SIMULATION 5 NURSING PRACTICE 1

COMMUNITY HEALTH NURSING

Situation: Pain was recognized as the "fifth vital sign" in the 1990's. According to this
concept, pain intensity should be regularly assessed, together with the classic four vital
signs.

1. Zach is constantly asking to be relieved from pain. Since morphine is an addicting drug,
which of the following is BEST for the patient?
a. Give instructions on relaxation technique to reduce frequency of pain sensation
b. Administer morphine on a routine schedule as ordered
c. Administer morphine PRN - morphine shouldn't be given as PRN due to higher risk for
addiction
d. Divert his attention by not limiting visitors

2. The client complained of abdominal distension and pain. Your intervention that can alleviate
pain is:
a. Instruct client to go to sleep and relax - does not alleviate the pain
b. Advice the client to close the lips and avoid deep breathing and talking
c. Offer hot and clear soup – keep on NPO esp. If cause is UNKNOWN
d. Turn to sides frequently and avoid too much talking

3. The client verbalizes, "I'm nothing", which of the following is the most appropriate response
by the nurse?
A. "Are you suggesting that you feel worthless?" - clarify
B. "Of course, you're everything!"
C. "That's not true."
D. "You should not feel that way"

4. Which of the following questions of statements would the nurse use to encourage client
evaluation?
A. "I can hear that it is still hard for you to talk about this."
B. "So what does this mean to you?"
C. "What did you do differently with your co-worker this time?"
D. "What will it take to carry out your new plans?"

5. A client with terminal cancer tells a nurse, "I've given up and I have no hope left. I'm ready to
die." Which of the following response is most therapeutic?
A. You've given up hope? – CLARIFYING
B. We should talk to your physician about your fears of dying so soon - passing the buck
C. You should talk to your social worker - passing
D. No, you shouldn't give up hope there are cures for cancer found yesterday - disagreeing
6. Which question by the nurse would be most helpful when obtaining a health history from a
client admitted with acute pain?
A. "Do you need anything now?"
B. "Why do you think you had a heart attack?"
C. "What were you doing when the pain started?”
D. "Has anyone in your family been sick lately?"

7. Mr. Chris Martinez has been confined for three days. His wife helped take care of him and he
had observed her to be
"too involved" in his care. He complained to the head nurse about this. Which of the following
would be the BEST response of the nurse?
A. "Don't worry, I will call the attention of your wife"
B. "your wife is just trying to help because she is worried in your care?"
C. "What are your thoughts about your wife's involvement in your care?"
D. "Your wife can assist you well in your care and recovery"

8. Which of the following statements by the family of Jenny with asthma indicates the need for
additional home care teaching?
A. "We need to identify what things trigger this attack"
B. "He is to use his bronchodilator inhaler before the steroid inhales"
C. "We'll make sure that he avoids exercise to prevent attacks" - exercise is encouraged
to help strengthen lung muscles
D. "He should make sure increase his fluid intake regularly to thin secretion"

9. George, a 43 years old executive, is scheduled for cardiac bypass surgery. While being
prepared for surgery, he says to the nurse "I may die because of the risk". Which response by
the nurse is most appropriate?
A. "Without the surgery you will most likely die sooner?"
B. "There are always risks involved with surgery"
C. "There is a client in the other room who had successful surgery and you can talk to him"
D. "This must be very frightening for you. Tell me how you feel about the surgery"

SITUATION: Tessie, mother of 2 young kids, 36 years old, had a mammogram and was
told that she has breast cysts and that she may need surgery. This causes her anxiety as
shown by increase in her pulse and respiratory rate, sweating and feelings of tension.
—> MODERATE ANXIETY

10. Considering her level of anxiety, the nurse can best assist Nancy by:
A. Giving her activities to divert her attention
B. Giving detailed explanations about the treatments she will undergo – for mild anxiety
C. Preparing her and her family in case surgery is not successful
D. Giving her clear but brief information at the level of her understanding - pt cannot
comprehend anymore, reduce anxiety first
11. Tessie blames God for her situation. She is easily provoked to tears and wants to be left
alone, refusing to eat or talk to her family. A religious person before, she now refuses to pray or
go to church stating that god has abandoned her. The nurse understands that Tessie grieving
for herself and is in the stage:
A. Bargaining
B. Denial
C. Anger
D. Acceptance

12. The nurse visits Tessie and prods her to eat her food. Tessie replies 'what's the use? My
time is running out." The nurse's best response would be:
A. "The doctor ordered full diet for you so that you will be strong for surgery"
B. "I understand how you feel but you have to try for your children's sake."
C. "Have you told your doctor how you feel? Are you changing your mind with your surgery?"
D. "You sound like you are giving up." - validate

13. Realizing that she feels angry about Tessie's condition, the nurse learns that being self
aware is conscious process that she should do in any situation like this because:
A. This is a necessary part of the nurse-client relationship process
B. The nurse is a role model for the client and should be strong
C. How the nurse thinks and feels affect her actions towards her client and her work -
nurse must be aware of her own biases
D. The nurse has to be therapeutic at all times and should not be affected

SITUATION: Nurse must ensure that quality is achieved and maintained when providing
care to patients. Quality Assurance Program is an ongoing systemic process designed to
evaluate and promote excellence in the health care provided to clients.

14. Nurse Felly is conducting an outcome evaluation if she is doing which of the following
activity?
A. An audit to determine the number of postoperative infections
B. Reviewing nursing documentation for compliance with hospital standards
C. Checking clients blood pressure before administering a new antihypertensive medication
D. Conducting a survey to analyze patterns of staffing
15. The nursing assistant assigned to a client forgets to measure his urinary output, and
discards the urine. Who is directly responsible for the nursing assistant action?
A. Nursing assistant
B. Client's physician
C. Registered Nurse caring for the client
D. Nursing Supervisor

16. Nurse Felly receives an order to insert an indwelling catheter in a client if he is unable to
void. The previous shift reports that the client has not voided in 12 hours. What should the nurse
do before inserting the catheter?
A. Ask family and visitors to leave the room
B. Reassess the client for a change in his position - non invasive first
C. Determine if help will be needed during the procedure
D. Gather supplies to perform the catheterization

17. A client who has been unable to void for 12 hours tells the nurse, "I just urinated in the
bathroom without any problem." Which of the following nursing orders should be implemented
next?
A. Asses character and quantity of urine
B. Check for bladder distension
C. Offer urinal every 4 hours
D. No further intervention are needed

18. The Quality Assurance staff of a hospital is conducting a study to determine infection rates
in postoperative clients. What type of quality assurance program is this?
A. Outcome evaluation
B. Process evaluation
C. Structure evaluation
D. Quality improvement

SITUATION: Disaster preparedness is crucial and should be everybody's business.

Comprehensive Emergency Management (CEM) is an integrated approach to the
management of emergency programs and activities for all emergency phases and for all
levels of government and private sector.

19. Which of the following best describes the action of a nurse who documents her nursing
diagnosis?
A. She charts if only when the patient is acutely ill
B. She documents it and charts it whenever necessary
C. She can be accused of malpractice
D. She does it regularly as an important responsibility – accurate and timely documentation
is the hallmark of nursing responsibility

20. Which of the following should the nurse AVOID doing in preventing spread of infection?
A. Do not give fresh & uncooked fruits & vegetables to Mr. Po, with Neutropenia
B. Recapping the needle before disposal to prevent injuries
C. Never pointing a needle towards a body part
D. Using only Standard precaution to AIDS patients

21. When initiating the implementation phase of the nursing process, the nurse performs which
of the following steps first?
A. Documenting interventions
B. Carrying out nursing interventions
C. Reassessing client
D. Determining the need for assistance

22. Personal Protective Devices in occupational health nursing is what type of prevention?
A. Primary
B. Secondary
C. Tertiary
D. None of the above

23. As an RN, you know that the entrance requirements for 3 day basic IVT is/are:
A. A letter of recommendation from PNA
B. RN with 1 year hospital experience
C. RN with units in Graduate school
D. Current PRC license or certified board rating for new nurses

SITUATION: Disaster preparedness is crucial and should be everybody's business.

Comprehensive Emergency Management (CEM) is an integrated approach to the
management of emergency programs and activities for all emergency phases and for all
levels of government and private sector.

24. Client assessment in the emergency department involves primary and secondary
assessment. The nurse understands the purpose of the primary assessment if she avoids doing
which of the following?
A. Uses the ABC's as a guide in assessing the client needs
B. Assesses the client who sustained a traumatic injury for signs of a head injury
C. Identifies any client problem that poses an immediate or potential threat of life
D. Obtains both subjective & objective data, a complete, focused physical assessment -
secondary

25. The term given to a category of triage that refers to life threatening or potentially life
threatening injury or illness requiring immediate treatment:
A. Emergent
B. Immediate
C. Urgent
D. Non-acute

26. Which of the following terms refer to a process by which the individual receives education
about recognition of stress reaction and management strategies for handling stress, which may
be instituted after a disaster?
A. Clinical incident stress management
B. Follow-up and follow through
C. Defusion - education regarding stress reaction and management
D. Debriefing - sharing of emotions

27. As part of disaster management, you should know as nurse that victim w/ a green tag
signifies: minimal
A. Indicates injuries are extensive & chances of survival are unlikely even w/ definitive care -
black
B. Has injuries that are minor & treatment can be delayed from hours to days
C. Has injuries that are significant & require medical care but can wait hours - yellow
D. Has injuries are threatening but survival is good m/ minimal intervention - red

28. Which of the following phases of emergency management is defined as "sustained action
that reduces or eliminates long term risk of people & property from natural hazard & their
effects?
A. Response
B. Mitigation
C. Recovery
D. Preparedness
SITUATION: Nursing involves all aspects of care across lifespan. One unique aspect of
Nursing is that, it extends up to giving respectful and dignifies dying. Post mortem care
concerns not only the decreased patient but the family as well.

29. A nurse has been caring for a dying client for the past week as the nurse is leaving her shift,
the client begins to rapidly decline with a minimal respirations. The family is distraught and
crying since they recognize that the client is dying. The nurse chooses to stay with the client's
family in the waiting room after she has clocked out. Which of the following best describes the
nurse's actions?
A. The nurse's action was appropriate
B. The nurse's action was inappropriate and may require disciplinary action
C. The nurse's action interfered with the grieving process of the family
D. The nurse's action though not appropriate, is not encouraged

30. The family of an accident victim who has been declared brain-dead seems amenable to
organ donation. What should the nurse do?
A. Discourage them from making decisions until their grief has eased
B. Listen to their concerns and answer their questions honestly
C. Encourage them to sign the consent form right away
D. Tell them the body will not be available for wake or funeral

31. Proper handling of the body following death is an important intervention for the client, family,
and nurse. An intervention that reflects an important principle of post mortem care is:
A. Preparing the body to look as clean as natural as possible
B. Pulling the sheet over the patients face until the family is comfortably seated in the room
C. Calling the physician to verify the time of death before taking the body to morgue
D. Humor is helpful in relieving stress, however use humor only after family has left
32. Which of the following is true regarding a patient with DNR order?
A. Nurses will most likely continue to implement most treatments
B. The patient may no longer make decisions regarding his or her own health care
C. The patient & the family recognize that the patient will most likely die w/in next 48 hours
D. A DNR order in place from previous admission is valid for this & subsequent admissions. -
DNR is only valid for 24 hours

33. An elderly client has been identified as a victim of physical abuse. In planning care, the
nurse places highest priority on:
A. Notifying the caseworker to intervene in the family situation
B. Removing the client from any immediate danger
C. Obtaining treatment for the abusing family member
D. Adhering to the mandatory abuse reporting laws

34. A nurse plans to carry out a multidisciplinary research project on the effects of immobility on
client's stress levels. The nurse understands that which principle is most important when
planning this project?
A. The office of the chief nurse should be consulted, because the project will take time
B. Collaboration w/ other disciplines is essential to the successful practice of nursing –
multidisciplinary research approach
C. All clients have the right to refuse to participate in research using human subjects
D. The cooperation of the physicians on staff must be ensure for the project protocol

35. In the recent technological innovations, which of the following describe researches that are
made to improve and make human life easier?
A. Basic research
B. Experimental research
C. Pure research
D. Applied research

SITUATION: When the total population appears to be very large the researcher may
decided to get a representative sample and yet to make research findings still and
acceptable.

