Tiêu đề RECALLS 3 (NP5) - STUDENT COPY ✅

RECALLS EXAMINATION 3 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: You are a nurse tasked to work with patients coping with their illnesses. 1. 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.” 2. 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. 3. 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?” 4. 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. 5. 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? A. Neologism B. Confabulation C. Flight of ideas D. Emotional lability 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. 6. 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.” 7. 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.” 8. 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. 9. 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. 10. 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.” 1 | Page
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 - Lizbeth, a 30-year old registered nurse with two children, legally separated from her husband was admitted to the psychiatric unit three weeks ago. 11. You are the nurse attending to Lizbeth. You have observed that she has a habit of washing her hands repeatedly for a long period of time. This is a manifestation of what kind of behavior? A. Negative B. Hyperactive C. Ritualistic D. Nonconformist 12. Lizbeth engages in this behavior to _____. A. protect herself from undesirable people B. relieve her anxiety C. occupy herself with purposeful activity D. call the attention of other 13. A new nurse introduce herself to Lizbeth and asks her name. Lizbeth responds “I am an obsessive- compulsive neurotic. I have had psychoanalysis for ten years. What do you think can you do for me?” Your BEST response would be _____. A. “Can we talk about that Lizbeth?” B. ” I need to know you better Lizbeth” C. ” You seem to feel hopeless” D. ” who was your psychoanalyst?” 14. Lizbeth tells you “That the new nurse makes me angry. Like you, she does not understand what my real problem is”. Your BEST reply would be _____. A. “You seems to be upset. I will come back later” B. “You have the right to be upset when people don’t seem to understand” C. “That’s a common feeling. I understand. Let’s talk about it” D. “I know what your problem is. You are an obsessive-compulsive personality” 15. Diazepam (Valium) was prescribe for Lizbeth. You gave her instructions on effects of the drug. What statement would indicate that Lizbeth needs further health teaching about the medication? A. “I’m so glad I can still eat chocolate while I’m taking this.” B. “I’m so glad no blood tests are necessary while I’m taking this.” C. “I’m so glad Valiums won’t affect my driving skills” D. “I’m so glad I will only have to take this until I learn to be less anxious” 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. 16. 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. 17. 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. 18. 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. 19. 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. 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. 20. 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 - Ms. Ligaya Co is a chief nurse in a secondary level hospital with nursing staff consisting of registered staff nurses, nursing assistants and aides. 21. Ms. Co stresses the importance of promoting ‘esprit d corps’ among the nursing staff. Which of the following statement indicates that they understand the meaning of the term? A. “In order that we achieve the goals of the institute, we must follow the directives coming from above.” B. “We will ensure that all resources we need are available when needed” C. “Let’s work together in harmony; we need to be supportive of one another.” D. “We need to show our competence to the higher management level.” 22. She assert the importance of promoting a positive organizational culture among the nursing staff. Which of the following behaviors indicate that this has been attained? A. Obedient and uncomplaining B. Powerful and oppositional C. Competitive and perfectionist D. Caring and nurturing with one another 23. Ms. Co is a visionary strategist, and desires to be a committed leader. Which of the following types of leadership do these behaviors reflect? A. Servant B. Transactional C. Connective D. Transformational 24. She knows that as a leader, she has to strategize in order to create followership in response to authority. This capacity to act or the strength to accomplish a goal is referred to as _____. A. power B. accountability C. responsibility D. authority 25. Ms. Co gathered the nursing staff and other health care worker in the hospital who support the idea of having a meeting to discuss problems that affect the delivery of care and to agree to speak with one voice. This power mechanism is called ______. A. coalition B. upward appeal C. rationality D. assertiveness SITUATION: You apply your knowledge on concepts of psychosocial health to patients assigned to you in the ward. 2 | Page
