1
Q
SITUATION: A nurse observes different responses among individuals exposed to similar life stressors. Some are able to maintain relationships, fulfill responsibilities, and adjust their coping
strategies as situations change.
- Which statement best reflects the definition of mental illness?
A. A deviation from what society considers acceptable behavior
B. A temporary inability to manage stress effectively
C.A disturbance in thoughts, emotions, or behavior that results in impaired functioning
D. An emotional response that occurs after a traumatic event
A
A. A deviation from what society considers acceptable behavior
B. A temporary inability to manage stress effectively
C.A disturbance in thoughts, emotions, or behavior that results in impaired functioning
D. An emotional response that occurs after a traumatic eve
2
Q
- A nurse is reviewing government agencies involved in the development and implementation of the national mental health program under Philippine policy. Which of the following government agencies is NOT directly involved in the implementation of national mental health programs as mandated by law?
A. Department of Health (DOH)
B.Department of the Interior and Local Government (DILG)
C. Commission on Higher Education (CHED)
D. Department of Education (DepEd)
A
A. Department of Health (DOH)
B.Department of the Interior and Local Government (DILG)
C. Commission on Higher Education (CHED)
D. Department of Education (
3
Q
SITUATION: Nurse Rey is recalling concepts about General Adaptation Syndrome by Hans Selye and Phases of Therapeutic Relationship by Hildegarde Peplau.
- According to the General Adaptation Syndrome, which statement best describes the alarm stage?
A. The body’s resources are depleted, leading to fatigue and illness
B. The body activates the fight-or-flight response to prepare for the stressor
C. The individual has adapted completely and no longer perceives stress
D. The body gradually returns to normal functioning after stress exposure
A
A. The body’s resources are depleted, leading to fatigue and illness
B. The body activates the fight-or-flight response to prepare for the stressor
C. The individual has adapted completely and no longer perceives stress
D. The body gradually returns to normal functioning after stress exposure
4
Q
- Nurse Rey observes that Mr. Santos, a hospital staff member, has been working long hours
without adequate rest. He reports severe headache, back pain, and extreme fatigue but
continues to perform his duties. Based on Hans Selye’s General Adaptation Syndrome (GAS),
which stage is Mr. Santos most likely experiencing?
A. Alarm
B. Resistance
C. Exhaustion
D. Recovery
A
A. Alarm
B. Resistance
C. Exhaustion
D. Recovery
5
Q
- Nurse Rey is assigned to a newly admitted patient who appears anxious and hesitant to communicate. During their initial interaction, Nurse Rey introduces himself, explains his role, clarifies what the patient can expect during hospitalization, and mutually agrees with the patient on goals and plans of care to be followed. According to Hildegard Peplau’s Interpersonal Relations Theory, which phase of the nurse-patient relationship is demonstrated when the nurse establishes trust and coordinates a contract with the patient?
A. Identification phase
B. Exploitation phase
C. Resolution phase
D. Orientation phase
A
A. Identification phase
B. Exploitation phase
C. Resolution phase
D. Orientation phase
6
Q
- Nurse Mish is caring for a client who is overly suspicious of others, believes people are trying to harm him, and consistently interprets others’ actions as threatening without sufficient basis. Paranoid Personality Disorder belongs to which cluster of personality disorders?
A. Cluster A: eccentric
B. Cluster B: dramatic/erratic
C. Cluster C: anxious/fearful
D. Mixed cluster
A
A. Cluster A: eccentric
B. Cluster B: dramatic/erratic
C. Cluster C: anxious/fearful
D. Mixed cluster
7
Q
- A 30-year-old patient diagnosed with bipolar disorder expresses difficulty forming intimate relationships and confusion about personal identity and life roles while under the care of Nurse Mish. Based on Erik Erikson’s Psychosocial Development Theory, which developmental stage is most relevant to addressing the client’s concerns?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Identity vs. Role Confusion
D. Integrity vs. Despair
A
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Identity vs. Role Confusion
D. Integrity vs. Despair
8
Q
- Nurse Mish is assessing a client who reports long-term mild depressive symptoms interspersed with brief periods of elevated mood that do not meet criteria for major depressive or manic episodes. Based on these observations, which mood disorder best describes this condition?
