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RECALLS EXAMINATION 14 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: Lexie, 52 years of age, was brought to the ED due to numbness on her left face and a confused mental state. The physician’s initial diagnosis is ischemic stroke. 1. The following are true regarding brain attack except: A. It can be caused by thrombosis or embolism B. The use of oral contraceptive increases the risk of having a brain attack C. Cerebral anoxia lasting longer than 20 minutes causes irreversible damage. D. Airway patency is always a priority. 2. Lexie’s father, Thatcher, asks the nurse if his daughter’s initial diagnosis is different from “hemorrhagic stroke” which his late grandfather experienced years ago. The nurse answers correctly if she answers: A. Yes, ischemic stroke patients may experience severe headaches, while hemorrhagic patients may not. B. Yes, ischemic stroke is more common and occurs when a blood vessel is blocked by a clot or thrombosis; while hemorrhagic stroke occurs when a blood vessel bursts and bleeds into the brain causing hemorrhage. C. No, they are generally the same. D. No, because manifestations of different types of stroke are similar. 3. The nurse is aware that the following should be implemented during the acute phase of stroke except: A. Maintaining a quiet environment B. Placing antiembolism stockings C. Administering oxygen D. Inserting a urinary catheter 4. Visual-perceptual disturbances can occur in stroke. The nurse should encourage the client to: A. Provide eye care for visual deficits B. Approach from the affected side C. Approach from the unaffected side D. Turn the head to scan the complete range of vision 5. What is the most ideal position of Lexie when eating? A. Sitting in a chair or up in bed, with the head and neck positioned slightly forward and flexed. B. Sitting in a chair or up in bed, with the head positioned slightly forward and flexed. C. Sitting in a chair or up in bed, with the neck positioned slightly forward and flexed. D. High-fowler Situation: Nurses have an important role in establishing an environment that satisfies the biological, psychosocial, and spiritual needs of clients. They are often challenged with issues and problems in creating therapeutic environment for clients. 6. In structuring a therapeutic environment, it is MOST important for the nurse to: A. Safeguard physical safety and psychological security. B. Keep an effective social order that recognizes authority. C. Keep a restrictive environment to prevent patient assaultiveness. D. Maintain a closed-door policy to instill order and disciple. 7. Environment as referred to in ‘milieu therapy’ refers to the: A. Building and grounds where patients interact. B. People with different personalities who relate with one another. C. Physical environment and relationships of people within. D. Immediate physical surroundings that create an ambience for the patients 8. Attitude therapy safeguards the therapeutic application of attitudes toward patients. Rico, seeks attention from the staff by repeatedly deviating and not participating in structured activities. It is BEST for the nurse to: A. Respond: “it is okay for as long as you don't bother anyone” B. Have a patient watcher monitor him closely. C. Ignore the behavior. D. Respond: “we have agreed on a schedule. I expect you to follow.” 9. The nurse is aware that these patients are likely to be exploited in a group setting. These are the patients who are: A. Suspicious B. Sociable C. Withdrawn D. Hostile 10. A therapeutic community aims to: A. Have team leaders to check physical presence and attendance of patients in ward activities. B. Constantly monitor implementation of ward policies and rules. C. Encourage patient interactions, group problem solving and decision making. D. Encourage patients to police themselves and impose sanctions on ward violations. Situation: A nurse researcher in the Psychiatric unit is undertaking a study on the relationship between depressive symptoms and motivation to lose weight among high school overweight teens in selected schools at the National Capital Region. 11. The study design to be used by the researcher is: A. Experimental B. Predictive correlational C. Non-experimental D. Descriptive correlational 12. Which of the following is true about the study design being used by the researchers? A. There is no researcher intervention. B. It is safe to infer causal relationships in this study design C. It proves causation. D. Effective means of collecting data 13. Which of the following inclusion criteria should be observed by the researcher in selecting the subjects? A. Current diagnosis of major depression. 1 | Page