36. In this type of sampling, data are collected from anyone available such as those who are
present in the coffee shop or those who are present in the emergency room at one time or
another:
A. Incidental sampling
B. Simple random sampling
C. Cross-sectional sampling
D. Systematic sampling

37. The type of sampling uses the technique whereby the population is subdivided into areas or
section and then taking random from each section.
A. Stratified sampling
B. Cluster sampling
C. Purposive sampling
D. Systematic sampling

38. The study group from where you will select your study subjects is referred to as the:
A. Study group
B. Population
C. Research subject
D. Universe

39. The proposed study (relationship between healthy values and the health promotion activities
of staff nurses in selected college of nursing) shows the relationship between the variable.
Which of the following is the independent variable?
A. Health promotion activities
B. Healthy values
C. Staff nurses in a selected college of nursing
D. Relationship between HV and HPA

40. Which part of the study is subjected to validity and reliability testing?
A. Methodology
B. Hypothesis
C. Instrument
D. Variables

SITUATION: You are educating people in Barrio Manuela about different diseases/
conditions and its specific prevention.

41. Among the following diseases which of the given condition is airborne?
A. Viral conjunctivitis
B. Acute poliomyelitis
C. Diphtheria
D. Measles

AIRBORNE ACRONYM:

42. Contamination of water in different housing facilities is common without proper maintenance.
The only microorganism monitored in cases of contaminated water is:
A. Vibrio Cholera
B. Escherichia Coli
C. Entamoeba Histolytica
D. Coliform Test

43. Which of the following options is not caused by a virus?

A. German Measles
B. DHF
C. Chicken Pox
D. Malaria - caused by plasmodium

44. In the Philippines, which condition is the most frequent cause of death associated with
schistosomiasis?
A. Liver Cancer
B. Liver Cirrhosis
C. Bladder Cancer
D. Intestinal Perforation

45. Diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following
teaching should you give as an early sign of leprosy
A. Macular Lesions
C. Sinking of the nose bridge
B. Inability to close eyelids (lagopthalmos)
D. Thickened painful nerves
SITUATION: For safety and quality purpose, it is equallyimportant to be mindful of the
roles and functions and the instituted systems, and procedures in relation to the
practices of Community Health Nursing (CHN). The following questions apply.

46. The focus activities in specific protection is a level of prevention classified as:
A. Secondary prevention
B. Intervention prevention
C. Tertiary prevention
D. Primary prevention

47. PHC embraces all of the following concepts EXCEPT:

A. People's participation
B. Community Organizing as core of PHC
C. Use of higher technology - appropriate technology
D. It is an approach to provide the basic needs of the community

48. The basic unit of care in CHN is:

A. Community
B. Groues
C. Family
D. Individual Client

49. The nurse as a community health practitioner functions as a community:

A. Evaluator
B. Planner
C. Leader
D. Facilitator

50. In patient and diagnostic care including surgery belongs to what level of health care?
A. Secondary level
B. Tertiary level
C. Primary level
D. Specialized level

SITUATION: One of the effective means of addressing inadequacy of treatment and

health measures at the community level is through collaboration and teamwork. First,
among health workers and second, through the cooperation of community residents.
Preventive health care can be achieved via this strategy. The following questions apply
51. From January to September, there were outbreaks of typhoid fever in Cavite city. As a public
health nurse, you should know that typhoid is caused by:
A. Fomites
C. Poor personal hygiene
B. Inhalation of contaminated air
D. Intake of contaminated water

52. Secondary prevention of malaria may be achieved through cooperation of community

residents by:
A. Growing larva eating fish in mosquito breeding area
B. Determining whether a place is an endemic area
C. Residual spraying of insecticides at night
D. Planting of Neem or Eucalyptus trees

53. Which of the following strategies implemented with the department of health to prevent
transmission of malaria?
1. Chemoprophylaxis of pregnant women in endemic areas
2. Chemoprophylaxis of non immune person going to endemic areas
3. Teaching of people in endemic areas the use of chemically treated mosquito nets
4. Teaching families to use adequate protective clothing when biting period of mosquito vector is
expected

A. 1 and 2
B. 3 and 4
C. 1, 2 and 3
D. 1, 2, 3 and 4

54. Even the conduct of epidemiologic investigation requires collaboration and teamwork and
purpose of which is to:
A. Delineate the etiology of epidemics
B. Encourage cooperation and support of the community
C. Identify geographical location of cases in the community
D. Identify who are at risk of contracting the disease
Situation: Community Health Nursing involves care to individuals, families, communities
and even population groups. One of the common population groups are the elders which
the nurse should not undermine.

55. The goal of health care and services for the older people is
A. A shorter disability free life
B. A longer disability free life
C. An increase in the life span
D. A redúced rate of illness

56. Knowing the data of the older sector in the community, the nurse can utilize all of the
following points as guidelines in providing health care for the elderly in her community, except:
A. Rights of the elderly
B. Traditions, beliefs and values
C. Developmental needs of the older population
D. Vulnerability to effects of drugs

57. In the care of the older population, the community health nurse recognizes that to promote
good health all are accurate, but
A. Maintaining ideal body weight
C. Eating proper diet
B. Performing regular physical exercise
D. Regular health check-ups - secondary prevention

58. The United Nations principles for the older adult population to maintain independence
include all with an exception to:
A. Have access to food, water, clothing, shelter and health care.
B. Have access to appropriate educational and training program.
C. Be able to live in safe environment adaptable to personal preferences and changing
capacities.
D. Should live in a nursing home providing quality care for the rest of their lives.

59. Taking care of the elderly can be draining and overwhelming. Elderly clients usually
complain of bodily changes. Which of the following physiological changes are considered
associated with aging? Except
A. Loss of visual acuity
B. Decreased emptying of the stomach
C. Increased arterial diameter
D. Chronic confusion

Situation: The nurse participates in community organization to achieve the ultimate goal
of increasing the level of wellness of the community.

60. The main concern of public health is: (generalized = main concern)
A. Promotion of mental health and alleviation of sufferings
B. Treatment and management of diseases of individuals themselves, increasing the level of
self-reliance
C. Preventing disease, prolonging life, promoting health/efficiency through organized
community efforts.
D. Prevention of illness, promotion, curative as well as rehabilitation

61. The nurse is aware that community organization is initiated in order to:
A. Develop leadership potentials of barangay health members
B. Identify common problems, plans and act on them
C. Plan for community activities for the common good of all
D. Promote social relationships among community members

62. In choosing a leader in the community during the organizational phase, who among these
people will you choose?
A. Cy, 35 years old, rich and famous to the community.
B. By, 45 years old, poor, breadwinner of the family with 12 members
C. Ry, 85 years old, willing to work for the desired change
D. Zy, 30 years old, influential and willing to work for the desired change

63. The nurse selects and identifies the secondary leaders on what phase of COPAR?
A. Entry
B. Community diagnosis
C. Community organization
D. Sustenance and strengthening

Situation: One of the functions of the nurse as specified in the scope of nursing practice
is the therapeutic use of self through utilization of the therapeutic technique of
communication. As the Community Health Nurse of Barrio Matalino, you have the
responsibility of educating them on their identified problems.

64. During a one-on-one interview, a client with prostate cancer stage IV says to the nurse, " I
just want to die." Which of the following is the most therapeutic response to this statement?
A. You feel as though there is no reason to live?
B. Don't be negative about it. There is always hope
C. Does your family know about this?
D. Why do you feel this way?

65. Another client, a 75 year old says that he sleeps 5-6 hours every night but he does not feel
rested upon waking up.
Which of the following responses is correct?
A. The REM cycle decreases normally with age.
B. You need more than 6 hours of sleep each night.
C. You have to have more physical activities to make your sleep longer
D. You have to reduce your daily coffee intake.

66. An ADHD client is brought in to the RHU due to uncontrolled burst of energy. Her mother
says to you, "Now let us see how well you can handle him." Which of the following is your most
therapeutic response?
A. It must have been very difficult for you to care for him by yourself.
B. You also need some help.
C. What did you mean by that?
D. Why did you not call your husband to help you?

67. After being confined in St. Benedict's Hospital, Mr. Lester, the president of a huge company,
is referred to the RHU for follow-up visits. During the assessment, he confides to you that he is
concerned about his wife who is nervous and dependent person and that looking after her is
tiring. Which of the following questions would be most therapeutic and helpful to ask Mr. Lester?
A. What do you do to address your problem with your wife?
B. Is your wife aware of how tired you become?
C. Can you not hire someone to help your wife's care?
D. Tell her that she cannot be dependent on you anymore?

68. When developing a therapeutic relationship with a client, the nurse should always maintain
a therapeutic interaction which is characterized by which of the following?
A. An opportunity for the nurse to obtain information.
B. Provide a healing experience for the client.
C. Necessitates a client's need and motivation for nurses
D. Requires a mutual exchange of ideas, perception and thoughts.

Situation: The nurse is collaborating with the RHMs and the members of the community
of Bagbag to achieve a reduced mortality rate among the common childhood illnesses.

69. An infant is brought by her mother, for his OPV immunization. You have assessed the infant
has diarrhea. What will be your next action?
A. Notify the physician
B. Give the OPV - but not given with fever and not counted/recorded
C. Refer immediately
D. Do no give the OPV

70. After assessing Junjun, your nursing diagnosis is dehydration secondary to diarrhea. ORS
was administered. Which health instruction regarding ORS therapy given by the midwife will be
given to the mother once the diarrhea has stopped?
A. Increase the administration of ORS
B. Stop the administration of ORS
C. Return to the Clinic
D. Decrease the administration of ORS

71. The midwife is discussing about home care. Which of the following is not true about home
care for all sick infants?
A. Blood in the stool is a danger sign that need to be reported
B. Bring the infant to the clinic if she/he shows sign of difficulty of breathing
C. Breastfeed frequently, day and night during sickness and health
D. Make sure the young infant stays cool at all times

72. A midwife may keep opened vials of OPV for use in the next session if:
A. You have taken out the vaccine at the health center for some other reasons
B. The expiry date has not passed
C. The vaccines have been stored at a room temperature between 2 deg to 8 deg C
D. The vaccines have change its color

73. The treatment of the child for prevention of low blood sugar includes giving breast milk,
breast milk substitute or sugar water. Prior to administration, you assessed that the child is not
able to swallow. What should you advice the midwife for her next action?
A. Gives 5 ml/kg of 10%dextrose solution over a few minutes
B. Administer the sugar water
C. Gives 50 ml of expressed milk or sugar water via NGT
D. Ask the mother to breastfeed the child

Situation: Informed consent is an agreement by a client to accept the course of treatment

or procedure after being provided complete information.

74. Nurse Mimi will obtain an informed consent from an alert, adult blind patient. What should
the nurse do:
A. Let the patient sign the consent
B. Let the S.O. sign the consent since she is blind
C. Let the S.O. sign the consent since she would be so anxious
D. Let the supervisor secure the consent.

75. The husband of the patient is insisting that he will be the one to sign the consent. The nurse
should:
A. Inform the husband that he can give the consent since the patient is blind.
B. Inform the husband that he can give the consent since the patient is incompetent.
C. Inform the husband that he cannot sign unless he has the power of attorney.
D. Inform the husband that he cannot sign unless the court decides on the matter. ?

