive problem solving to a level that is severely debilitating. The students respond correctly when you ask that at a mild, productive level of anxiety, one will expect to see which of the following cognitive characteristics of mild anxiety? A. Slight muscle tension. B. Occasional irritability. C. Accurate perceptions. D. Loss of contact with reality 13. You followed up a question to the student nurses. They answered you correctly when they stated that as a client’s anxiety level increases to a debilitating degree, they would expect which of the following psychomotor behavior indicating the panic level of anxiety: A. Suicide attempts or violence. B. Desperation and rage. C. Disorganized reasoning. D. Loss of contact with reality. 14. You admitted a patient dealing with personal issues and painful feelings. Which of the following is a crucial goal of therapeutic communication when helping this client? A. Communicating empathy through gentle touch B. Conveying client respect and acceptance even if not all of the client’s behaviors are tolerated C. Mutual sharing of information, spontaneity, emotions, and intimacy D. Guaranteeing total confidentiality and anonymity for the client 15. You are doing a follow up visit to the home of a client diagnosed with Alzheimer’s disease. You are assessing the stress level of the patient’s spouse, the primary caregiver. Which of the following questions is most appropriate for assessing the spouse’s level of stress? A. “So, what is a typical day like for you?” B. “What do you do to relieve stress for yourself?” C. “May I arrange for some part-time help for you?” D. “Being a full-time caregiver must be very stressful, isn’t it?” SITUATION: You are a nurse tasked to care for patients with schizophrenia. You use your knowledge on this concept to effectively and safely care for your patients. 16. You are caring for a patient diagnosed with paranoid schizophrenia. The patient reports hearing a voice saying “Do not remove your cap or they will be able to read your mind.” Which of the following responses is the most therapeutic for this patient? A. “Who are ‘they’?” B. “Why would someone want to read your mind?” C. “I do not believe that anyone can read another’s mind.” D. “It must be very frightening to believe that someone can read your mind.” 17. A patient diagnosed with a history of paranoid schizophrenia and chronic alcohol abuse was admitted to your unit. The patient has been taking Olanzapine for 14 days and has not consumed alcohol in the last 5 days. They report shaky hands and trouble sleeping because of frequent nightmares. The patient verbalized their concern that olanzapine may be causing these problems. Which of the following is your most therapeutic response to this patient? A. “These are not typical side effects for that drug.” B. “Just ignore the symptoms. They will go away in just a few days.” C. “These symptoms are more likely a result of not drinking alcohol for 5 days.” D. “It is possible, since this medication is contraindicated in those who abuse alcohol.” 18. A patient with a history of violent command hallucinations was observed to be mumbling erratically while making threatening gestures directed toward a particular staff member. Which of the following interventions is most appropriate when caring for patients with violent command hallucinations? A. Ask the client to explain the cause of anger. B. Place the client in seclusion to help de-escalate anger. C. Inform the client of pending restraint if behavior does not subside. D. Observe the client for signs of escalating agitation. 19. A patient diagnosed with paranoid schizophrenia was admitted to your unit. You include the nursing diagnosis of Disturbed thought processes secondary to paranoia in the patient’s care plan. Which of the following approaches is most appropriate for this patient? A. Avoid laughing or whispering in front of the client. B. Begin to identify social support in the community. C. Encourage the client to interact with others on the unit. D. Have the client sign a written release of information form. 20. The mother of a client diagnosed with paranoid schizophrenia visiting her son 2 days after his admission to the psychiatric unit approaches a nurse and states, “He is still talking about how the government is controlling his thoughts.” What is the most accurate nursing appraisal of the mother’s statement? A. The mother’s expectations of her son are realistic. B. The mother’s concern is reasonable. C. The mother should request a medication adjustment. D. The mother requires further education regarding the client’s diagnosis. SITUATION: You are tasked to care for Zoro, a patient newly diagnosed with obsessive compulsive disorder. You use your knowledge to effectively and safely care for the patient. 