A. Dysthymia (minor depression)
B. Bipolar II Disorder
C. Bipolar I Disorder
D. Cyclothymia
A
A. Dysthymia (minor depression)
B. Bipolar II Disorder
C. Bipolar I Disorder
D. Cyclothymia
9
Q
- A client in the ward presents with progressive cognitive decline accompanied by psychotic features and fluctuating levels of alertness. Which type of dementia is most consistent with these findings?
A. Alzheimer’s disease
B. Vascular dementia
C. Frontotemporal dementia
D. Lewy body dementia
A
A. Alzheimer’s disease
B. Vascular dementia
C. Frontotemporal dementia
D. Lewy body dementia
10
Q
- Nurse Mish encounters a client who suddenly becomes overwhelmed by intense anxiety, is unable to follow instructions, and appears fearful during interaction. What is the priority
nursing action at this time?
A. Encourage the client to verbalize feelings
B. Provide teaching on relaxation techniques
C. Administer prescribed anti-anxiety medication
D. Stay with the client
A
A. Encourage the client to verbalize feelings
B. Provide teaching on relaxation techniques
C. Administer prescribed anti-anxiety medication
D. Stay with the client
11
Q
Situation: The nurse is performing a holistic mental health assessment on a client to provide safe, appropriate, and individualized care using the nursing process.
- During a therapeutic session, a client with generalized anxiety disorder makes several statements. Which statement best represents transference?
A. “You are just like my controlling mother who never listened to me!”
B. “I feel anxious because I didn’t sleep well last night.”
C. “I get frustrated when I can’t solve my own problems.”
D. “I feel like a child again whenever I think about my exam failure”
A
A. “You are just like my controlling mother who never listened to me!”
B. “I feel anxious because I didn’t sleep well last night.”
C. “I get frustrated when I can’t solve my own problems.”
D. “I feel like a child again whenever I think about my exam failure”
12
Q
- During the interview, the nurse asks about the client’s relationships with others. Which of the following statements indicates that the client is exhibiting splitting?
A. “I feel like my therapist is the only person who truly understands me, but my nurse doesn’t care about me at all.”
B. “I feel anxious when I leave my house.”
C. “I often have trouble sleeping because of stress at work.”
D. “I have been feeling sad and hopeless for the past two weeks.”
A
A. “I feel like my therapist is the only person who truly understands me, but my nurse doesn’t care about me at all.”
B. “I feel anxious when I leave my house.”
C. “I often have trouble sleeping because of stress at work.”
D. “I have been feeling sad and hopeless for the past two weeks.”
13
Q
- During assessment of a client with suspected bulimia nervosa, the nurse observes calluses and scars on the knuckles and back of the hands. Which statement best explains the clinical significance of this finding?
A. Indicates Russell’s sign, suggesting repeated self-induced vomiting
B. Indicates lanugo, associated with prolonged malnutrition
C. Indicates petechiae, often from platelet disorders or trauma
D. Indicates dental enamel erosion, seen with acidic regurgitation
A
A. Indicates Russell’s sign, suggesting repeated self-induced vomiting
B. Indicates lanugo, associated with prolonged malnutrition
C. Indicates petechiae, often from platelet disorders or trauma
D. Indicates dental enamel erosion, seen with acidic regurgitation
14
Q
- A nurse is reviewing the DSM classification for a group of clients on a psychiatric unit. Which client behavior should the nurse categorize as belonging to “Cluster B”?
A. A client who is extremely suspicious of others and behaves in an eccentric, odd manner.
B. A client who is intensely fearful of being alone and displays dramatic, erratic emotional
outbursts.
C. A client who appears anxious and is obsessed with following rules and schedules perfectly.
D. A client who avoids all social interaction due to an extreme fear of being criticized.
A
A. A client who is extremely suspicious of others and behaves in an eccentric, odd manner.
B. A client who is intensely fearful of being alone and displays dramatic, erratic emotional
outbursts.