B. High school students with body mass index of 25 or greater. C. Enrolled in high school in NCR. D. High school students with aged limit of 16 – 20 years. 14. The independent variable for this study is: A. Weight loss B. Not applicable C. Depressive symptoms D. Motivation 15. One of the statistical approaches to be used by the researcher in analyzing whether a relationship exists between the number of depressive symptoms and motivation to lose weight is: A. Chi square test B. Analysis of covariance C. Pearson’s coefficient of correlation D. Product moment correlation Situation: Justine is 12 years old, looks like she is 9 and acts she is 4. She has lightning – quick hands and can grab things off the desk, out of the staff’s pockets and off food trays in the blink of an eye. She is cute and known for getting black eyes and bruises. Wherever she is, there is trouble, but according to her, it is always someone else’s fault. She loves to run away from the Child and Adolescent Unit of the hospital and being chased by young staff members. 16. From the behavior of Justine, the nurse infers that a fundamental issue is Justine’s: A. Difficulty developing stable relationships B. Inability to learn from past experiences C. Withdrawn attention D. Suspiciousness and mistrustful of others 17. With other children in the unit, Justine smiles with glee watching adult staff struggle to take time to fix the place and put things in order every time she and other children create chaos. This pattern of behavior is: A. Assaultive B. Demanding C. Hostile D. Manipulative 18. The psychodynamics of Justine’s behavior most likely would point to: A. Lack of social support for growing children from the local government. B. Lack of parenting, stressful and stormy family life. C. Failure of the school system to provide early education. D. Excessive media that portray sex and violence in TV programs. 19. In creating a therapeutic environment of Justine and kids of the same situation, it is foremost to: A. Develop a positive self-image. B. Give high calorie rich nutritional intake. C. Provide safety and security. D. Provide remedial education. 20. In the unit, it is not common to hear loud bangs and thuds with yelling, screaming, and cursing of these children with the company of Justine. A therapeutic activity that the staff can provide is: A. Leisurely and active gardening. B. Active ball games that are not competitive. C. Sports that foster cooperation and teamwork. D. Organizing book clubs for interaction. Situation: Nurses who are helping professionals and first responders in psychiatric emergencies and catastrophic situations often experience trauma and intense stress. Continuing education offered to nurses in this field aim to equip nurses’ knowledge and skills related to the important role in recognizing and responding to peers and colleagues struggling with maladaptive responses to trauma and stress. 21. Awareness of the varied responses of trauma and stress is a primary consideration in recognizing problems of helping professionals. Which of the following stress responses are cognitive in nature? A. Intrusive thoughts and reliving the incident, reduced ability to concentrate or mental confusion. B. Substance use, withdrawal from others, or acting out behaviors. C. Unfounded or unusual anger, depressive feelings, or anxiety reactions D. Fatigue, recurring headaches, or inability to sleep or eat. 22. Characteristic features of posttraumatic stress disorder include hyperarousal, i.e., exaggerated startle response, numbing effects and re-experiencing physiological and psychological reactions. The nurse notes that the duration of these symptoms MUST persist for at least: A. 2 days B. 1 month C. 2 weeks D. 3 days 23. Effects of compassion fatigue can be observed among emergency mental health professionals. This easily leads to: A. Somatic reactions B. Burnout C. Psychoses D. Neuroses 24. The idea of self – medication to cope with stress and trauma is common in helping professionals and first responders. This practice if it becomes pervasive has potential for: A. Substance use and abuse B. Behavioral changes and abuse C. Malpractice D. Avoidance behavior 25. A group strategy that allows processing of emotional effects of traumatic exposure is: A. Alcoholic anonymous B. Milieu therapy C. Psychodrama D. Avoidance behavior Situation: Nina, an adolescent, participating in a behavior therapy group cried while relating her experience of “cutting” on her skin, “the pain is so bad, this is the only way to get it out”. Nina is a survivor of sexual abuse perpetuated by her own father. She has history of repeated admission at Psychiatric Emergency Unit with repeated history of self – mutilation. She was diagnosed as Borderline Personality Disorder. 