CODE RED REVIEW SPECIALISTS INC SIMULATION PRE BOARD NURSING PRACTICE VSituation 1: Vilma, age 25, has been readmitted for uncontrolled blood sugar levels. The nursing team included themental health nurse who integrated a healthy lifestyle program in addition to monitoring her blood sugar levels, staying onher prescribed diet, doing regular exercise, stress reduction, and smoking cessation program.1. Vilma casually and unaffected says that she can’t be bothered with monitoring her blood sugar level. The nurseinterprets this behaviour as:A. realistic attitude because she can maintain the ability to be coolB. adaptive coping because she is expressing her feelings and thoughts directlyC. Ineffective coping because she is ignoring or refusing to acknowledge a distressing realityD. negative because she is showing thought disturbance2. Vilma claims that can’t be so bad because it keeps her “cool” and helps “calm” her nerves. She is using the defenseof: A. sublimation B. rationalization C. displacement D. intellectualization3. The attending nurse feels frustrated and irritated with Vilma’s behaviour. It is BEST for the nurse to do: A. self-awareness B. self-aasertion C. self-control D. self-denial4. In order to master positive coping skills, the nurse encouraged Vilma to practice sublimation by: A. avoiding thinking about disturbing problems and feelings B. anticipating concequences of her actions and considering realistic solutions C. turning to others for helps and support D. engaging in relaxation and hobbies5. The nurse’s goal in teaching Vilma about healthy lifestyle is for Vilma to develop: A. awareness B.insight C. maturity D. responsibilitySituation 2: A 60 year old male client is observed by his family to be forgetful, with pronounced personality changes andsometimes becomes violent. He begins to wander and this poses a serious safety problem. He is diagnosed with Stage IIAlzheimer’s Disease.6. The nurse is preparing a plan of care. Safe nursing care is ensured for the client when he is:a. participative c. oriented to reality as much as possibleb. familiar where he is d. able to recall meaningful past experiences7. The care of the client with Alzheimer’s Disease at home proved to be challenging to the family as cognitive functioningcontinues to deteriorate. The following nursing actions should serve as guide to the family to preserve cognitive functionEXCEPT:a. provide a low-stimulating environment c. set limitsb. call his name and tell him where he is d. talk to the client and ask him to tell stories about his past8. The physician prescribed Exelon (Rivastigmine) 1.5 mg BID. The family asks the nurse the benefit of this drug for theclient. The nurse responds accurately when she states that the medication:a. enhances the likelihood that the client will remember what to expect.b. makes the client feel more in control and not agitatedc. promotes a feeling of security and improves cognitive function.d. raises the acetylcholine level in the cerebral cortex to improve cognition function9. The nurse is doing full documentation of her nursing care. Which of the following include full documentation?a. ability to interact with others, medications given and side effects, strategies employed to enhance social interactions.b. visits of the family, health teachings, periods of interaction done, what the patient can and cannot do.c. discussing things that are of interest with the client, medications given and side effects, food intake and rest periods.d. medications given and side effects, responses to teachings given to the family and significant others and outcomes ofall interventions done.10. The client has impaired social interaction and communication related to reduced cognitive abilities. The outcomecriteria set by the nurse is that the client will:a. use appropriate languageb. have a reasonable and appropriate conversation with one personc. continue to socialize with othersd. manifest appropriate behaviour.Situation 3: When nurses are considering issues on control, shame and stigma, surrounding the subject of mental illness,one of the primary considerations should be nurse’s own sensitivity in recognizing signs of mental health problem. Ethicspervades good practice. The following situations apply11. A client is brought to the hospital by his officemates because he kept on blaming his immediate superior of getting himfired from his job. Ethical problems may arise when diagnosing psychiatric clients because of:a. subjectivity c. inadequate staffingb. lack of expertise d. inappropriate diagnostic procedures12. The nurse is administering psychotropic medication to the client. The client refused to take the medication. Which ofthe following situations would guide the nurse where a client refuses medications?a. may refuse the medications only if his attending physician agrees.b. cannot refuse his medication regardless of his medical diagnosisc. need a ourt order to allow the client to refuse his medicationd. can refuse this medication if he has not been deemed incompetent by formal legal proceedings13. Which of the following is a basic safeguard to ethical practice by the nurse providing care to clients with borderlinepersonality disorders who are extremely provocative and manipulative?a. applying person centered approach c. observing human to human relationshipb. practicing self-awareness constantly d. seeking clinical expert opinion