C. A client who appears anxious and is obsessed with following rules and schedules perfectly.
D. A client who avoids all social interaction due to an extreme fear of being criticized.
15
Q
- The nurse is assessing a client with Borderline Personality Disorder (BPD). The client states,
“My last nurse was an angel who saved my life, but you are a cruel, incompetent person who
doesn’t care if I live or die.
“ How should the nurse best document and interpret this behavior?
A. The client is experiencing transient psychotic delusions and hallucinations.
B. The client is showing signs of dysphoria and a chronic feeling of emptiness.
C. The client is demonstrating “splitting”.
D. The client is having a dissociative episode and is unaware of their current surroundings
A
A. The client is experiencing transient psychotic delusions and hallucinations.
B. The client is showing signs of dysphoria and a chronic feeling of emptiness.
C. The client is demonstrating “splitting”.
D. The client is having a dissociative episode and is unaware of their current surroundings
16
Q
- A nurse is beginning the first meeting with a client in an outpatient mental health clinic. According to Peplau’s theory, which action should the nurse prioritize during this phase?
A. Encouraging the client to make full use of all available community resources.
B. Helping the client work interdependently to set long-term goals.
C. Assessing the client’s readiness to close the relationship.
D. Clarifying the expectations of the relationship.
A
A. Encouraging the client to make full use of all available community resources.
B. Helping the client work interdependently to set long-term goals.
C. Assessing the client’s readiness to close the relationship.
D. Clarifying the expectations of the relationship.
17
Q
17.During a clinical session, a client begins to express deep-seated feelings and states,
“I feel stronger and more capable of handling my problems now that we are working together .
“ The nurse should identify that the relationship has moved into which phase?
A. Resolution
B. Exploitation
C. Identification
D. Orientation
A
A. Resolution
B. Exploitation
C. Identification
D. Orientation
RATIO: The Identification Phase is characterized by the client beginning to work interdependently with the nurse. It is during this time that the client starts to express feelings
and begins to feel a sense of personal strength and security within the relationship.
18
Q
- As the client prepares for discharge, the nurse notices the client is becoming more independent and no longer requires professional assistance for daily problem-solving. Which task is the priority for the nurse?
A. Reviewing the information and explanations provided at the start of treatment.
B. Encouraging the client to use all services offered by the facility one last time.
C. Helping the client give up dependent behavior and successfully end the relationship.
D. Redirecting the client to start the identification process with a new therapist.
A
A. Reviewing the information and explanations provided at the start of treatment.
B. Encouraging the client to use all services offered by the facility one last time.
C. Helping the client give up dependent behavior and successfully end the relationship.
D. Redirecting the client to start the identification process with a new therapist.
19
Q
- A 35-year-old patient presents to a primary care clinic with persistent low mood, loss of
interest in activities, and disturbed sleep for the past three weeks. According to the mhGAP
intervention guide, which of the following is a key clinical rule for the management of
Depression (DEP) in a non-specialist setting?
A. Avoid the use of antidepressants in children and adolescents as the first line of treatment.
B. Start antidepressant medication immediately for all patients reporting low mood, regardless
of severity.
C. Advise the patient to take as much bed rest as possible to recover their
D. Only consider a diagnosis of depression if the patient also exhibits psychotic symptoms like
A
A. Avoid the use of antidepressants in children and adolescents as the first line of treatment.
B. Start antidepressant medication immediately for all patients reporting low mood, regardless
of severity.
C. Advise the patient to take as much bed rest as possible to recover their
D. Only consider a diagnosis of depression if the patient also exhibits psychotic symptoms li
20
Q
- A patient presents with flashbacks, severe anxiety, and avoidance of certain locations following a violent physical assault one month ago. According to the mhGAP 2.2 protocol for PTSD, which intervention is specifically recommended
for adults with this disorder?
A. Routine prescription of benzodiazepines to manage the patient’s anxiety and sleep
disturbances.
B. Psychological treatments such as Cognitive Behavioral Therapy (CBT) with a trauma focus or
Eye Movement Desensitization and Reprocessing (EMDR).