76. During the signing of consent, the patient only puts her initials "J.D.", the nurse is correct
when she states:
A. That is an invalid signature
B. We need to have her complete signature.
C. That is a valid signature.
D. Let the husband sign to complete the signature.

77. After the nurse obtained the consent, the following should be part of the documentation,
except:
A. The consent form was read to the client before she signed it.
B. A reference of understanding of the procedure
C. If the husband assisted the patient during the signing
D. The discussion between the husband and wife on who will sign the consent

78. Nurse Joy is asking Nurse Emer the best defense against a malpractice claim. Nurse Emer
is correct when he states:
A. You should be updated on the current research findings.
B. You should know your responsibility and scope of practice
C. You should be moral and ethical.
D. All of the above.

Situation: Primary health care is essential health care made universally accessible to
individuals and families in the every stage of development.every stage by neans
acceptable to them, through their full participation and it a co indive onlunt can at on the
79. The members of barrio Magsakay attended a training seminar on coco burger making and
hair-cutting. This activity is supported by which of the following principles of primary health care?
A. Self-reliance
C. Community Participation
B. Social Mobilization
D. Accessibility and availability of health services

80. Mario, a resident of barrio Magsakay complains excruciating pain, swelling and inflammation
of his joints. As you observed you noticed a hard fairly large and irregular shaped deposits in
the skin on his toe and ear. Which of the following should the nurse encourage the client to use
to manage the condition under the principle of PHC?
A. Yerba Buena
B. Sambong
C. Pansit-pansitan
D. Bawang

81. June Faith, another client in barrio Magsakay complains of nausea and vomiting, fatigue and
even urinary frequency. She is suspecting that she is pregnant with his long time boyfriend, Luis.
With the complaints of the client the nurse can classify the symptom as
A. Probable
B. Positive
C. Presumptive
D. Predictive

82. Jo a 3 year old toddler is reported by his mother to have some developmental delays during
a home visit. When looking for a cause or contributing factors, which of the following
environmental factors would she considers MOST important to assess?
A. Dust mites on the child's toys
B. Lead paint in the crib
C. House pets
D. Presence of asbestos in the house

83. The nurse called a community assembly to discuss Disaster Management to disaster prone
community. The nurse is practicing what type of health care service:
A. Promotion
B. Primary prevention
C. Secondary prevention
D. Tertiary prevention

Situation: The nurse in the community is aware that her ultimate goal is the wellness of
the community yet the unit of her service is the family whether normal or with
risks/problems.

84. Jun-Jun, the new public health nurse in barrio Bogo, is being oriented by his direct
supervisor on the concept of family health nursing. The supervisor asks Jun Jun to identify
which among the following is considered a family: Select all that apply
1. Maryll and Nelvin with their adopted daughter Matilda
2. George and Jimmy with their foster daughter Dionisia
3. Gay Couple(Mark and Jay)
4. Boardmates Christy, Macky, Ellen, and Georgina.

A. 1, 2 and 3
B. 1, 2, and 4
C. 1 and 2 only
D. 1, 2, 3 and 4
85. In assessing the level of family cohesion, you have determined that family is very close and
has very high loyalty, and members are highly dependent on one another. You would document
this as which level of cohesion?
A. Separated
B. Enmeshed
C. Connected
D. Disengaged

86. Assessment is a set of actions which the nurse measures the status of the family. Jun-jun is
now collecting relevant information on the family of the client. He conducted interview to probe
the reason on the existence of the family's problem. This level of assessment is known as:
A. First line assessment
B. Second line assessment
C. Third line assessment
D. Fourth line assessment

87. Jun-jun formulated the objective for a family with a diabetic member. Which of the following
objectives is written in behavioural terms?
A. Mang Henry will know about diabetes-related foot care and the techniques and equipment
necessary to carry it out.
B. Mang Henry's daughter should learn about diabetes mellitus within the week.
C. Mang Henry's wife needs to understand the side effects of insulin.
D. Mang Henry's sister will be able to determine in two days his insulin requirement
based on blood glucose levels obtained from the glucometer.

Situation: IMCI as a strategy involves 3 Components: Improve case management skills,

Improve over-all health system and Improve family and community health practices. The
following questions pertain to the utilization of the IMCI
88. A client is rushed to your wellness baby clinic. The mother greeted the client and asks what
the child problems are. The following are the communication technique the nurse should use
during the assessment phase of IMCI with an exception to:
A. Listen attentively to the mother
B. Use words that the mother can easily comprehend
C. Give ample of time for the mother to answer your questions
D. Ask more clarifying questions to assess for understanding

89. After the interview on the child's problems, the nurse must assess the child for which of the
following problems next?
A. Convulsion
B. Unable to drink/breastfeed
C. Lethargic
D. Vomits everything

90. Ruth, mother of baby Chenie also reported that her daughter has passed 2 loose stools
yesterday. Per protocol, the nurse must do which of the following?
A. Go to the next question, assess for ear problem
B. Check for skin return after skin pinch
C. Assess for sunken eyes
D. Go to the next question, assess for fever

91. Jemalou with her baby Karen went to the clinic with complains that her daughter is warm to
touch and she noticed pus draining from the ears for 3 days. After the nurse complete
assessment, it reveals stiff neck, rash with cough and red eyes. Which of the following is the
best intervention the nurse should take?
A. Urgently refer to the child to the hospital
B. Treat the child with amoxicillin for 3 days and instruct the mother how to do ear wicking
C. Provide ear wicking and treat the child with topical quinolone eardrops
D. Provide vitamin A and tetracycline eye ointment.
Situation: IMCI has been established as an approach to strengthen the provision of
essential and comprehensive health package to children. It was developed in 1992 by the
WHO and UNICEF to reduce morbidity and mortality among the common childhood
illnesses and adopted by the DOH-Philippines. It utilizes the management chart as a
strategy to achieve its goals.

92. Before using any of the IMCI chart, the nurse must be aware of what vital client information?
A. General Danger Signs presented by the child
B. Vital signs of the child
C. Age of the child
D. Main Symptoms presented by the child

93. The chart utilizes a color coded triage: Pink (Severe), Yellow (Moderate) and Green (Mild).
The nurse is aware that finding a general danger sign (pink) will warrant the nurse to do which
of the following: select and arrange all that apply:
1. Give ampicillin-gentamicin
2. Continue the assessment immediately
3. Urgently refer the child
4. Give amoxicillin/cotirmoxazole
5. Give immunization

A. 2, 4, 5, 3
B. 2, 1, 5, 3
C. 2, 1, 3
D. 2, 4, 3

94. A client with his mother, presented with some palmar pallor 2 weeks ago returned for follow
up check-up. You noticed that the child still have some palmar pallor. Using the chart of IMCl,
which of the following recommended treatment should be done to the client?
A. Refer the child to the nearest hospital.
B. Give one shot iron injection to the child via Z tract technique.
C. Provide additional 14 doses of iron supplements to the child.
D. Tell the mother this is normal and return after 14 days.

95. Aside from the chart, one vital aspect of IMCI is the use of essential drugs. Which of the
following is a correct statement with regard to the use of essential drugs in IMCI?
A. Amoxicillin is the first line of drug for Pneumonia, Acute and Chronic Ear Problem.
B. Cotrimoxazole can be given as an alternative drug for Pneumonia.
C. Cholera can be treated by ORS and Ciprofloxacin.
D. Tetracycline is the first line of drug for the treatment of dysentery.

Situation: Nurse Jessica is conducting a research study as part of the requirements for
her master's degree in nursing major in Community Health Nursing.
96. Nurse Jessica selected a topic on the effects of health values and the health promoting
activities of the underserved families in one of the barangay covered by her care. The best
research design for this type of study is:
A. Correlational -?
B. Comparative
C. Experimental
D. Non-experimental

97. Nurse Jessica is correct when she identifies the independent variable?
A. Effects of values
B. Health promotion activities
C. Health values
D. Underserved families

98. Nurse Jessica's institution is currently conducting epidemiological study. As a rule, it follows
a certain framewor known as the Ecologic Triad. Which among the following refers to the sum
total of all the external conditions ar influences that affect the development of an organism?
A. Physical environment
B. Biological environment
C. Socioeconomic environment
D. Environment

99. The reason of poor health situation in the country is poverty. The following statement
regarding the illness -pove cycle, Except:
A. High participation in the production process means low purchasing power of
individuals
B. If salaries are low, people are not able to satisfy their basic needs
C. Health is determined by people's ability to provide food, shelter and clothing
D. Low participation to production process may eventually lead to death of the people
100. This is one of the leading causes of morbidity and mortality affecting Filipinos. It has high
incidence in congested communities despite of the more than 50 years of government program.
This is:
A. Diseases of the heart
B. Vascular diseases
C. Diarrhea
D. Tuberculosis

SIMULATION 5 NURSING PRACTICE 2

CARE OF HEALTHY/AT RISK MOTHER AND CHILD

SITUATION: Pregnancy poses risk to both the mother and the child. Nurse must be
knowledgeable about assessment and management of these conditions of these conditions to
ensure survival and wellness of both patients.

1. Which of the following is described as premature separation of a normally transplanted

placenta during the second half of pregnancy, usually with severe hemorrhage?
A. Placenta previa
B. Ectopic pregnancy
C. Incompetent cervix
D. Abruptio placentae

2. At 17 weeks gestation, a type 1 diabetic undergoes an ultrasound examination. What

information about the fetus at this time in pregnancy would the results of this examination
provide?
A. Placenta maturity
B. Estimated fetal weight
C. Gestational age
D. Fetal lung maturity

3. During a routine post partum assessment following a normal vaginal delivery, the nurse notes
the fundus to be slightly boggy. Which action should the nurse take to decrease the risk of
uterine inversion during uterine massage?
A. Massage only until cramping begins
B. Place one hand on the abdomen above the symphysis pubis
C. Ask the client to ambulate to the bathroom to empty the bladder
D. Position the client in a slight trendenlenburg position
4. Mrs. Cruz, 8 months pregnant, is admitted to the hospital because of pre eclampsia. Which of
the following nursing orders is MOST INAPPROPRIATE for the patient's condition?
A. Daily urinalysis for proteinuria
B. Record patient's intake and output
C. Keep padded tongue depressor at the patient's bed
D. Weigh the patient weekly
5. Oxytocin is administered to Sheila to augment labor. What are the first symptoms of water
intoxication to observe during the procedure?
A. Headache and vomiting - early
C. A high choking voice - late
B. A swollen tender tongue - late
D. Abdominal bleeding and pain - late

SITUATION: Nurse Cris is a family Planning and Contraception Specialist. The following
questions refer to this special need.

6. When preparing a woman who 2 days post partum is for discharge, recommendations for
which of the following contraceptive methods would be avoided?
A. Diaphragm
B. Female Condom
C. Oral contraceptives
D. Rhythm Method

7. A new couple is to undergo testing for infertility. Infertility is said to exist when:
A. A woman has no uterus
B. A woman has no children
C. A couple has been trying to conceive for 1 year
D. A couple has wanted a child for 6 months

8. For the client who is using oral contraceptives the nurse informs the client about the need to
take the pill at the same time each day to accomplish which of the following?
A. Reduce incidence of nausea
B. Maintain hormonal levels
C. Reduce side effects
D. Prevent drug interactions

9. For which of the following clients would the nurse expect that an intrauterine device would not
be recommended?
A. Woman over age 35
C. Promiscuous young adult – risk for pelvic inflammatory disease or STDs d/t multiple
partners
B. Nulliparous woman
D. Postpartum client

10. Wilma, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would be the
best answer?
A. Prostaglandins released from the cut fallopian tubes can kill sperm
B. Sperm cannot enter the uterus because the cervical entrance is blocked
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is nowhere for them to go

SITUATION: Health instructions are essentially given to pregnant mothers.