14. The client verbalizes to the nurse about thoughts of “threatening to kill his wife” The nurse is in dilemma whether to tellthe wife about this conversation. Given this situation which of the following is the appropriate action of the nurse?a. weigh carefully the situation by viewing it as a dilemma between disclosing confidential information or warningappropriate authoritiesb. alert immediately the proper authorities regarding the threat to safeguard the safety of the wifec. keep the information to herself and be vigilant on the action of the client to protect the wifed. tell the wife to be very extra careful as her life is in danger.15. The psychiatric diagnosing of clients is a morally charged issue and the assigning of diagnosis may be an ethicalissue.The role of the nurse in diagnosing psychiatric patient is important because nurses are:a. knowledgeable in the field of psychiatry due to extensive clinical experienceb. planners of psychiatric nursing carec. collaborators in the diagnostic processd. competent by virtue of their educational preparationSituation 4: Clients with manic disorders are often put on lithium therapy. The nurse’s undersanding of mood stabilizerswill be very important in the management of clients taking the medication.16. Before Lithium therapy begins, the nurse should make sure that the client has baseline data on client’s:a. neurologic studies c. fluid and electrolyte studiesb. enzyme studies d. renal studies17. Which of the following instructions will the nurse teach the patient when collecting a 24 hour creatine clearance for theperformance of prelithium workup?a. “Sign this consent form and then collect your urine for the next 24 hours after discarding the first urine of the morningand keep refrigerating the clean 3-liter container between voidings”b. “Sign this consent form and collect your urine in a clean 3-liter plastic container for 24 hours.”c. “Collect all urine when you wake up and for 12 hours thereafter, then discard all collected urine, noting the time. Begin ocollect all urine and refrigerate it for the the next 12 hours after your blood is drawn.”d. “Discard your first morning urine on awakening and then begin to time and collect your urine. Keep it refrigerated in aclean 3-liter plastic container. Your blood may be drawn atanytime during the collection.”18. Marita is prescribed Lithium Carbonate 1800 mg in divided doses daily. The client’s blood lithium level is monitoredregularly since lithium toxicity can be very dangerous to the client. The therapeutic range of lithium is:a. 3.0 to 5.0 mEq/L b. 0.2 to 1.0 mEq/L c. 2.0 to 3.0 mEq/L d. 0.5 to 1.5 mEq/L19. While taking Lithium, Marita is most likely to experience some common side effects of Lithium that are uncomfortableand ditressing. The nurse however, should be able to identify and be alert for signs of Lithium toxicity such as:a. increased urination, and increasing drinking c. severe vomiting, diarrhea, lack of coordinationb. mild nausea, metallic taste, fatigue d. weight gain, acne, fine hand tremors20. Signs of lithium toxicity are observed in Marita so Lithium is immediately discontinued and ordered resumed when it issafe. When teaching Marita about Lithium therapy, the following health instructions should be included EXCEPT:a. diet should include enough sodium and fluids c. blood lithium levels should be monitored regularlyb. take Lithium before meals for ease absorption d. lithium is contraindicated during pregnancySituation 5 – Poor insight into mental illness is associated with poor adherence to treatment for individuals with psychoticillnesses. The psychiatric nursing team organized to develop a program to identify strengths and weaknesses in insight inorder to promote beneficial change. The following questions apply.21. Many nurses observe that patients’ poor insight into their illness and their inability to recognize the potential forrecovery when taking their medication lead to poor adherence. Which of the following situations describe medicaladherence?a. proper observance of adequate nutrition and healthy lifestyle.b. extent to which clients behaviour coincides with medical