C. Advising the patient to avoid thinking about the event until their symptoms naturally fade
away.
D. Immediate referral for electroconvulsive therapy (ECT) to alleviate acute distress.
A
A. Routine prescription of benzodiazepines to manage the patient’s anxiety and sleep
disturbances.
B. Psychological treatments such as Cognitive Behavioral Therapy (CBT) with a trauma focus or
Eye Movement Desensitization and Reprocessing (EMDR).
C. Advising the patient to avoid thinking about the event until their symptoms naturally fade
away.
D. Immediate referral for electroconvulsive therapy (ECT) to alleviate acute distress.
21
Q
- The nurse is explaining the mechanism of action for Benzodiazepines to a student nurse.
Which statement correctly describes how these drugs produce an anxiolytic effect?
A. They bind to specific sites on GABA receptors, increasing the inhibitory effects of the GABA
neurotransmitter.
B. They act as serotonin agonists to decrease the turnover of neurotransmitters in the brain.
C. They block the reuptake of dopamine and norepinephrine to improve the client’s mood and
energy.
D. They selectively inhibit the influx of sodium and potassium into the neurons to prevent
depolarization
A
A. They bind to specific sites on GABA receptors, increasing the inhibitory effects of the GABA
neurotransmitter.
B. They act as serotonin agonists to decrease the turnover of neurotransmitters in the brain.
C. They block the reuptake of dopamine and norepinephrine to improve the client’s mood and
energy.
D. They selectively inhibit the influx of sodium and potassium into the neurons to prevent
depolarization
22
Q
- An elderly client is prescribed a benzodiazepine with a long half-life for generalized anxiety. Which assessment finding should the nurse prioritize as a significant safety risk for this specific client?
A. Complaints of mild nausea and a dry mouth.
B. Improved memory and increased focus during the day.
C. Impaired coordination and a history of nighttime falls.
D. A sudden increase in energy and heart rate..
A
A. Complaints of mild nausea and a dry mouth.
B. Improved memory and increased focus during the day.
C. Impaired coordination and a history of nighttime falls.
D. A sudden increase in energy and heart rate..
23
Q
- A nurse is providing discharge education to a client who has been taking a high dose of
Alprazolam for several months. Which instruction is the most critical for the nurse to include?
A. “You can stop taking this medication as soon as you feel your anxiety has resolved.”
B. “Drinking one glass of wine with your medication will help you sleep better.”
C. “This medication treats the underlying cause of your anxiety so you won’t need therapy.”
D. “Never discontinue this medication abruptly.”
A
A. “You can stop taking this medication as soon as you feel your anxiety has resolved.”
B. “Drinking one glass of wine with your medication will help you sleep better.”
C. “This medication treats the underlying cause of your anxiety so you won’t need therapy.”
D. “Never discontinue this medication abruptly.”
24
Q
- A nurse is developing a plan of care for a client with Borderline Personality Disorder. Which
outcome should the nurse prioritize as the most critical during the initial phase of treatment?
A. The client will verbalize greater satisfaction with interpersonal relationships.
B. The client will demonstrate advanced problem-solving skills for work-related stress.
C. The client will remain safe and free from significant self-inflicted injury.
D. The client will identify three personal strengths and positive attributes.
A
A. The client will verbalize greater satisfaction with interpersonal relationships.
B. The client will demonstrate advanced problem-solving skills for work-related stress.
C. The client will remain safe and free from significant self-inflicted injury.
D. The client will identify three personal strengths and positive attributes.
25
25. When evaluating the effectiveness of a long-term treatment plan for a client with a
personality disorder, which observation by the nurse indicates the most significant
improvement in the client's condition?
A. The client agrees to follow the hospital rules only when a favorite nurse is on duty.
B. The client experiences fewer emotional crises, and they occur less frequently over time.
C. The client states that they no longer need any form of therapy or medication.
D. The client successfully manipulates staff members into changing their scheduled
appointment.
A. The client agrees to follow the hospital rules only when a favorite nurse is on duty.
**B. The client experiences fewer emotional crises, and they occur less frequently over time.**
C. The client states that they no longer need any form of therapy or medication.
D. The client successfully manipulates staff members into changing their scheduled
appointment.