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 - 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. 31. A patient came in with sign of heat stroke. Which of the following are signs/symptoms of profound CNS dysfunction? A. Elevated temperature B. Hot, dry skin C. Tachypnea, hypotension, tachycardia D. Confusion, delirium, bizarre behavior 32. Which of the following is the primary goal in the care of patient with a heat stroke? A. To maintain cardiac functions B. To reduce immediately the high temperature C. To restore normal body temperature D. To prevent further complication 33. Which of the following is the best advice you would give to an athlete to prevent heat stroke? A. To monitor fluid losses and weight lost during workout activities and to replace fluids. B. To avoid immediate exposure to high temperature C. To maintain adequate fluid intake D. To avoid planning outdoor activities between 10 a.m. and 2 p.m. 34. to prevent heat stroke, the following pieces of advice are given to the community, EXCEPT: A. Avoid direct exposure to the sun especially late in the morning B. Always drink plenty of water C. Use a hat or an umbrella when going out of the house D. Just stay home and relax 35. Which of the following would your best advice to the community people during summer time to prevent dehydration? A. Use a hat or an umbrella when going out of the house B. Just stay home and relax C. drink plenty of fluids D. wear light-colored clothing SITUATION: You are caring for various patients with substance abuse disorder of methamphetamines. You utilize your knowledge to help care for these patients. 36. 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. 37. 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 38. 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. 39. 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.” 40. 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 a staff nurse at the Ear Unit of the Medical Ward of a government hospital. Clarita, a 25-year old stage actress was admitted with the chief complaint of on and off tinnitus at the right ear. The audiogram confirms conductive hearing loss or mixed loss especially in the low frequencies. Clarita was diagnosed with Otosclerosis. 41. Otosclerosis is a common cause of what condition? A. Premature labor B. Meningitis Auditory nerve C. Sensori-neural hearing loss 3 | Page
D. Conductive hearing loss 42. The audiogram also confirms a sensori-neural hearing loss. What ear structure is damaged when this condition is present? A. Outer and/or middle ear B. Tympanic membrane C. Cochlear nerve D. Stapes 43. Clarita was given Sodium Flouride. What is the rationale for giving this to her? A. To mature the spongy bone growth B. To remove the diseased stapes C. To prevent further complications D. To restore hearing 44. A surgical procedure was recommended for Clarita. Which of the following surgical procedures is useful in correcting her condition? A. Myringotomy B. Ossicular reconstruction C. Cochlear transplant D. to restore hearing 45. After her surgery, Clarita was placed on her left side with the head of the bed elevated. What is the rationale for placing her in this position? A. To minimize the pressure in the middle ear B. To prevent complication of bleeding C. To ensure patient safety D. To prevent vomiting 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. 46. 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. 47. 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. 48. 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. 49. 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.” 50. 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 - Ana, a 28-year old supervisor in a business processing office, consult at the Out-patient department of the hospital with the chief complaints of headache, drowsiness, nausea, and vomiting. She revealed that one week before consult she stopped drinking coffee which she used to take three to five times a day. She was diagnosed with Caffeine Discontinuation Syndrome (CDS). 51. What are the effects of drinking coffee two to three cups a day on the central nervous system? A. Feeling motivated and energized, less fatigue B. Feeling motivated and energized, headache C. Feeling motivated and drowsy, headache D. Headache, less fatigue 52. Which of the following reinforces a person to continue drinking coffee? A. Feeling of unpleasant symptoms when drinking is abruptly stopped. B. Drinking coffee at Starbucks is the “in-thing C. Feeling of well-being D. The price of coffee is getting lower 53. Ana was given Luminal 60 mg./day p.o. this drugs is a/an _____. A. intermediate-acting sedative B. short-acting sedative C. hypnotic drug D. long-acting sedative 54. While doing your assessment Ana complained of nausea. Which of the following would be you PRIORITY nursing action? A. Refer Ana to the attending physician immediately B. Let Ana put her head in-between her legs C. Administer an anti-emetic drug D. Offering Ana some ice chips 55. you have observed Ana to be pacing in the room, restless, and stutters when your speaking to her. You would assess Ana as manifesting which of the following global anxiety response? A. Cognitive B. Behavioral C. Motor D. Biological 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. 56. 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. 57. 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 58. 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. 59. 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. 4 | Page