or health advicec. degree to which clients with schizophrenia acknowledge to the health team that they have a serious mental illnessd. diligent monitoring of their signs and symptoms of disturbance22. A group discussion on poor insight was conducted. Literature review of insight include all of the following factorsEXCEPT:a. ability to recall recent and remote experiencesb. awareness of suffering from mental illnessc. acceptance of the need for treatmentd. ability to appreciate that symptoms such as delusion are abnormal23. A poor therapeutic alliance between the client and the nurse contributes to problems with effectiveness of therapeuticinterventions. This underscores a priority for the nurse to be able to:a. develop a working relationship c. establish rapport with clientsb. work out countertransference reaction d. ability to empathize24. Which of the following symptoms of illness pose a very high risk for potential for violence?a. limited interest in grooming c. poor eye contactb. fair reality testing d. command hallucinations25. When staff members perceptions of clients’ level of functioning vary markedly with the client’s own self-perception, it ismost likely that the client is minimizing his symptoms and employing:a. compensation b. rationalization c. denial d. projectionSituation 6: Community problems of substance use were noted in ER admission cases. The following situations refer todifferent stages of patients’ hospitalization.26. To manage alcohol withdrawal, which of these pharmacotherapeutic agents are commonly used?a. Librium (CHlordiazepoxide) and vitamin (thiamine) therapyb. Selective Serotonin Reuptake Inhibitorsc. Halperidol (Haldol) and calcium channel blockers
d. intravenous alcohol drip in decreasing doses27. The alcoholic has low frustration tolerance. The nurse intervenes initially by:a. encouraging verbalization of clientb. assisting with development of constructive coping skillsc. helping client utilize his support systemd. providing positive interpersonal experiences28. At endorsement report the nurse learns that MS. V is in opiate withdrawal. For what objective data should the nursebe alert?a. somnolence, constipation, normal pupils and hypothermiab. lacrimation, rhinorrhea, dilated pupils and muscle spasmsc. visual and tactile hallucinations, agitation and grand mal seizured. tremors, hypertension, constricted pupils and deep sleep29. A 35 year old male admitted to drinking six beers a day 5 years ago. He now requires 10 to 12 beers a day to achievethe same effect. The nurse assesses this as:a. ineffective coping b. tolerance c. altered mental status d. withdrawal30. A teen-age girl was admitted with a history of cocaine abuse. Her pupils are dilated and she complains of nausea andfeeling cold. She insists that she is not addicted but uses cocaine at parties with peers.a. Ineffective denial related to substance use as evidenced by refusal to admit problemb. Impaired verbal communication related to substance use as evidenced by giving untrue informationc. Perceptual alteration related to substance use as evidenced by distortion of realityd. altered growth and development related to substance use as evidenced by age of onsetSituation 7: Ethico-legal issues challenge the nurse as a researcher. The following situations apply.31. During the process of data collection in a survey an incidence of mental illness in the community, the nurse’s picturewas with the family who was the research subject and who were so nice and receptive to questioning. This action:a. must be avoided to protect the nurse from future exploitationb. encroached on the rights of the subjects to privacy and confidentialityc. is acceptable considering that Filipinos are generally friendlyd. has no bearing on the rights of the subjects to privacy and confidentiality32. The nurse observer is confronted of the need to provide counselling to a subject, a woman who had experiencedmastectomy. It is best for the nurse to:a. be guided with the research protocol c. refrain from doing anything except to observeb. refer the situation to the attending physician d. counsel the client as necessary33. In situations where a serious ethical problem occurs when data are falsified or misused in research reports, whocarries the principal responsibility for data fabrication?a. institution b. investigator/researcher c. project staff d. encoder of data34. The nurse researcher commonly encounters a conflict of interest in doing a research when he/she is also the:a. co-researcher b. nurse caregiver c. same sex d. same age-group35. The research process included exposure of subject to a very stressful situation prior to a structured interviewconducted by the researcher. Information must be withheld from participating subjects to ensure