1
Q
- A patient who has a hemorrhage in the vitreous cavity of the eye, the nurse knows that blood is accumulating
A. in the aqueous humor.
B. between the lens and the retina
C. between the cornea and the lens.
D. in the space between the iris and the lens.
A
B. between the lens and the retina
2
Q
- The nurse instructs a family member how to guide a visually impaired person when ambulating by:
A. holding the visually impaired person by his or her nondominant arm and walking side by side.
B. holding the nondominant hand, wrapping the arm around his or her waist, and walking side by side.
C. allowing the visually impaired person to hold the helper’s arm, with the helper slightly ahead.
D. allowing the visually impaired person to hold the shoulder of the helper and walk slightly behind the helper.
A
C. allowing the visually impaired person to hold the helper’s arm, with the helper slightly ahead.
3
Q
- The patient tells you that he has to hold his paper farther and farther away from his face to read it. It has become a joke in his family about how far away he needs to hold reading material. You tell the patient:
A. “You have myopia. Glasses will help you read.”
B. You may have astigmatism, and your eyes will get used to the problem.
C. “You have presbyopia, which is a normal age-related change. Reading glasses will help you.
D. “You may have an eye infection that is affecting your vision. You will need an antibiotic ointment to instill into your eyes
A
C. “You have presbyopia, which is a normal age-related change. Reading glasses will help you.
Presbyopia is a refractive error that makes it hard for middle-aged and older adults to see things up close.
4
Q
- A client with impaired vision is admitted to the hospital. The following interventions are appropriate to meet the client’s needs EXCEPT
A. Identify yourself by name
B. Stay in the client’s field of vision.
C. Explain the sounds in the environment
D. Decrease background noise before speaking.
A
D. Decrease background noise before speaking.
5
Q
- The nurse should always assess the patient with an ophthalmic problem for
A. Visual acuity.
B. pupillary reactions
C. intraocular pressure
D. confrontation visual fields
A
A. Visual acuity.
6
Q
- Increased intraocular pressure may occur as a result of
A. edema of the corneal stroma
B. dilation of the retinal arterioles.
C. blockage of the lacrimal canals and ducts.
D. increased production of aqueous humor by the ciliary body.
A
D. increased production of aqueous humor by the ciliary body.
7
Q
- A patient is diagnosed with close-angle glaucoma. The nurse prepares the patient on what diagnostic procedure to visualize the anterior chamber angle?
A. Ophthalmoscopy
B. Gonioscopy
C. Retinoscopy
D. Bio microscopy
A
B. Gonioscopy
Gonioscopy is an eye test that checks for signs of glaucoma. It uses a special lens and slit lamp to evaluate your eye’s drainage angle (anterior chamber angle).
8
Q
- The nurse should specifically question patients using eyedrops to treat glaucoma about
A. use of corrective lenses.
B. their usual sleep patterns
C. a history of heart or lung disease.
D. sensitivity to opioids or depressants.
A
C. a history of heart or lung disease.
9
Q
- When assessing the visual fields in acute glaucoma, the nurse would expect to find a:
A. clear cornea.
B. marked blurring of vision.
C. constricted pupil.
D. watery ocular discharge
A
B. marked blurring of vision.
10
Q
- A client is diagnosed with acute angle glaucoma and is placed on oral osmotic diuretic therapy. Which of the following will the Nurse include in his health teachings during acute phase of his illness?
A. Measurement of intake and output.
B. Using metal eye patch to protect the eye.
C. Otic drop administration.
D. Keeping his belonging well organized at all times.
A
A. Measurement of intake and output.
11
Q
- When irrigating a patient’s ear, the nurse will: straighten the ear canal and irrigate with a large-tipped bulb syringe.
A. Straighten the ear canal and irrigate with a large-tipped bulb syringe
B. direct the solution to the middle of the canal to avoid damaging the ear.
C. use a body temperature solution and have the patient hold a basin under the ear while directing the solution toward the top of the canal.
D. repeat the irrigation with hotter water.
A
C. use a body temperature solution and have the patient hold a basin under the ear while directing the solution toward the top of the canal.
12
Q
- Nurse Sylvia was approached by a teenager crying in pain because of an ant that has entered her ears. What should be Nurse Sylvia’s action?