26. Nina verbalized the intensity of her emotional pain and anger, desperation and anxiety that escalate to a feeling of mounting tension. With this overwhelming anxiety, she may resort to dissociation which is characterized by: A. Feelings of emptiness and numbness and experience of depersonalization B. Retreat to an earlier developmental stage C. Use of excessive reasoning rather that reacting or changing D. Blame of others for one’s own feelings and thoughts 27. Nurses may perceive clients like Nina with strong countertransference reactions and feelings of frustration, betrayal, anger, and disgust. To work therapeutic with clients who self -mutilate, it is MOST important for nurses to: A. Do - self disclosure and solicit understanding from clients B. Acknowledge and overcome strong emotions C. Suppress reactions to maintain professionalism D. Engage in constructive activities to dissipate strong emotions. 28. Nina has a pattern of “cutting ” as a self – mutilating act. All of the following are therapeutic interventions EXCEPT: A. Offer sympathy, and additional attention to the behavior while cleaning the wound B. Care for the wounds in a matter-of-fact manner C. Allow the client to express angry feelings D. Problem-solve the situation with the client 29. Which of the following is a necessary initial step in determining interventions for Nina? A. Explore her coping behaviors B. Determine the meaning of her personal crisis C. Assess her developmental level and experience D. Let her identify current stressors 30. The nurses involved in the care of Nina feel caught in a bind because there is a need to rescue in the event that she cuts herself again and a need not to be manipulated by her. It is MOST therapeutic for the nursing team to recognize: 2 | Page
A. Being strict regarding imposition of external controls B. Writing a “no cutting on self” contract C. Developing of a trust relationship D. Taking self- responsibility by signing a waiver Situation: Children are unique requiring specialize nursing care. To nurse a child, health care professional need to be aware that children are physically smaller and their bones grow and mature at different rates. 31. A 10-month-old infant has developmental dysplasia of the hip following confirmation of the diagnosis by ultrasonography. She is placed in Pavlik Harness. Which of the following should you expect the infant to be positioned? A. Supine B. Trendelenburg C. Flexed abduction D. Flexed adduction 32. With the application of the harness, the nurse should keep in mind the following EXCEPT? A. Assess skin daily. B. The baby should wear the harness at all times except while bathing C. Harness should be worn above the clothing continually. D. Instructing the parents on the practicalities of daily care and continuous support 33. The infant did not respond to treatment with Pavlik Harness. A surgical program is undertaken. She was admitted into hospital for a 1-week period of gallows traction. The mother asks the nurse what Gallows traction is. The nurse responds correctly if she states: A. It is a skin traction applied to the legs which are flexed at a 90-degree angle at the hips. B. The child’s head provides counter traction. C. Type of traction with the legs in an extended position D. Uses skin traction on the lower leg and a padded sling under the knee 34. The nurse should pay particular attention to which part of the body of the infant in gallows traction? A. Back B. Hips C. Lower extremities D. Skin 35. The tractions is removed after 1 week and the infant is bathed prior to surgery. Which of the following constitute this intervention? A. Bathing is necessary for hygienic measures B. Cleanse the skin and allows for the gentle removal of the adhesive traction C. Allows for adequate physical preparation D. A routine procedure prior to surgery to prevent complications Situation: Nurse Liza functions as a team leader and coordinates a small group of nurses in the psychiatric unit to provide care to a small group of patients. 36. As coordinator of the team her main function is to: A. Allow team members to practice high degree of authority B. Encourage the growth and training of each member C. Know the condition and needs of all the patients assigned to the team D. Assume responsibility of the team for planning, directing and evaluating the patient’s care 37. As team leader, Nurse Liza assumes which of the following duties? A. Assessing patients and planning care B. Directing and assisting team members C. Giving direct patient care D. Coordinating patient activities 38. Nurse Liza’s team is using a team nursing model. Weighing things, this model has advantages and also disadvantages. Of the following choices, which one is the ADVANTAGE: A. Use of each team member special expertise in caring for patients B. Direct patient care provided by a few nurses C. Team leader direct the team for effective care D. Provide total patient care 39. To make team nursing succeed, nurse Liza as coordinator of the team MUST possess which of the following? 