validity of the results. Theresearch design must incorporate:a. acknowledgement to the subject that deception was committed somehowb.compensation package for the subject for whatever moral and ethical inconsideration that have been inadvertentlycommitted.c. plans for debriefing at some time during the study, most commonly at its completiond. formal acknowledgement of particiapation at the end of the research.Situation 8: Myrna is a 15 year old female who was admitted to the Adolescent Unit because of impulsiveness,uncontrolled outbursts, profane language and involvement in fights in school and frequent absenteeism.36. During the assessment, Myrna seems upset and irritable. She asks, “Will you tell everything to my parents and write areport to my school?” Which of the following is the BEST response of the nurse to Myrna?a. “Myrna, I may not write a report to your teacher but I need to discuss with your parents.”b. “Myrna. It is best for your parents and teacher to know so they can guide you.”c. “Of course not Myrna. Everything you share with me is confidential.”d. “Myrna, I will maintain confidentiality on matters that are not a risk to you and others.”37. Which of the following questions would be MOST appropriate to obtain data about Myrna’s affect?a. “You look upset are you?” c. “Why do you think you always get into fights?”b. “are you angry or sad?” d. “How are you feeling?”38. In which part of the mental status examination would the nurse document Myrna’s interpretation of the proverb, “Arolling stone gathers no moss.”?a. quality of speech c. higher brain functionb. perceptual-sensory function d. thought content and process39. The nurse performed a mental status examination and assessed Myrna’s mood. What is the MOST important data todocument in Myrna’s record?a. congruency between thought processes, affect and mood.b. congruency between thought process and mood.c. congruency or incongruency between thought content, affect and mood.d. congruency or incongruency of delusions and mood changes.40. The data gathered using the Psychosocial Assessment Tool include all of the following EXCEPT:a. individual and family strengths and coping patterns c. personality typeb. baseline information about Myrna’s level of functioning d. actual and potential problems
Situation 9 – From the monthly meeting of nurses assigned at the mental health psychiatric nursing facility, a report onpatient assault were on the rise. This necessitated a series of nursing team conferences.41. Staff nurses become increasingly controlling initially because:a. they need to assert nurse’s professional roleb. patients must learn autonomy and self-reliancec. there is lack of trust and fear of future incidents of untoward eventsd. they must not be blamed by their colleagues and administration42. The staff’s reactions to both patient suicide and patient assault reported cognitive, affective and behavioural changes.Which of these reactions include all of the three aspects?a. exaggerated startle response, increased staff control over patients, compulsive behaviourb. self-blame, anger, change in relationships with co-workersc. flashbacks, pre-occupation with the incident and distressing recollection of the eventd. fear of another incident, anger at the institution and apprehension of being held liable43. An increase in burn-out, absenteeism and staff turnover as an aftermath of patient suicide or assault must be primarilyrecognized as:a. the nursing staff and anciliary staff are in a state of upheavalb. patient suicide and assault must constitute occupational hazards for psychiatric nurses and ancilliary staffc. the nursing staff and ancilliary staff need stress debriefingd. the quality of patient care is compromised44. As the nurse conducts the nursing audit, she checks completion of patient record with diagnosis of post-traumaticstress disorder. She particularly would look at records documenting:a. grief as a reaction to actual or perceived lossb. an element of traumac. effects of incident on significant disruption in client’s functioningd. painful feelings to threats to self-esteem, trust and perceived loss of control45. A corrective and preventive measure to mitigate the effects of post-traumatic stress disorder that the nurse prioritizeis:a. immediate pharmacologic treatment with anti-anxiety drugsb. conduct progressive relaxation exercisec. utilize family and social support to promote expression of feelings, thoughts and responses arising from the eventd. organize emergency preparedness programs for calamities such as fires, earthquakes and floods.Situation 10: The nurse wants to indentify factors conducive to the adjustment of discharged patients on their return to thecommunity. The following questions apply.46. The nurse examined the variable