A. Irrigate the ear using a cerumenolytic agent.
B. Use a moist cotton bud to remove the insect.
C. Instill a small amount of mineral oil
D. Blow a smoke towards the patient’s ear,
A
C. Instill a small amount of mineral oil
13
Q
Situation: Mr. Timothy Harris, a 78-year-old patient, subjected himself to medical treatment because of severely diminished hearing acuity. His ears were inspected by an Otolaryngologist and it was found Out that both of his auditory canals were obstructed by an impacted cerumen.
- Nurse Savannah is knowledgeable that Mr. Harris’ condition is most commonly caused by:
A. an acute ear infection.
B. overactive ceruminous glands
C. poor hygiene.
D. Concurrent dermatosis
A
C. poor hygiene.
14
Q
- Initial intervention for an impacted cerumen involves irrigation of a cerumenolytic agent to the involved ear. Nurse Savannah prepares which solution to most effectively soften the impacted cerumen?
A. 0.9% NaCI solution
B. Gentamycin drops
C. Atropine Sulfate drops
D. Peroxide in Glyceryl
A
A. 0.9% NaCI solution
15
Q
- When the nurse reads in the patient’s history that the patient has experienced otalgia, the nurse knows that the patient has:
A. difficulty hearing.
B. a buildup of cerumen.
C. ear pain.
D. ringing in ears.
A
C. ear pain.
16
Q
- Nursing instructions for a patient suffering from external otitis should include the
A. Application of heat to the auricle.
B. Avoidance of swimming.
C. Ingestion of over-the-counter analgesics, such as aspirin.
D. All of the above.
A
D. All of the above.
17
Q
- The nurse points out to the client that of the activities in which he is regularly involved, the one that contributes to accumulation of cerumen in the external ear is:
A. swimming in a chlorinated pool daily.
B. drinking 1500 mL. of fluid a day.
C. trimming hair from the ears every week
D. washing the ears with a washcloth every day.
A
A. swimming in a chlorinated pool daily.
18
Q
Situation: Otitis media is currently considered as an important public health problem which may produce long-term effects on language, auditory and cognitive development.
- Which classification of otitis media according to duration is APPROPRIATELY described?
A Acute Otitis Media = resolves within 6 months
B. Chronic Otitis Media = occurs longer than 12 months
C. Subacute Otitis Media = occurs for 6 to 12 months
D. All of the above
E. None of the above
A
E. None of the above
19
Q
- Identification of risk factors in key to prevention of Otitis Media. The nurse lists down the risk factors and includes which of the following? (Select all that apply)
A. Chronic upper respiratory infection
B. Congenital abnormalities (Cleft Palate Down Syndrome)
C. Daily intake of aspirin
D. Exposure to secondhand smoke
A
A. Chronic upper respiratory infection
B. Congenital abnormalities (Cleft Palate Down Syndrome)
C. Daily intake of aspirin
20
Q
- Suppurative Otitis media can be due to the following BUT ONE
A. May follow a viral disease.
B. Barotrauma.
C. Tympanic membrane perforation
D. Follows a forceful nose blowing
A
D. Follows a forceful nose blowing
21
Q
Situation: Mr. Tonio a 49-year-old, a jolly person works at the Commercial bank for 13 years had been informed for some changes in is work load.m
Three months after he was
observed of unbecoming behavior. He was diagnosed with Bipolar I disorder and experiencing a Manic episode is newly admitted to the inpatient psychiatric unit.
- Which nursing diagnosis is a priority at this time?
A. Risk for violence: other-directed R/T poor impulse control
B. Altered though process RT hallucinations
C. Social isolation R/T manic excitement
D. Low self-esteem R/T guilt about promiscuity
A
C. Social isolation R/T manic excitement
22
Q
- In the mental hospital Mr. Tonio is yelling at another peer in the milieu. Which nursing intervention takes priority?
A. calmly redirect and remove the client from the milieu
B. administer prescribed PRN intramuscular injection for agitation
C. notify the client to lower voice
D. obtain an order for seclusion to help decrease external stimuli
A
A. calmly redirect and remove the client from the milieu
23
Q
- Another client diagnosed with bipolar Il disorder has a nursing djagnosis of impaired social interactions R/T egocentrism. Which short-term outcome is an appropriate expectation for this client problem?