26
26. The nurse recognizes the shift of the trachea toward the left and the distended neck veins as
hallmark signs of which condition?ehp
A. Tension Pneumothorax
B. Open Pneumothorax
C. Hemothorax
D. Pulmonary Embolism
**A. Tension Pneumothorax**
B. Open Pneumothorax
C. Hemothorax
D. Pulmonary Embolism
27
27.Which immediate medical intervention should the nurse anticipate and prepare for to
prevent cardiac arrest in this patient?
A. Insertion of a small-bore nasogastric tube.
B. Immediate needle decompression in the second intercostal space.
C. Administration of a high-dose diuretic to reduce neck vein distention.
D. Preparing the patient for an emergency spiral CT scan.
A. Insertion of a small-bore nasogastric tube.
**B. Immediate needle decompression in the second intercostal space.**
C. Administration of a high-dose diuretic to reduce neck vein distention.
D. Preparing the patient for an emergency spiral CT scan.
RATIO: To relieve pressure
28
28. During percussion of the affected side of the chest, which sound should the nurse expect to
hear?
A. Dullness
B. Flatness
C. Hyperresonance
D. Resonance
A. Dullness
B. Flatness
**C. Hyperresonance**
D. Resonance
29
29. The nurse observes the monitor and notes that some premature ventricular complexes
(PVCs) have a tall, upright QRS shape, while others have a deep, downward-pointing QRS shape.
How should the nurse accurately describe these findings in the medical record?
A. Uniform PVCs
B. Unifocal PVCs
C. Multifocal PVCs
D. Successive PVCs
A. Uniform PVCs
B. Unifocal PVCs
**C. Multifocal PVCs**
D. Successive PVCs
RATIO: Multifocal (or multiform) PVCs are those that have different shapes. This indicates that
the irritable impulses are originating from more than one location in the ventricles.
30
30. The nurse reviews the patient's laboratory results. Which finding should the nurse identify
as a likely contributing factor to the increased irritability of the ventricular cells?
A. Serum potassium level of 3.1mEq/L
B. Serum sodium level of 142 mEq/L
C. Serum magnesium level of 2.2 mg/dL
D. Hemoglobin level of 14 g/dL
**A. Serum potassium level of 3.1mEq/L**
B. Serum sodium level of 142 mEq/L
C. Serum magnesium level of 2.2 mg/dL
D. Hemoglobin level of 14 g/dL
31
31. A patient with an acute myocardial infarction (MI) begins to have frequent, multifocal PVCs.
Which action should the nurse take first?
A. Increase the patient's IV fluid rate to improve preload.
B. Administer oxygen and administer amiodarone as prescribed.
C. Encourage the patient to perform the Valsalva maneuver.
D. Ask the patient to cough vigorously to terminate the dysrhythmia
A. Increase the patient's IV fluid rate to improve preload.
**B. Administer oxygen and administer amiodarone as prescribed.**
C. Encourage the patient to perform the Valsalva maneuver.
D. Ask the patient to cough vigorously to terminate the dysrhythmia
RATIO: Kailangan ng antiarrhythmic Drug
32
Situation: A 65-year-old male is admitted to the emergency department following a major motor vehicle accident. He has lost a significant amount of blood and with a blood pressure of 84/50 mmHg. His urine output has dropped to 15 mL per hour for the last 4 hours.
32. The nurse identifies that the patient's current kidney insult is which type of acute kidney
injury (AKI)?
A. Intrarenal acute kidney injury
B. Postrenal azotemia
C. Acute tubular necrosis (ATN)
D. Prerenal azotemia
A. Intrarenal acute kidney injury
B. Postrenal azotemia
C. Acute tubular necrosis (ATN)
**D. Prerenal azotemia**
33
33. The patient's laboratory results show that his Blood Urea Nitrogen (BUN) is rising significantly faster than his serum creatinine level. Based on the pathophysiology of AKI, how should the nurse interpret this specific finding?