on readmission rates to psychiatric hospitals. Which of the following are a socio-demographic variables?a. support of friends, spouse, relatives and co-workersb. frequency of follow-up visits at the mental health clinic and compliance with medicationc. leisure and church related activitiesd. gender, age, marital status, employment status47. Which of the following will yield data through a retrospective self-report questionnaire on social activities?a. hypothetical situations c. present experience of subjectsb. recall of subjects d. future plans or subjects48. Which questionnaire allowed respondents to give free comments regarding relationship with a significant other?a. indirect b. open ended c. closed ended d. direct49. Sixty percent of the respondents rated “friends” as personal support systems. If there were120 respondents, howmany respondents checked “friends” as greatest influence on avoiding hospitalization?a. 66 b. 60 c. 70 d. 7250. Given the list of work opportunities, which is the method of placing preference in an ascending or descending order?a. coding b. Q sort c. rating d. ranking50. Given a list of work opportunities, which is the method of placing preference in an ascending or descending order?A. Coding C. RatingB. Q sort D. RankingSITUATION 11- Lorena is a 30 year old single mother who is is dependent on her family for support. Her diagnosis is mildmental retardation with post traumatic disorder with depressive episodes. Her current symptoms include depressed moodwith irritability, difficulty tolerating, frustration, difficulty falling asleep, increased appetite and weight gain, hyper vigilanceand worry that something terrible will happen to her child.51. a cognitive assessment to Lorena indicated that according to Piaget’s theory she was functioning at the concreteoperational stage. Which of these behaviors wound the nurse observe on Lorena?A. makes and test hypothesisB. Feels her own reasoning should agree with the reasoning of others.C. Thinks logically and sees possibilitiesD. Understands only her own viewpoint.52. Lorena has difficulty tolerating frustration. The goal of the nurse is to assist Lorena to:A. mobilize her resources B. Recognize her needs C. Increase her self-esteem D. cope with anxiety53. Which of the following historical data MOST probably led to a Post-traumatic stress disorder?A. No gang-relationship with peers C. dropping out of schoolB. Suicide of her mother D. unstable relationship with ex-fiancee
54. Given her problems of hyper vigilance and worry that something terrible will happen to her child, nursing interventionswould be aimed at addressing her needs for:A. self-esteem B. Biological integrity C. Psychological security D. love and belongingness55. In terms of social support therapy, which of these is MOST appropriate and therapeutic?A. Vocational training with moderate supervision but not beyond second grade academic challenges.B. Individualized relationship with a caregiverC. High structured environment with constant aid and supervision.D. With appropriate supports, live in the community either independently or in supervised settings.SITUATION 12 – A 60 year old male client is brought to the hospital due to numbness of the face arm or leg, visualdisturbances and severe headache. His admitting diagnosis is cerebrovascular accident (CVA).56. The nurse must have been assessment skills to appropriately assess the client. Which of the following must bedetermined by the nurse during assessment?A. Past medical history, current medications and onset and progression of symptoms.B. Condition of the client, current medications and diagnostic test.C. Diagnostic test, Vital signs and current medication.D. Monitoring of vital signs, Fluids and Medications57. Which of the following is the responsibility of the nurse during the acute phase of the stroke client?A. Management of airway, breathing and cardiopulmonary support.B. Continuous assessment and monitoring of vital signs.C. Diagnostic test, Medications and fluids.D. Monitoring of vital signs, fluids and medications58. The nurse is planning the nursing care of the client. Without of the following is the goal in the management of strokeclient?A. Improve level of consciousness. C. Immediate rehabilitationB. Restore function and independence. D. Prevent further stroke59. The recommended plan of care using interdisciplinary services includes the following EXCEPT:A. Performing surgery for rapid evacuation of hematoma.B. Preventing recurrent stroke and complicationsC. Managing general health functions throughout all stages of treatment.D. Documenting and assessing acute and rehabilitation stages.60. Several disciplines join on the management of facilitating the recovery of the client following a stroke. Who of thefollowing