A. the client will have an appropriate one-on- one interaction with a peer by day 4
B. the client will exchange personal information with peers at lunchtime
C. the client will verbalize the desire to interact with peers by day 2
D. the client will initiate an appropriate social relationship with a peer
A
A. the client will have an appropriate one-on- one interaction with a peer by day 4
24
Q
- An adult client 52 years old, diagnosed with major depressive disorder is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse prioritize?
A. empathize with the client about fears regarding ECT
B. monitor for any cardiac alterations to avoid possible negative outcomes
C. discuss the client and family expected short-term memory loss
D. inform the client that injury related to induced seizure commonly occurs
A
C. discuss the client and family expected short-term memory loss
25
25. A nursing instructor is teaching about the cause of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders?
A. When clients experience loss, they learn that it is inevitable and become hopeless and helpless.
B. "There are alterations in the neurochemicals, such as serotonin, which cause the client's symptoms
C. "Evidence continues to support multiple causations related to an individual's susceptibility to mood symptoms.'
D. "There is a genetic component affecting the development of mood disorder."
C. "Evidence continues to support multiple causations related to an individual's susceptibility to mood symptoms.'
26
Situation: Paulo 9 years old is diagnosed with an autistic disorder makes no eye contact; is unresponsive to staff members and continuously twists, spins, and head bangs,
26. What is meant by the "fittingness" of a research study?
A. Truth of findings as judged by the participants
B. The appropriateness of the interview questions posed
C. Faithfulness to everyday reality of the participants
D. The adequacy of the coding system used
C. Faithfulness to everyday reality of the participants
27
27. What is a characteristic of an intrinsic case study?
A. It yields a better understanding of each case.
B. It provides a foundation to challenge a generalization.
C. It does not include quantitative data.
D. It can scrutinize only uncomplicated Phenomena.
A. It yields a better understanding of each case.
28
28. Which of the following is most accurate regarding the grounded-theory method?
A. Data are collected using an etic perspective.
B. It is a process of constructing human experience.
C. Secondary sources are sometires used
D. It is an inductive approach.
D. It is an inductive approach.
29
29. Nursing Research can be classified according to the time frame the research study has been made As a nurse, you know that the study entitled *Knowledge and practice of Staff Nurses in preventing needle prick injuries in a private hospital in Manila is classified as
A. Basic Research
B. Historical Research
C. Descriptive Research
D. Experimental Research
C. Descriptive Research
30
30. Nursing Research has a lot of purposes, Which of the following category do the study about sociodemographic profile of nursing students and their risk for depression belong?
A. Prescription
B. Exploration
C. Prediction and control
D. Explanation
B. Exploration
31
31. In an experimental research, as a nurse there must be an essential aclivily wherein the participants of the study will be able to understand the whole experimental design. This term is called:
A. Desensitization
B. Experimental Proper
C. Research Proper
D. Debriefing
D. Debriefing
32
32. Ethics in Nursing Research has always been an issue when it comes to the identity of the respondents. When the topics of research are very sensitive, which of the following rights of individual participants must be ensured when the researcher cannot link the information given by the respondent from the source of the information?
A. Confidentiality
B. Anonymity
C. Virility
D. Volunteerism
B. Anonymity
33
33. In starting a focused group discussion, Nurse Dina wants to stress out the confidentiality of the topics that they will be discussing. Which of the following instruction convey confidentiality?
A. "This discussion should not only be confined within this group of people. Any information discussed should be told publicly."
B. "This discussion should only be confined within this group of people. Any information discussed should not be told publicly."
C "This discussion should not be confined within this group of people. Any information discussed should not be told publicly.
D. "This discussion should only be confined within this group of people. Any information discussed should be told publicly."
B. "This discussion should only be confined within this group of people. Any information discussed should not be told publicly."
34
34. Based on the research title which of the following will be the general objective?
A. This study aims to determine the level of knowledge and practice of prevention of needle prick injuries of Staff Nurses in a certain private hospital.
B. This study aims to determine if there is a significant relationship between levels of knowledge regarding prevention of needle prick injuries and sociodemographic of Staff nurses in a certain private hospital.