A. The patient has developed extensive tubular damage and sloughing.
B. This indicates primary kidney dysfunction where the ratio remains constant.
C. Glomerular filtration has stopped because intrarenal pressure is lower than glomerular
pressure.
D. The rise in BUN is likely related to dehydration or increased protein breakdown.
RATIO: BUN is affected by diet
A. The patient has developed extensive tubular damage and sloughing.
B. This indicates primary kidney dysfunction where the ratio remains constant.
C. Glomerular filtration has stopped because intrarenal pressure is lower than glomerular
pressure.
**D. The rise in BUN is likely related to dehydration or increased protein breakdown.**
RATIO: BUN is affected by diet
34
34. A patient has intrarenal AKI. Which clinical manifestation should the nurse prioritize for
monitoring as the patient enters the oliguric phase?
A. Urine output of 500 mL/day.
B. Azotemia.
C. Increased glomerular filtration rate (GFR).
D. Rapid decrease in antidiuretic hormone (ADH) release.
A. Urine output of 500 mL/day.
**B. Azotemia.**
C. Increased glomerular filtration rate (GFR).
D. Rapid decrease in antidiuretic hormone (ADH) release.
RATIO: nitrogen/urea deposition
35
Situation: A 58-year-old female is brought to the Emergency Department by her husband. He reports that while they were eating dinner, she suddenly complained of the "worst headache of her life" and then became confused. Upon assessment, the nurse notes the patient has significant weakness on
the left side of her body.
35. Based on the patient's clinical manifestations, which area of the brain does the nurse suspect is primarily involved?
A. Left cerebral hemisphere
B. Right cerebral hemisphere
C. Brainstem
D. Cerebellum
A. Left cerebral hemisphere
**B. Right cerebral hemisphere**
C. Brainstem
D. Cerebellum
RATIO: Yung opposite side yung nadamage
36
36. The patient's CT scan confirms a subarachnoid hemorrhage (SAH) caused by a ruptured
aneurysm. The nurse monitors the patient closely for a "sudden and periodic constriction of a
cerebral artery" that can lead to further ischemia. Which term correctly describes this
complication?
A. Arteriovenous malformation (AVM)
B. Amaurosis fugax
C. Vasospasm
D. Hemianopsia
A. Arteriovenous malformation (AVM)
B. Amaurosis fugax
**C. Vasospasm**
D. Hemianopsia
RATIO: Nagkakaroon ng periodic constriction
37
37. Which clinical manifestation should the nurse identify as the earliest sign of hypovolemic
shock in this patient?
A. A decrease in systolic blood pressure below 90 mmHg.
B. The presence of mottled, cold skin on the extremities.
C. A decrease in urine output to less than 30 mL/hr .
D. An increase in heart rate.
RATIO: Early Sign
A. A decrease in systolic blood pressure below 90 mmHg.
B. The presence of mottled, cold skin on the extremities.
C. A decrease in urine output to less than 30 mL/hr .
**D. An increase in heart rate.**
RATIO: Early Sign
37
38. The nurse is caring for this patient and anticipates a prescription for a blood transfusion. Which IV fluid must the nurse ensure is used for the Infusion?
A. Lactated Ringer's solution
B. 5% Dextrose in Water
C. 0.9% Sodium Chloride
D. 0.45% Sodium Chloride
A. Lactated Ringer's solution
B. 5% Dextrose in Water
**C. 0.9% Sodium Chloride**
D. 0.45% Sodium Chloride
38
39. Following the current American Heart Association (AHA) guidelines for CPR, which sequence of actions should the nurse prioritize first?
A. Open the airway, check for breathing, and then start chest compressions.
B. Give two rescue breaths followed by 30 chest compressions (ABC approach).
C. Initiate chest compressions at a rate of at least 100 per minute and a depth of at least 2
inches.
D. Insert an oropharyngeal airway and set oxygen flow to 15L/min before starting compressions
A. Open the airway, check for breathing, and then start chest compressions.
B. Give two rescue breaths followed by 30 chest compressions (ABC approach).
**C. Initiate chest compressions at a rate of at least 100 per minute and a depth of at least 2 inches.**
D. Insert an oropharyngeal airway and set oxygen flow to 15L/min before starting compressions
39
40. The resuscitation team has arrived, and the monitor confirms the patient is in pulseless Ventricular Fibrillation (VF). What is the immediate priority for the nurse?