members of the interdisciplinary team works with the client to retain activities of daily living and practiceindependence using assistive devices?A. Occupational Therapist B. Health Care Therapist C. Physical Therapist D. Speech TherapistSITUATION 13 – Suicide as a major public health problem thought the world, poses a continuing challenge to healthprofessionals. The following questions have implications on the nurse’s role.61. Suicide is related life circumstances such as death, illness, family and work related issues. Which of the followinginterventions would be MOST appropriate in such life circumstances?A. behavior therapy C. crisis counseling and interventionB. mental health education D. Individual and group therapy62. For the family members of those at risk for suicide and community helpers, which of these training programs would beMOST appropriate?A. How to implement action programs to manage substance abuse and suicidal behaviorB. How to develop strategies to reduce the stigma associated with depressive illnessC. How to enhance resources in communities for suicide preventionD. How to recognize and respond to people exhibiting signs of suicide63. Suicide tends to be ignored by society mainly because of:A. apathy C. StigmaB. Ignorance D. Indifference64. In developing suicide prevention program for adolescents which of the following topics is MOST appropriate foradolescents?A. Peer interpersonal relationships C. Coping skills developmentB. Alcohol and drugs D. Healthy life style65. Suicide is a preventable problem and best addressed by:A. education approach in schools and work placesB. medical approach by psychiatristsC. community health approach of people and institutionsD. mental health approach by professionals in clinical settingsSITUATION 14 – Nurses partner with others in delivering health care services to clients.
Collaboration requires the nurse to use effective interpersonal skills, maximize coordination of members a involved ingiving care services and as necessary provide continuity of care.66. The nurse is caring for client diagnosed with rheumatoid arthritis. She coordinated with the physician and understoodthat the laboratory test to be done is:A. alkaline phosphatase C. erythrocyte sedimention rateB .c-reactive protein D. antinuclear antibody test67. The physician ordered low purine to a client with gout. The nurse made a special dietary consultation to fit the client’sbackground. Which of the following food should be nurse advice the clients to eliminate in the diet?A. Fish and Pork C. Beef and chickenB. Fruits and vegetables D. Organ meats, wine and mussels68. The physician ordered an axillary crutch to Mr. Elmer who is treated with fracture of the femur. The nurse collaboratedwith the physical therapist on safety measure in the use of crutch. The following are safety measures EXPECT:A. support body weight from the axillaeB. Use crutches that are measured for himC. inspect routinely crutch rubber tipsD. identify the danger of pressure in the axillae when learning on the crutches69. Mr. Nino is scheduled for magnetic resonance imaging (MRI) because of recurring back pain. The nurse made anarrangement with the diagnostic center for the procedure. In preparation for the procedure. It is essential for the nurse toask which of the following?A. “Do you have fear of open spaces?” C.” Do you get tired easily?”B. “do you have any allergy?” D. Do you have any mental in you body?”70. The management of client diagnosed with Parkinson’s disease is collaborative effort among nurses physician,physical therapist and the client himself or herself. What is the primary goal set for the client?A. To reduce muscle irritability C. To strengthen muscle tissuesB. To increase muscle endurance D. To maintain joint flexibilitySITUATION 15 – Communication is the fundamental element of nurse client relationship. It is a mechanism fordemonstrating compassion and caring. The nurse must be able to communicate clearly and accurately in order for theclient’s needs to be met. The following situations apply.71. Nurse is working a client with moderate hearing impairment. Which of the following nursing approaches should thenurse follow to promote communication?A. Invite the client in a room for privacy C. Speak louderB. Use visible expression D. Quietly slip from behind the client and speak softly.72. Lola Marta has closed angle glaucoma. She asks the nurse. If her condition is hereditary. The MOST appropriateresponse of the nurse should be:A. “There is a strong hereditary factor in glaucoma. Annual intraocular measurements is required for children age 40years and above”B. if you have children over 40 years old they should be evaluated for intraocular measurement. “C. There is no relationship between the occurrence of