C. The study aims to determine the levels of knowledge regarding prevention of needle prick injuries of staff nurses in a certain private hospital
D. This study aims to determine the isociodemographic of staff nurses in a certain private hospital.
D. This study aims to determine the isociodemographic of staff nurses in a certain private hospital.
35
35 All of these are specific objectives except
A. This study is for nursing researchers in the future.
B. This study aims to determine if there is a significant relationship between levels of knowledge regarding prevention of needle prick injunes and sociodemographic of Staff Nurses in a certain private hospital.
C. This study aims to determine the levels of knowledge regarding prevention of needle prick injuries of Staff Nurses in a certain private hospital.
D. This study aims to determine the sociodemographic of Staff Nurses in a certain private hospital.
A. This study is for nursing researchers in the future.
36
36 As a nurse, you know the appropriate data gathering tool, this is?
A. Survey
B. Questionnaire
C. Structured Discussion
D. Interview Method
B. Questionnaire
37
37. As a nurse, these are the following topics in the scope and limitations except.
A Limited to the hospital personnel of a private hospital
B. Limited only to the practice of preventing needle prick injuries of nursing personnel
C. The scope of the study involves the knowledge about prevention of needle prick injunes
D. The scope of the study involves the sociodemographic profile of nursing Personnel
A Limited to the hospital personnel of a private hospital
38
38. Which of the following is not a null hypothesis?
A. There is no relationship between the level of knowledge and practice of prevention of needle prick injuries
B. There is no relationship between the practice of prevention of needle prick injuries and sociodemographic profile of staff nurses
C. There is a significant relationship between the knowledge and sociodemographic profile of staff nurses in a certain private hospital.
D. All of the above.
E. None of the above
C. There is a significant relationship between the knowledge and sociodemographic profile of staff nurses in a certain private hospital.
39
39. Which of the following would correspond to Intervene in Nursing Process?
A. Select design plan
B. Report findings
C. Implement planned study
D. Select a plan analysis
C. Implement planned study
40
40. Which of the following would correspond to Plan in Nursing Process?
A. Select design plan
B. Report findings
C. implement planned study
D. Change the objectives after implementation
A. Select design plan
41
41. When it comes to steps in Problem Solving. Which of the following would be similar in research where in you implement the planned study?
A. Theorize about facts and possible
B. Gather, analyze relevant information–
C. Report findings
D. Determine information needs
B. Gather, analyze relevant information–
42
42. Using the Research perspective, when is the time that a nurse makes inferences?
A. Define purpose of review of literature
B. Formulate a problem, define variables
C. Select design sample
D. Report findings
B. Formulate a problem, define variables
43
43. Which of the following is does not belong to the group?
A. Assess; Identify the problem
B. Plan: Theorize
C. Intervene: Gather relevant information
D. Evaluate Outcomes
B. Plan: Theorize
44
44. In selecting a problem, these are the following consideration except:
A. Time Factor
B. Talents
C. Cost
D. Data availability
B. Talents
45
45. These are the purpose of Review of Related Literature except:
A. Reveal investigations
B. Reveal sources of data
C. Reveal what is the problem–
D. Reveal the significant research personalities
C. Reveal what is the problem–
46
46. As a nurse, you know the following a function of theoretical framework, except:
A. Specifies relationship among the concepts
B. Give a graphic view of the data
C. Clarifies the concept on which the study is built
D. State assumptions
B. Give a graphic view of the data
47
47. Which of the following would not be Qualitative Research?
A. Case study of Myocardial Infarction
B. A Review on Corona Trial
C. A Review on the Nursing Uniform
D. A Review on the Performance in Related Learning Experience of student nurses
D. A Review on the Performance in Related Learning Experience of student nurses
48
48. Using statistics in nursing research is a very vital tool in presenting the data. As a nurse you know the definition of sampling as:
A. Taking certain areas of the population dividing the areas into sections
B. Process of selecting a portion of the population to represent the entire population
C. Using every Nth name from the list of participants
D. Taking any sample as long as it comes up with the quota
B. Process of selecting a portion of the population to represent the entire population
49
49. A researcher plans to conduct a survey It the population on Marupok City is 67, 666, find the sample size it the margin of error is 23%.