11. Pregnancy - induced anemia are one of the common concerns during pregnancy. Which
among the following foods would recommend as the best source of iron in the diet?
A. Chicken liver - animal meat contains heme iron
B. Milk
C. Green leafy vegetables
D. Orange

12. Giving colostrum to the baby has the following benefits EXCEPT:
A. Prepares the baby's stomach to digest milk
B. Contains many protective substances against infection
C. Improves the baby's sucking and rooting reflex
D. Does not cause tummy ache or diarrhea

13. A public health nurse would instruct a pregnant woman to notify the physician immediately if
which of the following symptoms occur during pregnancy?
A. Presence of dark color in neck
B. Increased vaginal discharge
C. Swelling of the face - periorbital edema may indicate PIH/preeclampsia
D. Breast tenderness

14. Exclusive breastfeeding is ideal for the first 6 months. Exclusive breast feeding means that:
A. Giving only breast milk no other liquids, solids, not even water, vitamins and minerals
supplements not permitted.
B. Giving only breast milk no other liquids, solids, but water can be given, vitamins and minerals
supplements not permitted.
C. Giving only breast milk no other liquids, solids, but water can be given, vitamins and minerals
supplements permitted.
D. Giving only breast milk no other liquids, solids, not even water, vitamins and minerals
supplements permitted.
15. The community health nurse noticed that there are many out of school teenagers in the
neighborhood who use drugs, smoke, and drink alcohol. Their parents are working overseas
and these teenagers live with their aging grandparents who have difficulty controlling them.
Before arriving as a social diagnosis, the nurse should:
1. Determine if this situation results in breakdown of families – after a diagnosis has been
identified
2. Explore to what extent the situation affects life in the neighborhood
3. Determine what policies should be enacted to promote lifestyle changes – after a diagnosis
has been identified
4. Assess how the educational level of the community affects its ability to cope with the
problem

A. 1 and 3
B. 2 and 4
C. 1 and 2
D. 3 and 4

SITUATION: A mother during labor experienced difficulty both in their physical and
physiologic condition. Nursing intervention is one of your primary responsibilities during
this situation.

16. Which of the four signs of good attachment is true in this statement?
A. The chin should touch the breast while the mouth is wide open while the lower lip turned
inward and more areola visible above than below.
B. The chin should touch the breast while the mouth is wide open while the lower lip turned
outward and more areola is visible below than above.
C. The chin should touch the breast while the mouth is wide open while the lower lip
turned outward and more areola i visible above than below.
D. The chin should touch the breast while the mouth is wide open while the lower lip turned
inward and more area above than below.

17. Mika was admitted to hospital. She is in labor. When her medical record reveals a condition
in which the fetus cannot pass through the maternal pelvis. Nurse Bea interprets this as:
A. Contracted pelvis
B. Maternal disproportion
C. Cephalopelvic disproportion
D. Standing position

18. Nurse Lucy advises her client on how to relieve discomfort during labor by means of proper
positioning. This position may cause maternal hypotension and fetal hypoxia?
A. Supine position
B. Squatting position
C. Lateral position
D. Standing position
19. Nurse Lucy is preparing a primigravida for breastfeeding. Which of the following she needs
to do?
A. Tell her that lactation begins within a day after delivery.
B. Teach her nipple stretching exercises if her nipple is inverted. - to help with
breasfeeding which is essential for newborns survival, thus priority
C. Instruct her to wash her nipples with soap before and after each breastfeeding.
D. Explain to her that lactation will lessen blood loss after delivery. - depends on the cause of
bleeding, if due to laceration then lactation will not help

20. After 8 hours of active labor, Nurse Lucy notes that the contractions of a primigravida client
are not strong enough to dilate the cervix. Which of the following should she anticipate doing?
A. Obtain an order to begin IV oxytocin infusion.
B. Administer a light sedative to allow the patient rest for several hours.
C. Prepare for a CS for failure to progress.
D. Increase the encouragement to the patient when pushing begins.

21. Nurse Nicole knows that preterm labor can be best described as:
A. Labor that begins 27 weeks of gestation and before 39 weeks gestation
B. Labor that begins after 20 of gestation and before 37 weeks gestation
C. Labor that begins 16 weeks of gestation and before 37 weeks gestation
D. Labor that begins 22 weeks of gestation and before 28 weeks of gestation

SITUATION: You are working as a pediatric nurse in your own child health nursing clinic.
The following cases pertain to assessment and care of the newborn at risk conditions.

22. Which of the following signs and symptoms would you most likely find when assessing and
infant with Arnold-Chiari malformation?
A. Weakness of the leg muscles, loss of sensation in the legs, and restlessness.
B. Difficulty swallowing diminished or absent gag reflex, and respiratory distress
C. Difficulty sleeping, hyper vigilant, and an arching of the back
D. Paradoxical irritability, diarrhea, and vomiting

23. You are assessing newborn babies and infants during their hospital stay after birth and
notice which of the following symptoms as a primary manifestation of Hirschsprung's disease? -
presence of aganglionic cells in colon
A. A fine rash over the trunk
B. Failure to pass meconium during the first 24 to 48 hours after birth
C. The skin turns yellow then brown over the first 48 hours after birth
D. High grade fever

24. When assessing a baby diagnosed with Fetal Alcohol Syndrome which of the following
findings would you expect for this patient?
1. Alert
2. Irritable
3. Small head circumference
4. Excessive weight gain
5. Low birth weight

A. 1, 2, 3
B. 1, 3, 4
C. 2, 3, 5
D. 3, 4,5

25. The reason nurse Jhem keeps neonate in a neutral thermal environment is that when a
newborn becomes too cool, the neonate requires:
A. Less oxygen and the newborn's metabolic rate increases
B. More oxygen and the newborn's metabolic decreases
C. More oxygen and the newborn's metabolic rate increases
D. Less oxygen and the newborn's metabolic rate decreases

26. When assessing a newborn diagnosed with ductus arteriosus, Nurse Lem should expect
that the child most likely would have an:
A. Loud, machinery-like murmur
C. Decreased BP reading in the upper extremities
B. Bluish color of the lips
D. Increased BP reading in the upper extremities

SITUATION: You are the nurse in the OPD and during your shift you encountered multiple
children's condition.

27. Piccolo a 4-week old baby was brought for his first immunization. Which can be given to
him?
A. DPT1
B. OPV1
C. Infant BCG
D. Hepatitis B vaccine 1 - mandatory at birth

28. While assessing a child with visible severe wasting, you conclude he has:
A. Marasmus
B. Edema
C. Loose Bowel Movement
D. Kwashiorkor - protein only is the problem

29. You encountered a child with Laryngotracheobronchitis. Its common complication is hypoxia.
You know that this child should frequently assess for:
A. Restlessness
B. Drooling
C. Muffled voice
D. Low-grade fever

30. Paul, a young child suspected to have pinworms. You collect a stool specimen to confirm
and should schedule the collection of this specimen when:
A. Early in the morning
C. After bathing
B. Just before sleeping at night
D. Any time during the day

Situation - As the CPE is applicable for all professional nurse, the professional growth
and development of Nurses with specialties shall be addressed by a Specialty
Certification Council. The following questions apply to these special groups of nurses.

31. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing
Specialty Certification Program and Council, which two (2) of the following serves as the
strongest for its enforcement?
A. Advances made in Science and Technology have provided the climate for specialization in
almost all aspects of human endeavor; and
B. As necessary consequence, there has emerged a new concept known as globalization which
seeks to remove barriers in trade, industry and services imposed by the national laws of
countries all over the world;
C. Awareness of this development should impel the nursing sector to prepare our people in the
services sector to meet the above challenge;
D. Current trends of specialization in nursing practice recognized by the International Council of
Nurses (ICN) of which the Philippines is a member for the benefit of the Filipino in terms of
deepening and refining nursing practice and enhancing the quality of nursing care.

A. b & c are strong justifications

C. a & c are strong justifications
B. a & b are strong justifications
D. a & d are strong justifications

32. Which of the following IS NOT a correct statement as regards Specialty Certification?
A. The Board of Nursing intended to create the Nursing Specialty Certification Program
as a means of perpetuating the creation of an elite force of Filipino Nurse Professionals.
B. The Board of Nursing shall oversee the administration of the NSCP through the various
Nursing Specialty Boards which will eventually be created
C. The Board of Nursing at the time exercised their powers under R.A. 7164 in order to adopt
the creation of the Nursing Specialty Certification Council and Program - BON Res No. 14, 1999
D. The Board of Nursing consulted nursing leaders of national nursing associations and other
concerned nursing groups which later decided to ask a special group of nurses of the program

Situation - Please continue responding as a professional nurse in these other health

situations through the following questions.

33. The nurse would anticipate a cesarean birth for a client who has which infection present at
the onset of labor?
A. Herpes-simplex virus
B. Human papilloma virus
C. Hepatitis
D. Toxoplasmosis

34. The rationales for using a prostaglandin gel for a client prior to the induction of labor is:
A. Soften and efface the cervix
B. Numb cervical pain receptors
C. Prevent cervical lacerations
D. Stimulate uterine contractions

35. Lilia's cousin on the other hand, knowing nurse Lorena's specialization asks what artificial
insemination by donor entails. Which would be your best answer if you were Nurse Lorena?
A. Donor sperm are introduced vaginally into the uterus or cervix
B. Donor sperm are injected intra-abdominally into each ovary
C. Artificial sperm are injected vaginally to test tubal patency
D. The husband's sperm is administered intravenously weekly

Situation - Nurse Joanna works as an OB-Gyne Nurse and attends to several HIGH-RISK
PREGNANCIES: Particular women with preexisting or Newly Acquired illness. The following
conditions apply

36. Bernadette is a 22-year old woman. Which condition would make her more prone than
others to developing a Candida infection during pregnancy?
A. Her husband plays golf 6 days a week
C. She usually drinks tomato juice for breakfast
B. She was over 35 when she became pregnant
D. She has developed gestational diabetes

37. Bernadette develops a deep vein thrombosis following an auto accident and is prescribed
heparin sub-Q. What should Joanna educate her about in regard to this?
A. Some infants will be born with allergic symptoms to heparin
8. Her infant will be born with scattered petechiae on his trunk
C. Heparin can cause darkened skin in newborns
D. Heparin does not cross placenta and so does not affect a fetus

38. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may need further
instruction on prenatal care. What statement signifies this fact?
A. I've stopped jogging so I don't risk becoming dehydrated.
B. I take an iron pill every day to help grow new red blood cells - RBC production is not
the problem, it is the RBC shape
C. I am careful to drink at least eight glasses of fluid every day
D. I understand why folic acid is important for red cell formation

39. Bernadette received a laceration on her leg from her automobile accident. Why are
lacerations of lower extremities potentially more serious in pregnant women than others?
A. Lacerations can provoke allergic responses because of gonadothropic hormone
B. Increased bleeding can occur from uterine pressure on leg veins
c. A woman is less able to keep the laceration clean because of her fatigue
D. Healing is limited during pregnancy, so these will not heal until after birth.

Situation - You are working as a Pediatric Nurse in you own Child Health Nursing Clinic.
The following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK
conditions.

40. Theresa, a mother with a 2 year old daughter asks, "at what age can I be able to take the
blood pressure of my daughter as a routine procedure since hypertension is common in the
family?" Your answer to this is:
A. At 2 years you may
B. As early as 1 year old
C. When she's 3 years old - use right arm and use auscultation
D. When she's 6 years old

41. You typically gag children to inspect the back of their throat. When is it important NOT to
elicit a gag reflex?
A. when a girl has a geographic tongue
B. When a boy has a possible inguinal hernia
C. When a child has symptoms of epiglottitis
D. When children are under 5 years of age
42. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother
in labor. What drug is commonly used for this:
A. Naloxone (Narcan)
B. Morphine Sulfate
C. Sodium Chloride
D. Penicillin G

Situation - Please continue responding as a professional nurse in theses varied health

situations through the following questions.