glaucoma and heredity.”D. Family member all ages should have annual intraocular measurement.”73. Aling mameng, an elderly client is having ophthaimologic assessment by the nurse. She tells the nurse that she hasdifficulty focusing on near objects and lessened field of peripheral vision. The BEST response of the nurse is:A. “I will refer you to opthaimologist.”B. What made you say that?”C. “There is no relationship between the occurrence of glaucoma and heredity.”D. Family member all ages should have annual intraocular measurement.”74. Nurse Bette is caring for Mr. Dan who has eye patches on both eyes following eye surgery . To avoid starting theclient, which of the following interventions should the nurse do when entering the room during treatment and medication?A. Proceed to the beside and speak louder.B. “Quietly enter the room and greet the client.C. Knock at the door and introduce yourself.D. Announce presence, state name clearly before entering the room.75. Mr. Wency, 67 years old has a detached retina. He asks Nurse Rosalie what may have contributed to thedevelopment of his detached retina. The nurse’s MOST appropriate reply is:A. “Those with oranial terrors are predisposed to retinal detachment.”B. The most predisposing factor in the development of retinal tear is nearsightedness.”C. Sinusitis predisposes a person to retinal detachment.”D. Presons with hypertension are prone to develop retinal tear.”SITUATION 16 – Stabilizing and immobilizing of fractured on injured body parts are important components in restoringand preserving body functions. The following are situations where concept and principles of care apply.
76. A long leg plaster cast is applied to a client. Which of the following measures must be observed by the nurse afterthe cast is applied?A. Document procedures and teachings as well as family’s understanding of instruction.B. Check the cast if completely dry by palpating with the finger tips.C. Assess and document color, pulses movement of the casted legs.D. Support drying cast on a pillow but does not cover.77. A client is in skeletal traction. The nurse understands that this procedure involves pulling force:A. Using more than one force to support the injured extremity.B. Directly through pins inserted into the bone.C. Directly through the client’s skin.D. Physically on the extremity affected.78. In caring for clients with traction, an important consideration is to maintain the pulling force and direction. The nurseshould ensure that:A. Assessment of the affected part is monitored regularly. C. Complications be reported to the physician immediatelyB. Weight should hang freely and do not touch the floor. D. Care of the area with traction is observed.79. Which of the following types of traction uses more than one force of pull to raise and support the injured extremity offthe bed and ensure mobility while maintaining bone position?A. Balance suspension traction C. Skeletal tractionB. External fixator device D. Buck’s traction80. A client with cervical spinal cord injury is treated with a Halo Traction for cervical stabilization. The nurse shouldunderstand that this type of treatment is indicated for a client who:A. May achieve walking with braces. C. Needs excellent bed mobilityB. Does not require surgery and allows for early ambulation D. Needs adaptive device to propel wheelchair.SITUATION 17 – A child seizure disorder is brought to the hospital following another attack.81. Which of the following interventions should be initially performed by the nurse on admission?A. Discuss seizures events with the mother. C. Obtain seizure history.B. Observe for apnea and cyanosis. D. Loosen any tight clothing.82. The nurse expected outcome for the child is to remain free from physical injury. This can be accomplished when thenurse performs which of the following?A. Review medication protocol. C. Keep side rail up.B. Listen to parent concern and reassure as needed. D. Stay with the child.The child had seizure attack. After the nurse secure a safe position for the child, which of the following should be herfocus of documentation?A. Gathering data that precipitated the seizure attack.B. Making emergency equipment inventory available.C. Describing the preceding circumstances and the seizure itself.D. Prepare a report on the event of situation.84. The child felt tired and sore and could not remember anything after awakening from the deep sleep following theattack. Which of the following should be the appropriate nursing measures?A. Recognize the tension of the child C. Provide ongoing emotional and informational support.B. Reassure the child regarding the episode. D. Attempt to remove false idea regarding epilepsy.85. The child is on anticonvulsive therapy. The physician orders Phenobarbital 4mg/kg/day