A. 19
B. 15
C. 23
D. 29
A. 19
50
50. The nurse develops the following hypothesis: Elderly women receive less aggressive treatment for breast cancer than do younger women. Which variable would be considered to be the dependent variable?
A. Degree of treatment received
B. Age of the patient
C. Type of cancer being treated
D. Use of inpatient treatment
A. Degree of treatment received
51
51. in planning care for a newly admitted patient with depression, the highest priority for the nurse is
A. orienting the patient to the unit.
B. encouraginq expression of feelings.
C. providing a safe environment
D. meeting the patient at an appropriato affective level.
C. providing a safe environment
52
52. A patient displays disorganized, difficult to understand speech, behavioral disorganization, and a silly, inappropriate affect The patient prefers to sit alone and be uninvolved in unit activities, and often appears to be listening and responding to unseen stimuli. The nursing diagnosis that should be given priority is:
A. impaired verbal communication***
B. social isolation.
C. ineffective coping.
D. impaired social interaction.
D. impaired social interaction.
53
53. The nurse should focus assessment for a patient with type 1 schizophrenia primarily on gathering data about:
A. communication difficulties.
B. perceptual alterations.
C. social interactions.
D. avolition.
B. perceptual alterations.
54
54. A withdrawn patient exhibits peculiar gestures and waxy flexibility. She repeats what the nurse says to her in a high-pitched voice but does not otherwise respond verbally. The nurse should document that the patient demonstrates:
A. echolalia.
B. alogia
C. concrete thinking.
D. associative looseness.
A. echolalia.
55
55. The emergency room phones the psychiatric unit to say that a patient demonstrating symptoms of acute schizophrenia, including altered perceptions, is being admitted. The nurse can anticipate care by considering that the type of perceptual alteration most commonly displayed by patients with schizophrenia is:
A. waxy flexibility.
B. auditory hallucinations.
C. inappropriate affect.
D. loose associations.
B. auditory hallucinations.
56
56. A patient relates the following history Ile Plebence of continuous, intrusive thought her house is contaminated with lethal bacteria, and the uncontrollable urge to continuously clean the walls, Moors, and furniture. These symptoms are most consistent with the DSM-/V-TR diagnosis ot
A. social phobia.
B. panic disorder.
C. somatoform disorder
D. obsessive-compulsive disorder
D. obsessive-compulsive disorder
57
57. A patient whose husband was killed in the World Trade Center explosion has become unwilling to enter a tall building because she experiences severe physical and emotional symptoms when she does, During these episodes, she becomes diaphoretic, her heart races, and she feels as though she cannot breathe. She is filled with dread, thinking that the building will explode The nurse can assess these symptoms as being most consistent with the diagnosis of
A. obsessive-compulsive disorder
B. generalized anxiety disorder
C. acute stress disorder.
D. specific phobia.
B. generalized anxiety disorder
58
58. When working with a patient who has dissociative amnesia, the nurse should plan to begin by
A. taking measures to prevent identity diffusion
B. setting mutual goals for behavioral changes
C. helping the patient develop a realistic self- concept.
D. identifying and supporting patient strengths
D. identifying and supporting patient strengths
59
59. The nurse notes that a patient with obsessive- compulsive disorder (OCD) is pacing up and down the corridor while counting each circuit. The best action on the part of the nurse Would be to:
A. ask her why she is pacing and cousin
B. take her by the arm and lead her to her room
C. offer to play cards with her in the dayroom
D. permit her to pace and count until she's comfortable
D. permit her to pace and count until she's comfortable
60
60. A principle that should be applied when providing care for a patient with conversion disorder is
A. give attention to the patient, not the symptom
B. structure care to provide time for rituals
C. facilitate progressive review of the trauma.
D. permit dependence while the symplo is present.
A. give attention to the patient, not the symptom
61
61. Which symptom related to disordered communication is the nurse most likely to assess in a patient who is having a manic episode?