A. Deliver shock immediately, then resume CPR.
B. Continue CPR until the physician arrives to intubate the patient.
C. Administer a bolus of normal saline through a large-bore IV line.
D. Stop all activity to check for a carotid pulse for at least 10 seconds.
**A. Deliver shock immediately, then resume CPR.**
B. Continue CPR until the physician arrives to intubate the patient.
C. Administer a bolus of normal saline through a large-bore IV line.
D. Stop all activity to check for a carotid pulse for at least 10 seconds.
40
41. To address the emotional part of the message and reduce the risk of distortion, which
communication mode should the nurse manager prioritize for the initial counseling session?
A. Written communication via email to ensure the message is documented.
B. Telephone communication to allow for rapid clarification of the issue.
C. Formal written report submitted directly to the Human Resources
department.
D. Face-to-face communication to utilize both oral and nonverbal cues.
A. Written communication via email to ensure the message is documented.
B. Telephone communication to allow for rapid clarification of the issue.
C. Formal written report submitted directly to the Human Resources
department.
**D. Face-to-face communication to utilize both oral and nonverbal cues.**
41
42. After the counseling is complete, which action should the manager take to provide a permanent record of the expectations?
A. Send a text message to the nurse's personal phone.
B. Rely on nonverbal cues of agreement to confirm the nurse understood.
C. Call the nurse again later that evening to reiterate the main points.
D. Follow up with written communication.
A. Send a text message to the nurse's personal phone.
B. Rely on nonverbal cues of agreement to confirm the nurse understood.
C. Call the nurse again later that evening to reiterate the main points.
D. Follow up with written **communication.**
42
43. When charting the client's emotional state, which entry represents the most objective and
accurate clinical documentation?
**A. "The client states, 'I feel a little better today.' Sat in dayroom for 2 hours."**
B. "The client is depressed but had a good morning and ate well."
C. "The client seems to be in a better mood and is finally making friends."
D. "The client is still suicidal but is trying to act normal by sitting in the dayroom
**A. "The client states, 'I feel a little better today.' Sat in dayroom for 2 hours."**
B. "The client is depressed but had a good morning and ate well."
C. "The client seems to be in a better mood and is finally making friends."
D. "The client is still suicidal but is trying to act normal by sitting in the dayroom
43
44. A nurse is reviewing the chart of a client with Borderline Personality Disorder. The previous shift documented that the client was "manipulative and difficult during the medication pass." Why is this documentation considered ineffective?
A. It uses labels instead of describing the specific behaviors observed.
B. It is too concise and should include the client's vital signs.
C. Mental health charting should only focus on positive progress.
D. Documentation of "difficult" behavior is only allowed in physician notes.
**A. It uses labels instead of describing the specific behaviors observed.**
B. It is too concise and should include the client's vital signs.
C. Mental health charting should only focus on positive progress.
D. Documentation of "difficult" behavior is only allowed in physician notes.
44
45. When using the SBAR communication tool to report this change in the client's status, which
statement should the nurse include in the "Assessment" portion of the report?
A. "I am calling because the client is acting out and refusing to follow the unit schedule."
B."The client was admitted three days ago following a suicide attempt by overdose."
C."The client is currently pacing, has a rigid posture, and appears to be escalating in
agitation."
D."I suggest we order Lorazepam 2 mg IM to be given now for the client's
agitation."
A. "I am calling because the client is acting out and refusing to follow the unit schedule."
B."The client was admitted three days ago following a suicide attempt by overdose."
**C."The client is currently pacing, has a rigid posture, and appears to be escalating in agitation."**
D."I suggest we order Lorazepam 2 mg IM to be given now for the client's
agitation."
45
46. Following the conversation with the psychiatrist, the nurse receives a verbal order for a
medication. According to the I-SBAR-R modification, what is the final step the nurse must take
to ensure the communication was accurate?