43. Which of the following medications would the nurse expect the physician to order for
recurrent convulsive seizures of a 10-year old child brought to your clinic?
A. Phenobarbital - anti seizure meds
B. Nifedipine
C. Butorphanol
D. Diazepam

44. RhoGAM is given to Rh-negative women to prevent maternal sensitization from occurring.
The nurse is aware that in addition to pregnancy, Rh-negative women would also receive this
medication after which of the following?
A. Unsuccessful artificial insemination procedure
B. Blood transfusion after hemorrhage
C. Therapeutic or spontaneous abortion
D. Head injury from a car accident

45. Which of the following would the nurse include when describing the pathophysiology of
gestational diabetes?
A. Glucose levels decrease to accommodate fetal growth
B. Hypoinsulinemia develops early in the first trimester - should be hyperinsulinemia
C. Pregnancy fosters the development of carbohydrate cravings
D. There is progressive resistance to the effects of insulin

46. When providing prenatal education to a pregnant woman with asthma, which of the following
would be important for the nurse to do?
A. Demonstrate how to assess her blood glucose levels
B. Teach correct administration of subcutaneous bronchodilators
C. Ensure she seeks treatment for any acute exacerbation
D. Explain that she should avoid steroids during her pregnancy

47. Which of the following conditions would cause an insulin-dependent diabetic client the most
difficulty during her pregnancy?
A. Rh incompatibility
B. Placenta Previa
C. Hyperemesis Gravidarum
D. Abruptio Placenta
Situation - While working in the clinic, a new client, Geline, 35 years old, arrives for her
doctor's appointment. As the clinic nurse, you are to assist the client fill up forms, gather
data and make an assessment.

48. The purpose of your initial nursing interview is to:

A. Record pertinent information in the client's chart for health team to read
B. Assist the client find solutions to he her health concerns
C. Understand her lifestyle, health needs and possible problems to develop a plan of care
D. Make nursing diagnoses for identified health problems

49. While interviewing Geline, she starts to moan and doubles up in pain. She tells you that this
pain occurs about an hour after taking black coffee without breakfast for a few weeks now. You
will record this as follows:
A. Claims to have abdominal pains after intake of coffee unrelieved by analgesics
B. After drinking coffee, the client experienced severe abdominal pain
C. Client complained of intermittent abdominal pain an hour after drinking coffee
D. Client reported abdominal pain an hour after drinking black coffee for three weeks now.

50. Geline tells you that she drinks black coffee frequently within the day to "have energy and be
wide awake" and she eats nothing for breakfast and eats strictly vegetable salads for lunch and
dinner to lose weight. She has lost weight during the past two weeks. In planning a healthy
balanced diet with Geline, you will:
A. Start her off with a cleansing diet to free her body of toxins then change to a vegetarian diet
and drink plenty of fluids
B. Plan a high protein diet, low carbohydrate diet for her considering her favorite food.
C. Instruct her to attend classes in nutrition to find food rich in complex carbohydrates to
maintain daily high energy level.
D. Discuss with her the importance of eating a variety of food from major food groups
with plenty of fluids.

51. Geline tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also
smokes up to a pack of cigarettes daily. She confesses that she is in her 2nd month of
pregnancy but does not want to become fat that is why she limits her food intake. You warn or
caution her about which of the following?
A. Caffeine products affect the central nervous system and may cause the mother to have a
"nervous breakdown"
B. Malnutrition and its possible effects on growth and development problems in the
unborn fetus
C. Caffeine causes a stimulant effect on both mother and the baby
D. Studies show conclusively that caffeine causes mental retardation

52. Your health education plan for Geline stresses proper diet for a pregnant woman and the
prevention of non-communicable diseases that are influenced by her lifestyle. These include the
following EXCEPT:
A. Cardiovascular diseases
B. Cancer
C. Diabetes Mellitus
D. Osteoporosis

Situation - There are various developments in health education that the nurse should
know about

53. The provision of health information in the rural areas nationwide through television and radio
programs and video conferencing is referred to as:
A. Community health program
B. Telehealth program
C. Wellness program
D. Red Cross program

54. A nearby community provides blood pressure screening, height and weight measurement,
smoking cessation classe: and aerobics class services. This type of program is referred to as
A. outreach program
B. hospital extension program
C. barangay health program
D. wellness program

55. Part of teaching client in health promotion is responsibility for one's health. When Danica
states she needs improve her nutritional status this means:
A. Goals and interventions to be followed by client are based on nurse's priorities
B. Goals and intervention developed by the nurse and client should be approved by the doctor
C. Nurse will decide goals and interventions needed to meet client goals
D. Client will decide the goals and interventions required to meet her goals

56. Nurse Beatrice is providing tertiary prevention to Mrs. De Villa. An example of tertiary
prevention is
A. Marriage counseling
B. Self-examination for breast cancer
C. Identifying complication of diabetes
D. Poison Control

57. Mrs. Ostrea has a schedule for Pap Smear. She has a strong family history of cervical
cancer. This is an example of
A. tertiary prevention
B. secondary prevention
C. health screening
D. primary prevention

58. Which action should nurse Marian include in the care plan for a 2 month old with heart
failure?
A. Feed the infant when he cries.
B. Allow the infant to rest before feeding.
C. Bathe the infant and administer medications before feeding.
D. Weigh and bathe the infant before feeding.

59.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months.
The nurse should advise her to include which foods in her infant's diet?
A. Skim milk and baby food.
B. Whole milk and baby food.
C. Iron-rich formula only.
D. Iron-rich formula and baby food.

60. Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the
clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware
that estimated age of the infant would be:
A. 6 months
B. 4 months
C. 8 months
D. 10 months
61. The nurse is caring for a primigravid client in the labor and delivery area. Which condition
would place the client at risk for disseminated intravascular coagulation (DIC)?
A. Intrauterine fetal death.
B. Placenta accreta.
C. Dysfunctional labor.
D. Premature rupture of the membranes.

62.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:
A. 80 to 100 beats/minute
B. 100 to 120 beats/minute
C. 120 to 160 beats/minute
D. 160 to 180 beats/minute

63. The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should
instruct the mother to:
A. Change the diaper more often.
B. Apply talc powder with diaper changes.
C. Wash the area vigorously with each diaper change.
D. Decrease the infant's fluid intake to decrease saturating diapers.

64.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome
(tri-somy 21) is:
A. Atrial septal defect
B. Pulmonic stenosis
C. Ventricular septal defect
D. Endocardial cushion defect

65. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate.
The adverse effects associated with magnesium sulfate is:
A. Anemia
B. Decreased urine output
C. Hyperreflexia
D. Increased respiratory rate

66.Nurse Gina is aware that the most common condition found during the second-trimester of
pregnancy is:
A. Metabolic alkalosis
B. Respiratory acidosis
C. Mastitis
D. Physiologic anemia

Situation - Management of patients in the clinical setting of Women and Children

67. Nurse Lynette is working in the triage area of an emergency department. She sees that
several pediatric clients arrive simultaneously. The client who needs to be treated first is:
A. A crying 5 year old child with a laceration on his scalp.
B. A 4 year old child with a barking coughs and flushed appearance.
C. A 3 year old child with Down syndrome who is pale and asleep in his mother's arms.
each encil
pt, pa
D. A 2 year old infant with stridorous breath sounds, sitting up in his mother's arms and
drooling- airway

68.Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding.
Which of the following conditions is suspected?
A. Placenta previa
C. Premature labor
B. Abruptio placentae
D. Sexually transmitted disease

69.A young child named Richard is suspected of having pinworms. The community nurse
collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of
this specimen for:
A. Just before bedtime
B. After the child has been bathe
C. Any time during the day
D. Early in the morning

70.In doing a child's admission assessment, Nurse Betty should be alert to note which signs or
symptoms of chronic lead
A. Irritability and seizures
C. Bradycardia and hypotension
B. Dehydration and diarrhea
D. Petechiae and hematuria

71.To evaluate a woman's understanding about the use of diaphragm for family planning, Nurse
Trish asks her to explain how she will use the appliance. Which response indicates a need for
further health teaching?
A. "I should check the diaphragm carefully for holes every time I use it"
B. "I may need a different size of diaphragm if I gain or lose weight more than 20 pounds"
C. "The diaphragm must be left in place for atleast 6 hours after intercourse"
D. "I really need to use the diaphragm and jelly most during the middle of my menstrual
cycle".

72. Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should

frequently assess a child with laryngotracheobronchitis for:
A. Drooling
B. Muffled voice
C. Restlessness
D. Low-grade fever

73. How should Nurse Michelle guide a child who is blind to walk to the playroom?
A. Without touching the child, talk continuously as the child walks down the hall.
B. Walk one step ahead, with the child's hand on the nurse's elbow.
C. Walk slightly behind, gently guiding the child forward.
D. Walk next to the child, holding the child's hand.

74.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
A. Loud, machinery-like murmur.
B. Bluish color to the lips.
C. Decreased BP reading in the upper extremities
D. Increased BP reading in the upper extremities.

75.The reason nurse May keeps the neonate in a neutral thermal environment is that when a
newborn becomes too cool, the neonate requires:
A. Less oxygen, and the newborn's metabolic rate increases.
B. More oxygen, and the newborn's metabolic rate decreases.
C. More oxygen, and the newborn's metabolic rate increases.
D. Less oxygen, and the newborn's metabolic rate decreases.

76.Before adding potassium to an infant's I.V. line, Nurse Ron must be sure to assess whether
this infant has:
A. Stable blood pressure
B. Patant fontanelles
C. Moro's reflex
D. Voided

77.Nurse Carla should know that the most common causative factor of dermatitis in infants and
younger children is:
A. Baby oil
B. Baby lotion
C. Laundry detergent
D. Powder with cornstarch

78. During tube feeding, how far above an infant's stomach should the nurse hold the syringe
with formula?
A. 6 inches - not higher than 10 inches to prevent vomiting
B. 12 inches
C. 18 inches
D. 24 inches
79. In a mothers' class, Nurse Lynnete discussed childhood diseases such as chicken pox.
Which of the following statements about chicken pox is correct?
A. The older one gets, the more susceptible he becomes to the complications of chicken
pox.
B. A single attack of chicken pox will prevent future episodes, including conditions such as
shingles.
C. To prevent an outbreak in the community, quarantine may be imposed by health authorities.
D. Chicken pox vaccine is best given when there is an impending outbreak in the community.

80. Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in the first trimester of pregnancy in the barangay
Pinoy?
A. Advice them on the signs of German measles.
B. Avoid crowded places, such as markets and movie houses.
C. Consult at the health center where rubella vaccine may be given.
D. Consult a physician who may give them rubella immunoglobulin.

Situation - Concepts in MCN in are a staple know-how for every globally competitive nurse.

81. Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to
live outside the womb) is:
A. 8 weeks
B. 12 weeks
C. 24 weeks
D. 32 weeks
82. When teaching parents of a neonate the proper position for the neonate's sleep, the nurse
Patricia stresses the importance of placing the neonate on his back to reduce the risk of which
of the following?
A. Aspiration
B. Sudden infant death syndrome (SIDS)
C. Suffocation
D. Gastroesophageal reflux (GER)

83. Which finding might be seen in baby James a neonate suspected of having an infection?
A. Flushed cheeks
B. Increased temperature
C. Decreased temperature
D. Increased activity level

84. Baby Jenny who is small-for-gestation is at increased risk during the transitional period for
which complication?
A. Anemia probably due to chronic fetal hyposia
B. Hyperthermia due to decreased glycogen stores
C. Hyperglycemia due to decreased glycogen stores
D. Polycythemia probably due to chronic fetal hypoxia

85.Marjorie has just given birth at 42 weeks' gestation. When the nurse assessing the neonate,
which physical finding is expected?
A. A sleepy, lethargic baby
B. Lanugo covering the body
C. Desquamation of the epidermis
D. Vernix caseosa covering the body

86.After reviewing the Myrna's maternal history of magnesium sulfate during labor, which
condition would nurse Richard anticipate as a potential problem in the neonate?
A. Hypoglycemia
B. Jitteriness
C. Respiratory depression
D. Tachycardia
87. Which symptom would indicate the Baby Alexandra was adapting appropriately to
extra-uterine life without difficult
A. Nasal flaring
B. Light audible grunting
C. Respiratory rate 40 to 60 breaths/minute
D. Respiratory rate 60 to 80 breaths/minute

88. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include
which information?
A. Apply peroxide to the cord with each diaper change
B. Cover the cord with petroleum jelly after bathing
C. Keep the cord dry and open to air
D. Wash the cord with soap and water each day during a tub bath.