A. Mutism
B. Flight of ideas
C. Loose associations
D. echolalia
B. Flight of ideas
62
62. A principle of greatest value when interacting with a patient who is experiencing a manic episode is:
A. use a calm matter of fact approach
B. avoid mentioning limits
C. do not interrupt patient
D. encourage joking
A. use a calm matter of fact approach
63
63. A nursing diagnosis that can be established for a grossly hyperactive manic patients who runs wherever he goes, exercises wildly, and is argumentative with other patients is :
A. powerlessness
B. risk for injury
C. deficient diversional activity
D. disturbed thought processes
C. deficient diversional activity
64
64. During community meeting, a manic patient tells another patient, You need to push yourself away from the table more. You're too fat for your own good!" The nurse should intervene by:
A. calmly telling the patient that unit rules do not permit insulting others,
B. telling the patient that he must leave the meeting and go to his room.
C. telling the patient that he can remain in the meeting only if he apologizes.
D. suggesting that the patient take prn medication.
A. calmly telling the patient that unit rules do not permit insulting others,
65
65. A patient with bipolar I disorder is noted to be laughing and giddy one minute and within seconds is angry and sarcastic. The assessment that the nurse should make is that the patient's mood is:
A. incongruent.
B. inappropriate.
C. incandescent.
D. labile.
D. labile.
Labile mood refers to unpredictable, uncontrollable, and rapid shifts in emotions.
66
66. A psychiatric technician mentions to the nurse, "I think I heard the ED doctor say that the patient I just brought to the unit has a personality disorder." To follow up on this, the nurse could look at the diagnostic sheet under the DSM-IV-TR axis
A. I
B. II
C. III
D. IV
B. II
67
67. A nursing diagnosis appropriate to consider for a patient with any of the personality disorders is:
A. noncompliance.
B. impaired social interaction.
C. disturbed personal identity.
D. disturbed sensory perception.
B. impaired social interaction.
68
68. A patient who is suspicious of the motives of others has had a long-time feud with his two siblings over their parents' wills. He reacts quickly with anger whenever he thinks that someone is threatening his welfare. The nurse would assess these characteristics as being most consistent with the profile known as:
A. schizoid personality.
B. paranoid personality.
C. borderline personality.
D. narcissistic personality.
B. paranoid personality.
69
69. The characteristic of individuals with dramatic erratic personality disorders that makes it advisable for staff to have frequent patient- centered meetings is the individuals propensity for :
A. Behaving responsibly in the peer grou
B. Quickly and successfully adapting to stress
C. manipulating others to evade limits
D. coping successfully with a stressful Environment.
C. manipulating others to evade limits
70
70. A 27-year-old is admitted for diagnostic Workup. She is described as having a history of frequent intoxication and promiscuity. Recently, she has stolen money from her grandmother to finance a trip to Las Vegas with her new boyfriend. She indicates that she is not sorry for stealing the money. Only sorry that her grandmother pressed charges instead of "being a good sport." The nurse assesses this as being consistent with:
A. conduct disorder
B. narcissistic personality
disorder
C. antisocial personality disorder.
D. Borderline personality disorder.
B. narcissistic personality
disorder
71
71. The wife of a patient with a sexual disorder asks, "What's a paraphilia?" The nurse, who knows that the physician has talked to the patient and spouse and has used this term, assumes that the spouse is seeking information. The nurse should respond:
A. "Any homosexual act:
B. "Inhibition of the sexual response cycle
C. "Intense sexual urges with an
abnormal focus.
D. "Discomfort with one's biological gender."
C. "Intense sexual urges with an
abnormal focus.
72
72. When working with a patient regarding sexual concerns, a necessity for providing nonjudgmental care is:
A. limit setting.
B. assertiveness training.
C. sexual self-awareness.
D. effective communication
D. effective communication
73
73. A patient with premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my wife. Do you have any suggestions that would be helpful?" The remark that clarifies the nurse's role is:
A. "Sex therapy isn't my specialty, but I will try to help.
B. "I can refer you to the sexual disorders clinic to see a physician who specializes in this disorder"
C. "Have you spoken with your physician about using Viagra?"
D. "There are several techniques here in this pamphlet that might be helpful."
B. "I can refer you to the sexual disorders clinic to see a physician who specializes in this disorder"
74
74. A patient who is a pedophile tells the nurse that he is feeling a huge amount of guilt and shame over molesting a child. He is concerned about the impact on his family and states that the family would be better off without him. The nurse should:
A. explore his feelings in greater depth.
B. set limits on patient disclosure
C. consider instituting suicide precaution
D. provide prn anxiolytic medication.
C. consider instituting suicide precaution
75
75. A 56-year-old man has been feeling much tension since losing his job. He leaves home one morning and, while sitting in the park feeding birds, impulsively exposes himself publicly to a group of mothers and children. This behavior should be assessed as:
A. voyeurism.
B. dyspareunia.
C. exhibitionism.
D. sexual masochism.
C. exhibitionism.
76
76. When assessing a patient with cognitive disorder, the nurse should base observations on knowledge that the foundation of the cognitive process is:
A. memory
B. reasoning.
C. orientation,
D. perception.
A. memory
77
77. The highest priority for nursing care for a patient with dementia is
A. improving cognition.
B. individualizing care.
C. maintaining an optimal level of function
D. promoting self-confidence and self- esteem.
C. maintaining an optimal level of function
78
78. An elderly individual is having difficulty recognizing ordinary objects such as pencils and water faucets. When he fails to think of the word, he describes the function of the Object- "that thing that writes" or "the thing that gives water." The nurse assesses this as
A. apraxia.
B. aphasia.
C. agnosia.
D. amnesia.
C. agnosia.
Agnosia (also known as primary visual agnosia, monomodal visual amnesia, and visual amnesia) is a neurological disorder characterized by an inability to recognize and identify objects or persons using one or more of the senses.
79
79. The nurse notes that an elderly patient has fluctuating levels of awareness. She seems anxious. She tells the nurse that she saw her granddaughter standing at the foot of the bed during the night. Later, the nurse sees her moving her hands as though picking things out of the air. The nurse should suspect:
A delirium.
B. dementia.
C bipolar disorder.
D. schizophrenia
A delirium.
80
80. The patient need that is of primary importance in the care of a patient with severe Alzheimer's disease is:
A. promotion of self-care activities.
B. maintenance of nutrition and hydration
C. demands that exceed capacity to function.
D. periodic change of routine and environment.
B. maintenance of nutrition and hydration
81
81. A patient with anorexia nervosa has the nursing diagnosis "imbalanced nutrition: less than body requirements related to inadequate food intake." The expected outcome should be that the patient will:
A. gain 1 to 3 pounds weekly
B. exhibit fewer signs of malnutrition.
C. restore healthy eating patterns and normalize weight.
D. identify cognitive distortions about weight and shape.
C. restore healthy eating patterns and normalize weight.
82
82. When a patient with anorexia nervosa spills milk over her plate of partially eaten food, the best approach for the nurse to take would be to say
A. "Nice try, but it won't work."
B Why are you deliberately making mealtime difficult?
C. "I'll get you another plate of food so you can finish."
D. That little trick will cost you television privileges.
C. "I'll get you another plate of food so you can finish."
83
83. A personality characteristic the nurse would expect to find in a patient with an eating disorder is:
A. extroversion.
B. high self-esteem.
C. perfectionism.
D. callous disregard for other
C. perfectionism.
84
84. School nurses should be particularly vigilant for signs of eating disorders:
A. in fourth graders.
B. among unpopular, studious high school boys
C. among popular, high-achieving high school girls.
D. at transitions from elementary to middle school and middle school to high
school.
D. at transitions from elementary to middle school and middle school to high
school.
85
85. The nurse caring for individuals with eating disorders should determine that the general way in which bulimic and anorexic individuals differ is:
A. indiscernible
B. anorexia is life-threatening; bulimia is not
C. bulimia has a biologic origin; anorexia does not.
D. patients with anorexia are proud of their eating habits; patients with bulimia are ashamed.
A. indiscernible
86
86. A patient asks the nurse, "How would I know if I were dependent on alcohol?" The nurse should respond by telling the patient that dependence is defined by:
A. a compulsion to use the drug
B. a loss of control over use of the drug.
C. a physiologic need to use the drug.
D. continued use despite adverse consequences.
C. a physiologic need to use the drug.
87
87. The wife of an individual who is alcohol- dependent asks the nurse, "What do you mean when you ask if my husband ever experienced a blackout?" The best explanation would be that "A blackout is:
A. a comatose period related to alcohol withdrawal."
B. a comatose period related to alcohol intoxication."
C. a time period in which the person is 'passed out."
D. a period of time in which the person under the influence of alcohol functions normally but later is unable to remember.