1. Good communication skills 2. Delegation ability 3. Strong clinical skills 4. Create a cooperative working environment A. 2,3,and 4 B. 1 and 3 C. all except 4 D. all 40. Nurse Liza brings together the members to work as a group. She has successfully accomplished teamwork by means of: A. Expertise of each member B. Well define goals and objectives of the team C. Clinical skills of team members D. Adequate planning and control Situation: Romina, age 19, was admitted with acute pyelonephritis and has elevated temperature. The nurse on duty reported that she refused acetaminophen and has had only sips of fluid to supplement her IV therapy. The patient appears sad and has remained in bed with the covers over her head most of the day. Her history includes a psychiatric hospitalization two years ago for major depressive disorder. She was started on antidepressant medication. 41. Depressed mood or loss of interest in pleasure and activities in depressive disorder is with duration of at least: A. A month B. Two weeks C. 2-3 days D. one week 42. Romina has been withdrawn and appears sad. Which of the following approaches validate your initial impression? A. “I noticed that you've been withdrawn. Describe your mood for me” B. “what happened that brought your sadness?” C. “in a scale of 1 - 10, 10 being the highest, what level is your feeling sad?” D. “how long have you been feeling sad?” 43. Romina describes feeling like her body is “numb” and feels “helpless to do anything to feel better”. The nursing diagnosis is: A. Anxiety B. Risk for injury C. Acute confusion D. Powerlessness 44. Structuring a therapeutic environment places urgency in providing: A. Cheerful environment to counteract depression B. Access to security personnel C. Adequate fluids and nutrition D. Precautions regarding self-harm 45. Romina is being treated with SSRI; /selective serotonin reuptake inhibitor. The nurse watches for serotonin syndrome characterized by: A. Tremors, seizures, nausea, vomiting, and confusion B. Robot like inflexible movements C. Bizarre behavior like hallucinations and delusions D. Agranulocytosis, jaundice, signs of infection Situation: It is important for a psychiatric nurse to be knowledgeable about the different psychiatric medications administered to patients. The following questions will test you about psychopharmacology: 46. Patient Santino is being treated for his bipolar disorder. He is prescribed with Eskalith. As a nurse, which of the following should you exclude from your health teachings? A. Medication can be administered with food. B. He is allowed to drink coffee every morning. C. Notify the physician if fever occurs. D. He can take the missed dose within 2 hours of the scheduled time. 47. While reviewing about Eskalith, you know that severe lithium toxicity is manifested by: A. Anuria B. Severe diarrhea C. Apathy 3 | Page
D. Muscle twitching 48. Patient Cleo’s chart states that dystonia is noted on her while taking antipsychotic medications. Which manifestations do you expect to see? A. Dysphagia, facial grimacing B. Oculogyric crisis, increased heart rate, drooling C. Twisting of the torso D. Drowsiness, restlessness 49. Fluoxetine is prescribed to Patient Mark Lee. How should it be administered? A. On full stomach B. On an empty stomach C. At the same time each morning D. At the same time each evening 50. A mother of a child with ADHD asked you the most effective medication in controlling the disorder. Your answer would be: A. CNS stimulants B. CNS depressants C. Donepezil D. Rivastigmine Situation: A client is brought to the Emergency Department complaining of generalized weakness of all extremities and facial muscles and drooping of the eyelids since a week ago His condition fluctuates from day to day. The examining physician tested the client with an acetylcholinesterase inhibitor test to diagnose myasthenia gravis. 