21. Zoro is utilizing a defense mechanism commonly used by patients with obsessive compulsive disorder. Which of the following defense mechanisms is this? A. Suppression. B. Repression. C. Undoing. D. Denial. 22. You start your assessment on Zoro. Which behavioral symptom would you expect to assess in this patient? A. The client uses excessive hand washing to relieve anxiety. B. The client rates anxiety at 8/10. C. The client uses breathing techniques to decrease anxiety. D. The client exhibits diaphoresis and tachycardia. 23. Which cognitive symptom would you expect to assess in Zoro who has obsessive compulsive disorder? A. Compulsive behaviors that occupy more than 4 hours per day. B. Excessive worrying about germs and illness. C. Comorbid abuse of alcohol to decrease anxiety. D. Excessive sweating and an increase in blood pressure and pulse. 24. Zoro is leaving his home for the first time in a year. He arrived in the unit wearing a surgical mask and white gloves. He states, “The germs in here are going to kill me”. Which correctly written nursing diagnosis addresses Zoro’s problem? A. Social isolation R/T fear of germs AEB continually refusing to leave the home. B. Fear of germs R/T obsessive-compulsive disorder. 2 | Page
C. Ineffective coping AEB dysfunctional isolation R/T unrealistic fear of germs. D. Anxiety R/T the inability to leave home, resulting in dysfunctional fear of germs. 25. Zoro has been in your care in the psychiatric unit for 4 days now for the treatment of their OCD. Which outcome takes priority for the patient at this time? A. The client will use a thought-stopping technique to eliminate obsessive and/or compulsive behaviors. B. The client will stop obsessive and/or compulsive behaviors in order to focus on activities of daily living. C. The client will seek assistance from the staff to decrease obsessive and/or compulsive behaviors. D. The client will use one relaxation technique to decrease obsessive and/or compulsive behaviors. SITUATION: You apply your knowledge on concepts of psychosocial health to patients assigned to you in the ward. 26. You are attending a seminar regarding coping skills. You were asked about the beneficial effects of humor. You respond to the question appropriately based on which of the following documented beneficial effects of humor? A. Lessened depression B. Increased relaxation C. Reduced aggression D. Improved sleep 27. As a knowledgeable nurse, you know that body image is the subjective view an individual has about his or her physical appearance including body shape, size, weight, and proportions. Which of the following conditions would put a patient at risk for disturbed body image? A. Urinary tract infection B. Hyperlipidemia C. Rheumatoid arthritis D. High blood pressure 28. You are a preoperative nurse preparing a client for an upcoming surgery. While you’re preparing this patient, you inform them of what they can expect after surgery and how their pain will be controlled postoperatively. Which of the following stress management techniques is being utilized in this scenario? A. Relaxation B. Guided imagery C. Progressive muscle relaxation D. Anticipatory guidance 29. An elderly patient you’re caring for is about to be discharged. Which of the following statements, if made by the patient, would indicate that they lack a support system at home? A. “My sister and her husband are taking me home today.” B. “My church members have been sending cards and letters while I have been in the hospital.” C. “I am not sure how I am going to get to the grocery store after I get home.” D. “My neighbor is retired. We visit and have our meals together every day.” 30. You are to assess a newly admitted patient regarding their health care practices. As a culturally competent nurse, which of the following factors would you include in your assessment? I. Health-seeking behaviors II. Responsibility for health care III. Folklore practices IV. Barriers to health care A. I B. III C. I, II, IV D. I, II, III, IV SITUATION: You are caring for various patients with substance abuse disorder of methamphetamines. You utilize your knowledge to help care for these patients. 31. You are assessing a patient diagnosed with substance abuse disorder. They stated, “My wife causes me to abuse methamphetamines. She uses methamphetamine and she also expects me to.” As a knowledgeable nurse, you know that the patient is using which of the following defense mechanisms? A. Rationalization. B. Denial. C. Minimization. D. Projection. 