D. a period of time in which the person under the influence of alcohol functions normally but later is unable to remember.
88
88. The nurse would suspect a disulfiram (Antabuse)-alcohol reaction when a patient presents with symptoms of:
A. skin rash, itching, and urticaria.
B. pallor, hypotension, and muscle cramping.
C. dry skin bradycardia fatigue, and headache
D. headache dyspnea, nausea, vomiting, and flushing
D. headache dyspnea, nausea, vomiting, and flushing
89
89. A patient report experiencing insomnia and taking diazepam and wine in increasing amounts to be able to sleep. The nurse should teach the patient about:
A. the danger of ENS depression
B. the risk of acetaldehyde toxicity
C. the risk of fetal alcohol syndrome
D. diazepam and dietary precautions
A. the danger of ENS depression
90
90. nurse assessing an individual who is a multidrug abuser should ask about recent use of the drug that produces the most sustained high, which is:
A. crack
B. heroin.
C. cocaine.
D. methamphetamine
B. heroin.
91
91. An important ECT pretreatment responsibility of the nurse is to:
A. thoroughly assess the patient's pretreatment level of functioning.
B. order and interpret skull and spine film
C. obtain informed consent for treatment.
D. prepare the light box for early morning use
A. thoroughly assess the patient's pretreatment level of functioning.
92
92. Which drug is the nurse most likely To administer 30 to 45 minutes before ECT?
A. Anectine
B. Atropine
C. Alprazolam
D. Amobarbital
B. Atropine
93
93. An 8-year-old boy is referred to the clinic for diagnosis and treatment. He is described by his parents as disobedient and argumentative. He has an explosive temper and low frustration tolerance. Other children relate poorly to him. These behaviors are most consistent with the medical diagnosis of:
A. autistic disorder.
B. conduct disorder.
C. oppositional defiant disorder.
D. attention-deficit/hyperactivity disorder.
C. oppositional defiant disorder.
94
94. The behaviors the nurse would expect to document in a child who has Tourette's syndrome are:
A. inattention and restlessness.
B. hostility and defiance.
C. body rocking and head banging.
D. involuntary motor movement and vocalization.
D. involuntary motor movement and vocalization.
95
95. A nursing diagnosis that would be universally applicable for children with autism is:
A. impaired social interaction related to inability to relate to others.
B. anxiety related to disturbed thought processes
C. chronic low self-esteem related to excessive negative feedback.
D. deficient fluid volume related to peculiar eating habits.
A. impaired social interaction related to inability to relate to others.
96
96. The nurse working with a victim of spousal abuse should factor into care planning the fact that a deterrent to leaving the abusive situation is the events that occur in the:
A. tension-building sage
B. honeymoon stage
C. battering incident.
D. processing stage
B. honeymoon stage
97
97. A woman who has been repeatedly abused by her partner comes to the ED for treatment of severe contusions. As her injuries are being treated, she tells the nurse "He almost killed me this time, I quess I'm going to have to do something. The priority intervention for the nurse is to:
A. tell the abuser to stop the abuse and seek help.
B. Help the patient devise a safety or escape plan.
C. encourage the patient to take independent action.
D. provide referrals contingent on the patient leaving the abuser.
B. Help the patient devise a safety or escape plan.
98
98. A survivor of childhood abuse enters the hospital following an episode of wrist cutting. The patient has a history of binge-purge eating disorder and difficulty trusting and relauna to others. A nursing intervention of high priority is:
A. setting limits on self-harmful behavior.
B. fostering belief in and valuing family
C. encouraging sharing of blame for the abuse with the perpetrator.
D. identifying and confronting abnormal responses and feelings
A. setting limits on self-harmful behavior.
99
99. The nurse caring for victims of violence should plan care based on the understanding that most victims begin to react emotionally to the effect that the crime has on their lives. This stage of recovery is known as:
A. impact
B. recoil
C.reorganization
D.retribution
B. recoil
100
100. In preparing a care plan for an abuse victim, it is most important to include a
long-term outcome that addresses the need for:
A. moving the individual from victim to survivor status.
B. providing support groups for long-term assistance.
C. using empathy to establish rapport and build trust.
D. shifting blame for the incident from patient to perpetrator.
A. moving the individual from victim to survivor status.
101
s
NP
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