51. Nurse Liza is assigned to care for the client. Which of the following medications prescribed by the physician should nurse Liza prepare to diagnose myasthenia gravis? A. Atropjne sulfate B. Tensilon C. Mestinon D. lsuprel 52. Thirty minutes after injection, nurse Liza noted an immediate Improvement in the muscle strength. This can be interpreted as a: A. Autoimmune disorder B. Positive test confirming the diagnosis C. Negative failure D. Negative for myasthenia gravis 53. The client asked if he will take Tensilon for MG treatment. Nurse Liza answered “NO” because: A. It is toxic to the body B. It is only short-acting C. It causes adverse effects D. It crosses the blood-brain barrier 54. Nurse Liza noticed the client suddenly developed cramps and sweating. In a situation like this, which of the following drugs must be made available to control the side effects of he tested drug? A. Prednisone B. Mestinon C. Atropine sulfate D. Potassium supplement 55. Nurse Liza is administering pyridostigmine (Mestinon) orally to the client. Which of the following nursing intervention indicates safety measure before administering the medication? A. Instructing the client to be in bed when taking the medication B. Determining client’s ability to swallow C. Positioning the client to lie down on his left side D. Requiring the client to lei still in bed Situation: Abbey is a 40-year-old wife who was brought by neighbors to the emergency room confused and crying with body bruises and swollen eyes. She claimed that she was physically abused by her husband who was intoxicated with alcohol. She is admitted for brief hospitalization for further observation and crisis intervention. 56. The admitting nurse is aware that the following should be carefully documented EXCEPT: A. Quote of Abbey’s account of the incident that led to the injuries B. Specific and factual assessment of physical injuries incurred by Abbey C. Photographs of Abbey’s physical injuries D. Neighbors claim regarding estranged relationship of Abbey and husband 57. The nurse did a process recording of an interaction with Abbey. The following descriptions about process recording are true EXCEPT: A. Recording of the verbatim account of the entire interaction, including verbal and non-verbal B. Tool to improve interpersonal communication techniques C. A form of documentation for professional development D. Helps the nurse in analyzing content of interaction 58. Which of the following information about Abbey is LEAST ESSENTIAL FOR CRISIS ITNERVENTION? A. Abbey perception of the event B. Longitudinal life history C. How Abbey is coping with the present situation D. Availability of friends or family for support 59. Abbey asked the nurse if she may have a photocopy of her records. The nurse is aware that client records belong to the: A. Health facility B. Health team members C. Family of the client D. Client 60. Potential benefits of the use of computers in documentation have been recognized, however clients are MOST concerned about: A. Validity B. Accuracy C. Reliability D. Confidentiality Situation: A 67 year old female client is diagnosed with Senile Nuclear Cataract OU (both eyes) H25.1; Dry Eye Syndrome. 61. The nurse is conducting nursing assessment and preparing a nursing history. Which of the following clinical manifestations of the client gathered by the nurse is characteristic of cataracts? A. Narrow anterior chamber B. Optic nerve damage C. Painless blurry vision D. Age factor 62. Based from the information gathered the nursing diagnosis is: A. Self-care deficit related to impaired vision B. Disturbed sensory perception related to visual impairment C. Acute pain related to eye dysfunction D. Anxiety related to possible vision loss 63. The physician scheduled the client for Phacoemulsification with intraocular lens implantation surgery. The physician informed the client of the nature of the procedure and what to expect after surgery. The client verbalized to the nurse,” I have never had surgery before”. Given this situation, the nurse appropriate expected outcome for the client to: A. Maintain asepsis aids in protecting the surgical site form infection and complications B. Know sign and symptoms of complications that are to be reported to physician immediately C. Verbalize preoperative routine activities and postoperative procedures and expectations D. Understand handwashing and aseptic technique for postoperative eyes care 64. The admitting order include: Phacoemulsification with intraocular lens implantation surgery right eye local anesthesia 7:00AM OPD. Start Sanmyd – P Ophthalmic Solution 1 drop every 5 minutes to right eye once the client is admitted. The client demonstrates understanding of the pre – operative medication when she states that the administration to eye drops: A. Reduce intraocular pressure B. Minimize swelling C. Dilate the pupils D. Relieve pain 65. The client is given post – cataract surgery instructions consisting of instillation of eye meds, Tobrex, 1 drop every 3 hours (waking hours), Pred Fortre – 1 drop every 3 hours (waking hours): oral meds for pain including health teaching and other instructions. Client education guide should include the following EXCEPT: 4 | Page