32. The mother of one of your patients who are newly admitted to the mental health unit expresses her concern that his son may be using methamphetamine. Which physical examination findings are consistent with methamphetamine abuse by the client? A. Hypotension and bradycardia B. Bruises and scrapes on the extremities C. Constricted pupils and fatigue D. Anorexia and recent weight loss 33. One of the patients you’re caring for in the unit is in methamphetamine withdrawal. When caring for this patient, the most appropriate intervention by the nurse should be to? A. Administer sedatives routinely to prevent seizures. B. Allow the client to sleep and eat as desired. C. Administer antipsychotic medications to manage hallucinations. D. Encourage involvement in the treatment milieu. 34. You are assessing one of the patients in your unit who abuses methamphetamine. The patient appears not to be willing to give up the usage of the drug, as evidenced by their statement, “I do not plan to quit meth. I can work for days when I am high.” Which of the following is your best response to the patient’s statement? A. “You’ll exhaust yourself doing that.” B. “You can’t see the real problem yet because you are in denial.” C. “You think using drugs helps you?” D. “Good point. You probably work long hours while you are on meth.” 35. One of your patients regularly uses projection to protect themselves against the negative realities resulting from their methamphetamine use. Which of the following statements will the nurse most likely document when the patient uses projection as a coping mechanism? A. “My dad and I don’t get along because he thinks that I’m a failure.” B. “I can’t go back to work. I’d be so embarrassed for anyone to find out I’ve been in treatment.” C. “I’m not giving up alcohol, just the methamphetamine. I never had a problem with alcohol.” D. “Everything will be all right again if I can just stop using drugs.” SITUATION: You are caring for Robin, a patient diagnosed with Multiple Sclerosis. The following questions apply. 36. Robin is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which of the following information should you relay to Robin about the test? A. The client will have wires attached to the scalp and lights will flash off and on. B. The machine will be loud and the client must not move the head during the test. C. The client will drink a contrast medium 30 minutes to one (1) hour before the test. D. The test will be repeated at intervals during a five (5)- to six (6)-hour period. 37. Robin stated her frustration regarding her recent diagnosis of MS. She states, “I do not understand how I got this disease. Is it genetic?” On which statement should you base your response? A. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. B. There is no evidence suggesting there is any chromosomal involvement in developing MS. C. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. D. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on. 38. Which of the following issues presented by Robin is of most importance to you at this time as her primary nurse? A. She refuses to have a gastrostomy feeding. B. She wants to discuss if she should tell her fiancé. C. She tells the nurse life is not worth living anymore. D. She needs the flu and pneumonia vaccines. 3 | Page
39. Robin stated that she has been investigating alternative therapies to treat her disease. Which of the following interventions is most appropriate? A. Encourage the therapy if it is not contraindicated by the medical regimen. B. Tell the client only the health-care provider should discuss this with him. C. Ask how his significant other feels about this deviation from the medical regimen. D. Suggest the client research an investigational therapy instead. 40. You enter Robin’s room after her diagnosis of acute exacerbation of MS. You find her crying. Which of the following statements is the most therapeutic response you can make as her nurse? A. “Why are you crying? The medication will help the disease.” B. “You seem upset. I will sit down and we can talk for awhile.” C. “Multiple sclerosis is a disease that has good times and bad times.” D. “I will have the chaplain come and stay with you for a while.” SITUATION: You are caring for patient Luffy who has seizures. You apply your knowledge on concepts of seizures to better assess, diagnose, plan, and evaluate their condition. 41. Luffy is sitting in the chair when suddenly, his entire body went rigid with his arms and legs contracting and relaxing. He is not aware of what’s going on and is making guttural sounds. Which of the following actions should you implement first? A. Push aside any furniture. B. Place the client on his side. C. Assess the client’s vital signs. D. Ease the client to the floor. 