Situation - The nurse encounters different scenarios and situations that allows you to be
flexible and practice the skills you have acquired in your journey.

89. Nurse John is performing an assessment on a neonate. Which of the following findings is
considered common in the healthy neonate?
A. Simian crease
B. Conjunctival hemorrhage
C. Cystic hygroma
D. Bulging fontanelle

90.Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor.
Following this procedure, the nurse Hazel checks the fetal heart tones for which the following
reasons?
A. To determine fetal well-being.
B. To assess for prolapsed cord
C. To assess fetal position
D. To prepare for an imminent delivery.

91. Which of the following would be least likely to indicate anticipated bonding behaviors by new
parents?
A. The parents' willingness to touch and hold the new born.
B. The parent's expression of interest about the size of the new born.
C. The parents' indication that they want to see the newborn.
D. The parents' interactions with each other.

92.Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree

laceration. Which of the following would be contraindicated when caring for this client?
A. Applying cold to limit edema during the first 12 to 24 hours.
B. Instructing the client to use two or more peripads to cushion the area.
C. Instructing the client on the use of sitz baths if ordered. - may cause active bleeding
D. Instructing the client about the importance of perineal (kegel) exercises.

93. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery
area. She states that she's in labor and says she attended the facility clinic for prenatal care.
Which question should the nurse Oliver ask her first?
A. "Do you have any chronic illnesses?"
B. "Do you have any allergies?"
C. "What is your expected due date?"
D. "Who will be with you during labor?"
94.A neonate begins to gag and turns a dusky color. What should the nurse do first?
A. Calm the neonate.
B. Notify the physician.
C. Provide oxygen via face mask as ordered
D. Aspirate the neonate's nose and mouth with a bulb syringe.

95. When a client states that her "water broke," which of the following actions would be
inappropriate for the nurse to do?
A. Observing the pooling of straw-colored fluid.
B. Checking vaginal discharge with nitrazine paper.
C. Conducting a bedside ultrasound for an amniotic fluid index.
D. Observing for flakes of vernix in the vaginal discharge.

96. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is
successfully resuscitated.
Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and
retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a
ventilator. Which nursing action should be included in the baby's plan of care to prevent
retinopathy of prematurity?
A. Cover his eyes while receiving oxygen.
B. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
D. Humidify the oxygen.

97. Which of the following is normal newborn calorie intake?

A. 110 to 130 calories per kg.
B. 30 to 40 calories per Ib of body weight.
C. At least 2 ml per feeding
D. 90 to 100 calories per kg
98. Nurse John is knowledgeable that usually individual twins will grow appropriately and at the
same rate as singletons until how many weeks?
A. 16 to 18 weeks
B. 18 to 22 weeks
C. 30 to 32 weeks
D. 38 to 40 weeks

99. Which of the following classifications applies to monozygotic twins for whom the cleavage of
the fertilized ovum occurs more than 13 days after fertilization?
A. conjoined twins
B. diamniotic dichorionic twins
C. diamniotic monochorionic twin
D. monoamniotic monochorionic twins

100. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta
previa. Which of th following procedures is usually performed to diagnose placenta previa?
A. Amniocentesis
B. Digital or speculum examination
C. External fetal monitoring
D. Ultrasound

SIMULATION 5 NURSING PRACTICE 3

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART A)

SITUATION: The OR team performs distinct roles for one surgical procedure to be
accomplished within a prescribed time frame and deliver a standard patient outcome.

1. Which of the following role would be the responsibility of the scrub nurse?
A. Evaluate the type of anesthesia appropriate for the surgical client
B. Assess the readiness of the client prior to procedure.
C. Account for the number of sponges, needles, supplies used during surgical procedure
D. Ensure that the airway is adequate
2. Which of the following should be given highest priority when receiving patient in the OR?
A. Check for the jewelry, gown, manicure & dentures
B. Verify patient identification and informed consent
C. Assess level of consciousness
D. Assess vital signs

3. Another nursing check that should not be missed before the induction of general anesthesia
is:
A. Check for presence of dentures
B. Check for presence of underwear
C. Check patient's ID
D. Check baseline vital signs

4. While the surgeon performs the surgical procedure, who monitors the status of the client like
urine output and blood loss?
A. Surgeon
B. Scrub nurse
C. Circulating nurse
D. Anesthesiologist

5. Who among the surgical team is considered as the guardian of asepsis during surgery?
A. Surgeon
B. Scrub nurse
C. Circulating nurse
D. Anesthesiologist

SITUATION: Mr. Roger a 65 year old cardiac client was admitted at Philippine Heart
Center after experiencing constant chest pain that is relieved only with a forward leaning
or sitting position. He was diagnosed with Pericarditis.

6. Which of the following medication ordered by the physician would nurse Myrna question
before administering it to the client with pericarditis?
A. Indomethacin - DOC in pericarditis
B. Ibuprofen
C. Prednisone - steroids contraindicated while ( first line treatment are NSAIDs/ Aspirin)
D. Colchicine

7. Nurse Myrna is performing chest assessment to Mr. Roger. The most characteristic sign of
pericarditis she would most likely note is the presence of:
A. Swelling of the ankles
B. Light-headedness and faintness
C. Pericardial friction rubs
D. Dyspnea and shortness of breath
8. Which of the following medications ordered by the physician would 'Nurse Myrna question
before administering it to a client with pericarditis?
A. ibuprofen
B. Indomethacin
C. Prednisone
D. Colchicine

SITUATION: Nurse Jack is assigned in the Oncology Unit handling patients with breast
cancer

9. A 40 year old client with a history of breast conserving surgery, axillary node dissection and
radiation therapy calls th clinic to report that her arm is red, warm to touch, and slightly swollen.
Which of the following actions should the nurs suggest?
A. See the physician immediately.
C. Schedule an appointment within 2-3 years
B. Apply warm compresses to the affected area.
D. Elevate the arm on two pillows

10. The procedure that involves the removal of the entire breast tissue including the nipples
areola complex and a portion of the axillary lymph nodes is termed as:
A. Simple mastectomy
B. Radical mastectomy
C. Modified radical mastectomy
D. Total mastectomy

11. Which of the following is not a predisposing factor breast cancer'?

A. Menarche at 12 years
B. Height of 5'3" and weight of 110 lbs
C. Late menopause
D. Family history

12. The patient's relative asked Nurse Jack how often she should perform BSE. The nurse's
best response would be:
A. "Every month, 5 to 7 days after menses start"
B. "Every month, 5 to 7 days before menses start"
C. "Every month in any date"
D. "Whenever the patient is convenient"
13. A 66 year old woman has had a left modified radical mastectomy with axillary node
dissection.The nurse is aware that lymphedema is a common complication that can occur.
A. In older women
C. 7 to 10 days after surgery or not at all
B. 6 to 8 weeks after surgery
D. With right-sided radical mastectomies

14. The physician has ordered Fluorouracil 700 mg IV once a week to a 60 year old patient with
malignant tumor of the breast. When the patient heard this, she says to the nurse, "Am I going
to lose my hair?" Which is the best response of the nurse?
A. "Hair loss is normal and you can use a wig until your hair grows back"
B. "Flouroucil usually does not cause you to lose your hair"
C. "The physician will prescribe a medication to prevent this side effect from occurring"
D. "Losing your hair is less traumatic than losing your breast"

SITUATION: Baby Carlo, a 2 month old male infant, was born with a cleft lip. He is to
undergo cheiloplasty. As a nurse caring for a client with this condition, Nurse May should
be aware of nursing interventions involved to effectively assist Baby Carlo towards
recovery post-surgery.

15. To prevent Baby Carlo from pulling on the suture line post cheiloplasty, Nurse May should
apply:
A. Hand mittens
3. Elbow restraint
C. Clove-hitch restraint
D. Mummy restraint

16. After cleft lip surgery, Nurse May should place Baby Carlo in what position?
A. Prone
B. Supine
C. Side lying
D. Fowler's

17. Nurse May is teaching the parents of Baby Carlo regarding the ESSR method of feeding.
She is correct when she states that ESSR stands for:
A. Enlarge the nipple, stimulate the suck reflex, swallow, rest
B. Enlarge the nipple, stimulate the suck reflex, sucking, rest
C. Elevate the nipple, suck, swallow, rest
D. Elevate the nipple, swallow, suck, rest

18. Nurse May is aware that crusting on suture line should be avoided to prevent infection and
subsequent scarring post cheiloplasty. She is correct when she does which of the following
nursing actions to prevent crusting on suture line?
A. Rub the cotton-tipped applicator into the lips when applying cleansing solution
B. Clean the suture line with sterile water.
C. Rinse the area with 50% hydrogen peroxide after cleaning
D. Dry the suture line with a wet sterile cotton-tipped applicator

19. Nurse May is giving health instructions to parents of Baby Carlo. Which of the following
statements, if made by Nurse May, is considered as inaccurate? •
A. "Avoid hard or sharp objects from coming in contact with recent cleft suture line".
B. "Encourage use of straw to drink".
C. "As soon as Baby Carlo's sutures have been removed, he may be bottle-fed or breastfed"
D. "Baby Carlo needs to be bubbled well after feeding"

SITUATION: You as the charge nurse are monitoring a client with acute respiratory failure
who is intubated and placed on mechanical ventilation.

20. Which assessment parameter is most important for the nurse to review before weaning the
patient from ventilator?
A. Fluid intake for the last 24 hours
B. Baseline arterial blood gas (ABG) levels
C. Prior outcomes of wearing
D. Electrocardiogram (ECG) results

21. Based on the situation which physical finding alerts the nurse to an additional problem in
respiratory function?
A. Dullness to percussion in the third to fifth intercostals space, midclavicular line
B. Decreased paradoxical motion
C. Louder breath sounds on the chest - consolidation
D. pH of 7.36 in arterial blood gas

22. When suctioning this client, which intervention is most appropriate to apply?
A. Insert the suction catheter while applying suction
B. Apply suction until all the secretions have been removed
C. Use the same catheter to first suction the mouth, then the endotracheal tube
D. Pre-oxygenate with 100% oxygen before suctioning

SITUATION: You are the nurse caring for Melissa; 45 years old who is undergo
bronchoscopy

23. Atropine is given to Melissa prior to bronchoscopy as part of preoperative medications

primarily to:
A. Relieve anxiety
B. Sedate the patient
C. Suppress the cough reflex
D. Inhibit vagal stimulation
24. Which of the following does NOT reflect the purpose of therapeutic bronchoscopy?
A. To examine tissues or collect secretions - for diagnostic bronchoscopy not
therapeutic bronchoscopy
B. To remove foreign bodies from the trachebronchial tree
C. To treat postoperative atelectasis
D. Destroy and excise lesions

25. After bronchoscopy, once the patient demonstrates a cough reflex, the nurse may offer:
A. Ice cream
B. Soft foods
C. Any foods as long as tolerated since patient's is just under local anesthesia
D. Ice chips

NPO → Clear liquids → general liquids → soft diet → DAT → full diet (no restriction at all)

26. Which of the following complaints by Melissa should be noted as a possible complication?
A. Sore throat and hoarseness
B. Nausea and vomiting
C. Shortness of breath and laryngeal stridor → bronchospasm
D. Blood tinged sputum and coughing

27. Nursing interventions before bronchoscopy includes the following except:

A. Obtain signed consent form from the patient
B. Withhold food and fluids for 8 hours prior to the procedure - 4-6 hours NPO only
C. Administer preoperative medications as prescribed
D. Allow patient to verbalize his feelings to allay anxiety

SITUATION: Nurse Candy is performing an assessment to Mang Boy, a 45 year old

carpenter, who visited the clinic with complain of burning sensation in the mid
epigastrium. After series of laboratory exams, he was diagnosed with Peptic Ulcer
Disease.