A. Identify themselves and their professional credentials to the physician.
B. Document the order in the electronic health record immediately.
C. Ask the Case Manager (CM) to verify the cost-effectiveness of the medication.
D. Repeat the order back to the psychiatrist to confirm the response
A. Identify themselves and their professional credentials to the physician.
B. Document the order in the electronic health record immediately.
C. Ask the Case Manager (CM) to verify the cost-effectiveness of the medication.
**D. Repeat the order back to the psychiatrist to confirm the response**
46
47. During a hemodialysis session, the nurse monitors the patient for complications. Which
statement correctly explains the movement of substances across the dialyzer membrane?
A. Red blood cells and plasma proteins move from the blood into the dialysate to reduce
azotemia.
B. Water moves from the blood to the dialysate through osmosis because the dialysate has a
lower osmolarity.
C. Bicarbonate and calcium generally move from the dialysate into the patient's plasma to
restore acid-base and electrolyte balance.
D. The dialysate is kept at room temperature (21C) to prevent the rapid diffusion of potassium
out of the blood.
A. Red blood cells and plasma proteins move from the blood into the dialysate to reduce
azotemia.
B. Water moves from the blood to the dialysate through osmosis because the dialysate has a
lower osmolarity.
**C. Bicarbonate and calcium generally move from the dialysate into the patient's plasma to restore acid-base and electrolyte balance.**
D. The dialysate is kept at room temperature (21C) to prevent the rapid diffusion of potassium
out of the blood.
47
48. The pharmacy notifies the nurse that the next bag of TPN solution will be delayed by two hours. Which nursing action is the priority to maintain patient safety during this delay?
A. Increase the current TPN rate to "catch up" so the patient receives the total daily volume.
B. Hang 10% Dextrose in water (D/W) or 20% D/W at the prescribed TPN rate for the meantime.
C. Flush the IV line with Heparin and wait for the TPN bag to arrive to avoid fluid overload.
D. Change the IV tubing and dressing while waiting for the new TPN solution.
RATIO: High in Glucose
A. Increase the current TPN rate to "catch up" so the patient receives the total daily volume.
**B. Hang 10% Dextrose in water (D/W) or 20% D/W at the prescribed TPN rate for the meantime.**
C. Flush the IV line with Heparin and wait for the TPN bag to arrive to avoid fluid overload.
D. Change the IV tubing and dressing while waiting for the new TPN solution.
RATIO: High in Glucose
48
49. A patient is being weaned from mechanical ventilation using Synchronized Intermittent
Mandatory Ventilation (SIMV). Which feature of SIMV should the nurse monitor to distinguish it
from Assist-Control (AC) ventilation?
A. The ventilator allows the patient to breathe at their own rate and tidal volume.
B. The patient is unable to breathe at their own rate between ventilator breaths.
C. The ventilator delivers a preset tidal volume even during spontaneous breaths.
D. It is used primarily as a "resting mode" where the ventilator does all the work of breathin
**A. The ventilator allows the patient to breathe at their own rate and tidal volume.**
B. The patient is unable to breathe at their own rate between ventilator breaths.
C. The ventilator delivers a preset tidal volume even during spontaneous breaths.
D. It is used primarily as a "resting mode" where the ventilator does all the work of breathin
49
50. The high-pressure alarm sounds on the ventilator of a patient with ARDS. The nurse notes the Peak Airway Pressure (PIP) has increased from 25 cmH20 to 40 cmH2O. Which condition should the nurse investigate as a potential cause of this change?
A. The patient has a leak in the ventilator tubing or a deflated cuff.
B. The patient's lungs have decreased pulmonary compliance.
C. The patient is experiencing a decrease in airway resistance.
D. The Positive End-Expiratory Pressure (PEEP) has been accidentally turned off
A. The patient has a leak in the ventilator tubing or a deflated cuff.
**B. The patient's lungs have decreased pulmonary compliance.**
C. The patient is experiencing a decrease in airway resistance.
D. The Positive End-Expiratory Pressure (PEEP) has been accidentally turned off
Closed Door
flashcards
Decks in class (6)
# Cards