42. Luffy is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which of the following preprocedure teaching should you implement? A. Tell the client to take any routine antiseizure medication prior to the EEG. B. Tell the client not to eat anything for eight (8) hours prior to the procedure. C. Instruct the client to stay awake for 24 hours prior to the EEG. D. Explain to the client that there will be some discomfort during the procedure. 43. Luffy just had a 3 minute seizure. He has no apparent injuries, is oriented to name, place, and time but he is very lethargic and just wants to sleep. Which of the following interventions should you implement? A. Perform a complete neurological assessment. B. Awaken the client every 30 minutes. C. Turn the client to the side and allow the client to sleep. D. Interview the client to find out what caused the seizure. 44. Which statement by Luffy indicates that he understands factors that may precipitate his seizure activity? A. “It is all right for me to drink coffee for breakfast.” B. “My menstrual cycle will not affect my seizure disorder.” C. “I am going to take a class in stress management.” D. “I should wear dark glasses when I am out in the sun.” 45. Luffy is prescribed the anticonvulsant phenytoin (Dilantin) for his seizure disorder. Which statement indicates that Luffy understands the discharge teaching regarding this medication? A. “I will brush my teeth after every meal.” B. “I will check my Dilantin level daily.” C. “My urine will turn orange while on Dilantin.” D. “I won’t have any seizures while on this medication.” SITUATION: You are a new nurse assigned in the operating room. You will apply your knowledge on perioperative nursing to effectively and safely handle patients in this area. 46. You are preparing your patient for an upcoming surgery. Which of the following interventions should you implement first? A. Check the permit for the spouse’s signature. B. Take and document intake and output. C. Administer the sedative. D. Complete the preoperative checklist. 47. You are conducting an interview with the surgical patient in the holding area. Which of the following information should you report to the anesthesiologist? Select all that apply. I. The client has loose, decayed teeth. II. The client is experiencing anxiety. III. The client smokes two (2) packs of cigarettes a day. IV. The client has had a chest x-ray which does not show infiltrates. V. The client reports using herbs. A. I, II, III, IV B. II, III C. I, III, V D. III, V 48. The circulating nurse intervenes when she notices which of the following violations of surgical asepsis? A. Surgical supplies were cleaned and sterilized prior to the case. B. The circulating nurse is wearing a long sleeve sterile gown. C. Masks covering the mouth and nose are being worn by the surgical team. D. The scrub nurse setting up the sterile field is wearing artificial nails. 49. The following statements are not an expected outcome for the postoperative client who had a general anesthesia, except? A. The client will be able to sit in the chair for 30 minutes. B. The client will have a pulse oximetry reading of 97% on room air. C. The client will have a urine output of 30 mL per hour. D. The client will be able to distinguish sharp from dull sensations. 50. Which of the following problems should you identify as the priority for a patient who one day postoperative? A. Potential for hemorrhaging. B. Potential for injury. C. Potential for fluid volume excess. D. Potential for infection. 51. Antibiotics have limited use in the actual treatment of Mastoiditis because________. A. Tissue destruction is extensive B. It is a long-term treatment C. Antibiotics do not easily penetrate the infected bony structure of the mastoid D. Culture has to be done to identify which antibiotic is most effective for the treatment of Mastoiditis Situation– You are a staff nurse in a government hospital being transferred to the Psychiatric Unit. You were required to equip yourself by attending the enhancement program on Crisis Intervention. To assess your knowledge and skills on the subject you were given a pre-test. 52. A crisis that is acute but temporary and due to an external source is__________. A. Developmental B. Transitional C. Traumatic D. Dispositional 53. The MAIN objective of crisis intervention is to_____________ A. Make the person realize his/her mistakes B. Ensure patient’s safety C. Return the person to the root of the crisis to identify the cause D. Eliminate the stressor 54. Which of the following is NOT an assumption in the concept of crisis? A. Crisis is acute and resolved within a short period of time B. All individuals experience a crisis C. Crisis is a growth-retarding factor to the emotional development of a person D. Specific identifiable events precipitate a crisis 55. Which of the following nursing interventions is the most appropriate for a client who is in the early state of crisis? 4 | Page