28. Mang Boy has also been prescribed with Nexium.(Esomeprazole) Nurse Candy is aware
that this drug is classified as:
A. Histamine-2 receptor antagonist
B. Prostaglandin analog
C. Proton pump inhibitor
D. Anti diarrheal

29. Man Boy has been prescribed with Zantac (Ranitidine). Which of the following is the correct
action of the medication?
A. Decreases gastric acid secretion by slowing the hydrogen-potassium adenosine triphosphate
pump on the surface of the parietal cells of the stomach
B. Increase mucous production and bicarbonate levels
C. Creates a viscous substance in the presence of gastric acid that forms a protective barrier,
binding to the surface of the ulcer, and prevents digestion by pepsin
D. Decreases amount of HCl produced by stomach by blocking action of histamine on
histamine receptors of parietal cells in the stomach

30. Nurse Candy is teaching dietary modifications to Mang Boy. Nurse Candy should suggest
avoiding:
1. Meat extracts
2. Alcohol
3. Decaffeinated coffee
4. Cream
A. 1 and 2
B. 1 and 4
C. 1, 2, and 3
D. 1, 2, 3, and 4

31. Nurse Candy provides medication instructions to Mang Boy. Which statement if made by
MangBoy, indicates the best understanding of the medication therapy?
A. "Antacids will coat my stomach"
B. "Sucralfate (Carafate) will change the fluid in my stomach"
C. "Cimetidine (Tagamet) will cause me to produce less stomach acid"
D. "Omeprazole (Prilosec) will coat the ulcer and help heal it" → inhibits gastric secretion

32. Nurse Candy is aware that peptic ulcer disease is associated with which of the following
cause:
1. Blood type AB and stress
2. H. Pylori infection and chronic use of NSAIDs
3. H. Pylori and diet indiscretions
4. Ingestions of milk and caffeinated beverages
A. 1 and 3
B. 2 and 4
C. 1, 2 and 3
D. 2, 3 and 4

SITUATION: Aling Fe, 49 years old, was admitted to the hospital due to complain of
frequent nausea and vomiting hours after heavy meal. Cholelithiasis was ruled out after
series of laboratory exams was performed.

33. Nurse Sassy has just received Aling Fe's lab results from the Laboratory Department. Upon
evaluation, she notes that which of the following an expected laboratory finding in a client with
cholelithiasis?
A. Elevated serum bilirubin
B. Decreased serum bilirubin
C. Elevated somatostatin
D. Elevated serum amylase

34. In assessing Aling Fe who has cholelithiasis, Nurse Sassy would expect the client to report
pain in what site?
A. Mid-epigastrium
B. Mc Burney's point
C. Right upper abdomen radiating to the back or right shoulder → biliary colic pain
D. Sacral area that sweeps down to abdomen

35. Which of the following food should be avoided by Aling Fe to prevent exacerbation of her
condition?
1. Mashed potatoes
2. Coffee
3. Cheese
4. Alcohol

A. 1 and 2
B. 2 and 4
C. 3 and 4 - avoid oil and alcohol
D. 2, 3 and 4

36. Which of the following medications used in the management of the cholelithiasis acts by
inhibiting the synthesis and secretion of cholesterol, thereby desaturating bile?
A. Dilaudid - Opioid
B. Protonix - PPI
C. UDCA - ursodeoxycholic acid
D. LSD

37. Which of the following statements accurately describes the cause of pain in cholelithiasis?
A. When the gallstone obstructs the cystic duct, the gallbladder becomes distended, inflamed,
and eventually infected → cholecystitis
B. When fat enters the duodenum, the gallbladder will contract and distend until it comes
in contact in the right ninth and tenth costal cartilages
C. When the gallstone continues to obstruct the duct, abscess, necrosis, and perforation results
D. The sphincter of Oddi becomes spastic due to morphine administration

SITUATION: Mang Gary, a 67 year old Retired General, was admitted at St. Luke's Medical
Center due to liver cirrhosis. Nurse Mark was assigned to care for this client.

38. Nurse Mark is providing health teachings to Mang Gary. Which of the following statements if
made by the client indicates a need for further instructions?
A. "I will take Tylenol if I get headache"
B. "I will obtain adequate rest"
C. "I need to include sufficient amounts of carbohydrates in my diet"
D. "I should monitor my weight on a regular basis"

39. The physician arrives on the nursing unit and deflates the Sengstaken Blakemore tube.
Afterward, the nurse should inform the client closely for which of the following?
A. Swelling of the abdomen
B. Bloody diarrhea
C. Hematemesis → recurrence of bleeding
D. An elevated temperature and a rise in BP

40. Nurse Mark is reviewing the chart of Mang Gary and expecting to find which of the following
laboratory values?
A. Decreased serum creatinine
B. Decreased serum sodium
C. Increased serum ammonia
D. Increased serum calcium

41. Nurse Mark is reviewing the record of Mang Gary and notes that there is a documentation of
the presence of asterixis. How should he assess for its presence?
A. Dorsiflex the client's foot
B. Measure the abdominal girth
C. Ask the client to extend the arms
D. Instruct the client to lean forward

42. Which diet does Nurse Mark anticipate to be prescribed for this client?
A. Low-protein diet
B. High-protein diet
C. Low-fat, low-residue diet
D. High-carbohydrate diet → with low protein and low fat diet to reduce stress on the liver

43. After the Sengstaken-Blakemore tube is inserted. The client has difficulty of breathing,
based on this information the first action of the nurse should:
A. Deflate the esophageal balloon
C. Take immediately the vital signs
B. Encourage him to take deep breaths
D. Notify the physician

44. Nurse Mark is preparing to care for Mang Gary with esophageal varices who has just had a
Sengstaken-Blakemore tube inserted. Which of the following items must be kept at the bedside
at all times?
A. Obturator
B. Kelly clamp
C. Irrigation set
D. Scissors
SITUATION: Nurse Susy is assigned as a scrub nurse in the operating room. She is
assisting the surgeon in cesarean delivery.

45. What suture is being used during final closing in cesarean surgery?
A. Chromic
B. Silk
C. Gut
D. Nylon - non absorbable

46. What is the most appropriate position of the client during cesarean surgery?
A. Supine with wedge on the right hip
B. Lithotomy
C. Genupectoral
D. Trendelenburg

47. Before the client is transported in Post Anesthesia Care Unit, what final step by the scrub
nurse is performed during cesarean surgery?
A. Cleansing the uterine cavity with sterile gauze
B. Painting the wound site with antiseptic
C. Placing sterile wound dressing
D. Evacuating blood clots from the vaginal vault

48. When closing the first layer of uterine cavity during cesarean surgery, what suturing
technique is being utilized?
A. Continuous interlocking
B. simple continuous
C. Simple interrupted
D. Simple interrupted with lembersts

49. When closing the peritoneum during cesarean surgery, what type of suture is being used?
A. Chromic
B. Silk
C. Gut
D. Nylon

SITUATION: Aling Zaida, a 69 year old female client admitted due to myocardial infarction. She
is hooked in a cardiac monitor and is under cardiac drug therapy including heparin. Nurse Anna
is in charge for the care of this patient. The following questions apply.
\
50. Aling Zaida who is on heparin therapy has APTT result of 80 seconds. This indicates that:
A. She is prone to bleeding
B. It is the therapeutic effect of the drug
C. She may develop thromboembolism
D. She is not receiving adequate dose of the drug

51. Since Aling Zaida is receiving heparin, you as her nurse knows that the main reason for this
is to:
A. Prevent formation of a thrombus
B. Dissolve small clot that have lodged in the coronary arteries
C. Decrease the amount of time it takes the blood to clot
D. Enhance the action of thrombin in the bloodstream

52. During Aling Zaida's second night of admission the client develops congestive heart failure.
A Swan-Ganz catheter is inserted to monitor the client for left ventricular function because:
A. It provides information about pulmonary resistance
C. It controls renal blood flow
B. It measure myocardial oxygen
D. It controls after load

53. The acute nursing management of a client with CHF will include all of the following goals
except:
A. Increase in cardiac output
B. Elevation in renal blood flow
C. Reduction in the hearts workload
D. Decrease in myocardial contractility
54. You as the nurse should take note that this Aling Zaida is thin. When injecting heparin S.C.
the nurse should:
A. Aspirate after the injection
B. Use the Z-track method
C. Use a 45--degree angle for insertion
D. Always use the same injection site

55. Which medication should be readily available since Aling Zaida is receiving heparin?
A. Magnesium sulfate
B. Vitamin K
C. Warfarin sodium
D. Protamine sulphate

56. Which of the following nursing interventions is not included in the prevention of vasovagal
stimulation in the case of Aling Zaida who has MI?
A. Avoiding extreme temperature of foods and drinks
B. Administer colace as ordered
C. Obtaining rectal temperature
D. Advise client to avoid holding his breath

SITUATION: Lorna is experiencing left sharp pain and occasional hematuria. She was
advised to undergo IVP by her physician.

57. Post IVP, Lorna should excrete the contrast medium. You instructed the family to include
more vegetables in the diet and:
A. Increase fluid intake - washout the dye through urine
B. Barium enema
C. Cleansing enema
D. Gastric lavage

58. What will nurse monitor and instruct the client and significant others post IVP?
A. Report signs and symptoms for delayed allergic reactions
B. Observed NPO for 6 hours
C. Increase fluid intake
D. Monitor intake and output

59. The presence of calculi in the urinary tract is called

A. Cholelithisasis
B. Nephrolithiasis
C. Ureterolithiasis
D. Urolothiasis

SITUATION: Hypokalemia is a life threatening condition that could immediately lead to

death if not assessed properly. It has no specific signs that could lead to misdiagnosis.
60. In patients with diuretic-induced hypokalemia, a diuretic that prevents further hypokalemia
is:
A. Mannitol
B. Ethacrinic acid
C. Furosemide
D. Spironolactone

61. The nurse knows that the appearance of U wave in the ECG tracing could occur when the
patient's potassium level is:
A. 3 mEq/L
B. 4 mEq/L
C. 5 mEq/L
D. 6 mEq/L
Anything going down in the ECG is hypo while anything going up is hyper

62. Which of the following conditions is contraindicated when administering oral or IV potassium
supplements?
A. Liver disease
B. Oliguria → indicates hyperkalemia
C. Anorexia
D. Pyrexia

63. The nurse is to administer parenteral potassium. The nurse is correct when she:
A. Administers the drug via IV push
B. Uses regular infusion set instead of infusion pump
C. Agitates the IV bag- evenly distributes contents
D. Administers the drug via IM

64. Which of the following symptoms could the nurse observe being manifested by clients
suspected of hypokalemia?
A. Presence of Z wave
B. Leg weakness
C. Oliguria
D. Increased bowel motility

SITUATION: Baby Jamby is a 5 week old infant who was brought to the hospital and was
diagnosed with cryptorchidism.