parenterally for 7 to 10 days.Which of the following measures MUST be observed by the nurse when administering the partial does of Phenobarbitalthru the IV infusion?A. Instruct the parents to report the health care provider if the child develops severe dizziness.B. Injected partial dose into tubing and assess response of the client before continuingC. Assess vital signs closely during IV administration.D. Warn the parents that the drug will make child drowsy.SITUATION 18 – The nurse volunteered to register in a Disaster Preparedness Program. After undergoing a review ofbasic nursing knowledge and skills she indicated she/he is now ready to be On Call. The following questions apply.86. The crisis intervention model that the nurse utilizes in emergency situation is the best flitted in which prespective?A. Socio- Cultural C. SpiritualB. Medical D. Biological87. Soledad lost her 3 school aged children in a fire that razed an overly crowded depressed are. Crisis intervention focuson the following EXCEPT:A. Immediate social integration C. The here and nowB. The event in perspective of Soledad’s life D. Past psychological history of Soledad88. The nurse expects to be called to do crisis intervention for affected clients in these situation EXCEPT:A. Catastrophic events like fire and floods C. Civil riotB. Chronic phase of mental illness D. Terrorist attacks89. The onset of crisis is triggered by a:
A. Long standing deep seated interpersonal issues. C. History of disturbed family relationshipB. Sudden Precipitating event D. Childhood conflicts90. The nurse must refer to a psychiatrist a client who:A. Verbalizes helplessness of hopelessness C. Is unable to problem-solveB. Intermittently lies and seems confused D. Has suicidal tendencySITUATION 19 – As a follow-up of patients who have been discharged, the nurse conducts small group meetings to allowthem to share their thoughts and feelings regarding going back to their communities.91. Which of the following would BEST demonstrative effecting copy of clients to live in the community?A. Avoidance of interpersonal conflicts. C. Active involvement in their care.B. Availability of strong support system. D. Strict compliance with medical regime92. Martha, 40 year old, expressed feelings of isolation. Of the following behaviors, which is the BEST coping behavior?A. Goes to church everyday to attend Mass?B. Helps around the house and do errands outside the homeC. Regularly reads a book, “The Art Living”D. Engages in computer word games like “Scrabble”93. Julia, married, 45 years old woman reports difficulties in dealing with family stressors and conflicts. The nurserecognizes the patients need for:A. Social support on a daily basis C. Continued nurse-patient relationshipB. Intensive marital therapy D. Work therapy94. Tony, middle aged man expressed, “I heard voices and things yesterday while shopping at SM mall. I was realnervous.” Which of the following is a behavior strategy that is helpful in coping with hallucination?A. Increase his psychotropic medication C. Retreat to a less stimulating environment.B. Talk about those voices with his family. D. Examine which of his thoughts is irrational.95. Psychosocial rehabilitation is BEST achieved through:A. Full community support C. Provision of adequate housing facilitiesB. Balance of control versus caring behaviors D. Compliance with home medicationsSITUATION 20 – The nurse is admitting a client with complaints of paroxysmal whirling vertigo, aural fullness andfluctuating hearing loss. She reported that these feeling last for days. She is diagnosed with Meniere’s disease.96. When assessing a client with Meniere’s disease, the nurse expects the client to experience:A. Headache C. Postural HypotensionB. Nystagmus D. Ring of the ears97. The nurse plans to reduce the risk of injury of the client’s tendency to lose balance. Which of the following should thenurse do while the client is in bed?A. Assess client’s hearing acuity.B. Darken the room and encourage the client to move in bed slowlyC. Encourage client to perform balance exercisesD. Encourage client to talk about feelings and personal perception of danger98. The nurse’s focus of care on clients with hearing and balance problem is:A. Diet and medication C. Prevention and control of infectionB. Activity and rest D. Safety and promotion of independence99. The client continues to have the disabling effect of vertigo. A labyrinthectomy can be performed to treat Meniere’sdisease. This procedure results in:A. Accumulation of cerumen C. Loss of sense of smellB. Permanent irreversible deafness D. Persistent earache100. The physician modifies the diet of the client. Which of the following is the appropriate diet for the client?A. Low Fat C. Low proteinB. High carbohydrate D. Low sodium