65. Baby Jamby's parents gave consent for their child to undergo surgery. Which of the
following surgical procedure corrects this condition?
A. Orchiectomy - removal of testes
B. Orchiopexy - procedure to treat undescended testes
C. Sclerotherapy - treat blood vessel malformation (varicose veins)
D. Circumcision

66. Nurse Amy should emphasize to the child's parents that:

A. Baby Jamby needs lifetime follow up since it is associated with testicular cancer
B. Orchiectomy should be performed when Baby Jamby reaches 15 years old
C. Sperm banking should be considered once Baby Jamby reaches adolescence for future
family planning
D. The child should be given chronic gonadotropin hormone annually until Baby Jamby reaches
adolescence

67. Nurse Amy is aware that this condition is usually caused by:
A. Abnormal dilation of veins of the spermatic cord
B. Collection of fluid in procassus vaginalis
C. Twisting of the spermatic cord
D. Dry labor or prematurity

68. Nurse Amy is aware that surgery by laparoscopy for Baby Jamby is ideally performed
during:
A. 2-4 months
B. 4-6 months
C. 6-24 months - Advisable at 6 - 18 months
D. 24-32 months

69. When assessing Baby Jamby for cryptorchidism, Nurse Amy is expected to find:
A. A palpable mass on abdomen
B. Soreness in the inguinal canal
C. Light that is transmitted after transillumination
D. Constricted foreskin

SITUATION: Nurse Flor is caring for Mang Emie who has been diagnosed with cataract
and Aling Poring who has been diagnosed with glaucoma in the ENT Ward.

70. Which of the following eye drops will Nurse Flor expect to be prescribed for Mang Ernie as a
preparation for cataract surgery?
A. Antibiotic
B. Miotic agent
C. Mydriatic agent
D. Muriatic acid

71. The chief manifestation that Nurse Flor would expect to note in the early stages of cataract
formation is:
A. Eye pain
B. Floating spot
C. Blurred vision - central blindness
D. Diplopia

72. Which of the following instructions would be appropriate to include in the plan of care for
Aling Poring?
A. Decrease fluid intake to control the intraocular pressure
B. Avoid watching TV and reading newspaper
C. Decrease the amount of salt in the diet
D. Eye medication will need to be administered for the rest of your life

73. A client with glaucoma asks the nurse if complete vision will return. The most appropriate
response is:
A. "Although some vision has been lost and cannot restored, further loss may be
prevented by adhering to th treatment plan"
B. "Your vision will return as soon as the medication begins to work"
C. "Your vision will return to normal"
D. "Your vision loss is temporarily and will return in about 3-4 weeks"

74. In administering eye drops to a client with glaucoma, on which part would you instil the drug
to facilitate maxin absorption:
A. Conjunctival sac
B. Pupil
C. Sclera
D. Vitreous humor

75. The nurse reviews the last results as documented in the client's chief chart and understands
that the nor intraocular pressure is:
A. 2-7 mmHg
B. 10-21 mmHg
C. 22-31 mmHg
D. 31-35 mmHg

76. A client with retinal detachment is admitted to the nursing unit in preparation for sclera
buckling procedure. Which of the following would the nurse anticipate to prescribe?
A. Bathroom privileges only
6. Elevating the head of the bed to 45 degrees
C. Placing an eye patch over the clients affected eye - by the book, eye patch is used on
both eyes
D. Wearing dark glasses to read and watch TV

77. Post cataract surgery, Nurse Flor should advise Mang Ernie to lie on the bed and position;
A. On the operative side
B. Non-operative side
C. Supine
D. Trendelenburg
78. After Mang Ernie undergone cataract removal with intraocular lens implant. Nurse Flor is
giving the client discharge instructions. These instructions should include which of the following?
A. Avoid lifting objects weighing more than 5 Ibs. (2.25 kg) → limit should be 15lbs
B. Lie on your abdomen when in bed
C. Keep rooms brightly lit.
D. Avoiding straining during bowel movement or bending at the waist

SITUATION: Marco, 16 years old, comes to the ER with acute asthmatic attack. RR is
46/min and he appears to be in acute respiratory distress.

79. Based on this situation, which of the following nursing actions should be initiated first?
A. Promote emotional support
B. Administer oxygen at 6L/min
C. Suction the client every 30 minutes
D. Administer bronchodilator by nebulizer

80. Marco stops wheezing and breath sounds aren't audible. The nurse should be alert since
the reason for this change is:
A. The attack is over
B. The airways are so swollen that no air can get through
C. The swelling has decreased
D. Crackles have replaced wheezes.

81. You will give health instructions to Marco, a case of bronchial asthma. The health
instructions will include the following EXCEPT:
A. Avoid emotional stress and extreme temperature
C. Avoid pollens, dust, and sea food
B. Avoid pollution like smoking
D. Practice respiratory isolation

82. Aminophylline was ordered for acute asthmatic attack. The mother asked the nurse, what its
indication is. The nurse knows that it is given to:
A. Relax smooth muscles of the bronchial airway
C. Prevent thickening of secretions
B. Promote expectoration
D. Suppress cough.

83. The asthmatic client asked you what breathing technique he can best practice when
asthmatic attack starts. What will be the best position?
A. Sit in high Fowler's position with extended legs
C. Push on abdomen during exhalation
B. Sit up with shoulders back
D. Lean forward 30-40 degrees with each exhalation - orthopneic position
84. As a nurse, you are always alerted to monitor status asthmatics who will likely and initially
manifest symptoms of:
A. Metabolic alkalosis
B. Respiratory acidosis → manifests when it worsens
C. Respiratory alkalosis → initial: compensatory hyperventilation
D. Metabolic acidosis

SITUATION: As a registered nurse, the practice is guided with competencies designed to

improve quality nursing practice and enhance professional development.

85. What is the basic requirement of the state for nurse to practice her profession?
A. Willingness to practice the profession
B. A BSN degree
C. A nursing license
D. An NCLEX and CGFNS passer

86. The standardized guidelines and procedures for implementation of Continuing Professional
Education (CPE) for all should be:
professional. Resolution provides that the total CPE credit units for registered professionals with
baccalaureate degree
A. 20 credit units per year
C. 60 credit units for 3 years
B. 30 credit units for 3 years
D. 15 credit units required

87. The Board of Nursing is vested with power to issue, suspend or revoke for cause, the:
A. Certificate of Good Moral Character
B. Certificate of Practice
C. Certificate of Registration
D. Certificate of Employment

88. The Code of Good Governance for the professions in the Philippines shall be adapted by:
A. All registered professionals
C. All professionals
B. All Filipino professionals
D. All registered nurses

SITUATION: Perioperative nurses should be aware of the different procedures and

protocols as part of his/her competency in the practice of Perioperative Nursing.

89. Spaulding categorized instruments according to use. Where do you classify endoscopic
instrument?
A. Decontaminated instruments
B. High-level disinfected instruments
C. High technology instruments
D. Sterile instruments

90.Medical gases are used a lot in the ER. Some gases are used to operate equipment and
some are to administer general anesthesia through inhalation. What is the identifying color of
the tank which contains "laughing gas"?
A. Yellow
B. Green
C. Black
D. Blue

91. An anesthesiologist is preparing to do a spinal anesthesia to a 220 pounds, 30 year old

athlete.She requests circulating nurse to prepare a pink spinal set with another blue set as
stand by. What gauge spinal sets will you make available in the OR suite?
A. gauge 16 and 22
B. gauge 18 and 24 - should be 18 (pink) and 23 (blue)
C. gauge 16 and 20
D. gauge 25 and 22

92. What OR attires are worn on the restricted area?

A. Scrub suit, OR shoes, head cap
B. Head cap, scrub suit, mask, OR shoes
C. Mask, OR shoes, scrub suit
D. Cap, mask, gloves, shoes

93. Which of the following nursing interventions should be given the highest priority when
receiving a client in OR?
A. Check the presence of dentures, jewelry, nail polish, and other accessories B. Receive the
client at the semi-restricted area and change his gown
C. Assess level of consciousness
D. Verify the identification and informed consent

94. You just transferred out a post-op client to her room. What would your instruction to the
family include to prevent accidents?
A. Report when the IV infusion is almost finished
B. Test the call system if functioning
C. Keep the room lights on for 24 hours
D. Make sure that the side rails are up

SITUATION: Client with Total Parenteral Nutrition (TPN).

95, TPN is ordered for a ient with Crohns disease. While administering the PN solution, it is
important for the nurse to remember that the total parenteral solutions are used to:
A. Increase cell nutrition – umbrella answer
B. Treat metabolic acidosis
C. Provide hydration
D. Reverse a positive nitrogen balance

96. Which of the following interventions should the nurse include in the client's care plan to
prevent complication associated with TPN administered through a central line?
A. Use a clean technique for all dressing changes
B. Tape all connection of the system
C. Encourage bed rest
D. Cover insertion site with a moisture-proof dressing

Common complications:

97. A client with inflammatory bowel disease is receiving TPN. The basic component of the
client's TPN solution is most likely to be:
A. An isotonic dextrose solution
B. A hypertonic dextrose solution
C. A hypotonic dextrose solution
D. A colloidal dextrose solution

98. The nurse would regularly assess a client's ability to metabolize the TPN solution
adequately by monitoring the clien for which of the following?
A. Elevated blood urea nitrogen concentration
B. Hypertension
C. Tachycardia
D. Hyperglycemia — check for CBS q4-6hrs

99. When developing a care plan for a client who is- receiving TPN, which one of the following
potential nursi diagnoses would be most appropriate?
A. Impaired swallowing
B. Impaired Gas Exchange
C. Risk for Fluid Volume Excess
D. Ineffective Tissue Perfusion

100. For a nurse to assess an upper respiratory tract infection, you should palpate the following:
A. The ears, eyes, nose, and throat
B. Adenoids, tonsils, and nose
C. Nose and throat only
D. The tracheal and nasal mucosa including the frontal sinuses

SIMULATION 5 NURSING PRACTICE 4

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART B)

SITUATION: Carbon Monoxide poisoning is said to be the 2nd leading cause of poisoning
death. It is said inside ar leading cause of inhalation poisoning. Mr. Santos was rushed to
the hospital after being unconscious inside enclosed parking lot. Carbon monoxide
poisoning suspected.

1. The pulse oximeter reading of mr. Santos is 100%. This suggests that:
A. That the client has an improved chance of surviving, since the client is well oxygenated
B. There is no carbon monoxide poisoning, it should be ruled out
C. This is not a reliable sign to rule out carbon monoxide poisoning
D. There is longer of hypoxia

2. If the client demonstrated psychoses, visual disturbance, ataxia, amnesia and confusion even
after completion of resuscitation and the return of normal oxygenation, this will indicate that:
A. The client suffered from an irreversible brain damage
B. That the client will need a longer rehabilitation to go back to the previous functioning
C. The client need to evaluate for this evidence that resuscitation is not yet complete
D. That the client is exhibiting secondary gains

3. Which of the following laboratory results is constantly checked in clients undergoing treatment
for carbon monoxide poisoning?
A. Skin color
B. Oxygen saturation
C. RBC count
D. Carboxyhaemoglobin – should be less than 5%

4. Initially, in patient with suspected inhalation poisoning, the most important intervention at the
scene of poisoning is:
A. Assess the patient's airway breathing and circulation
B. Administer oxygen and loosen the client clothing
C. Conduct a head to toe physical assessment
D. Carry the client on the fresh air immediately, opening all windows & doors if closed.

5. Which of the following is a sign that the nurse will expect to see Mr. Santos?
A. Restlessness
B. Pale skin
C. Cyanotic
D. Cherry red skin

SITUATION: Jerry, 35 years old, was diagnosed with Meniere's disease.

6. The nurse is assessing the patient with inner ear disorder. Which question will the nurse ask
to elicit information regarding the most common complaint associated with this type of disorder?
A. "Do you experience ringing in the ear?"
B. "Do you hear the words clearly?"
C. "Is your ear always itchy?"
D. "Do you have hearing loss?"

7. The nurse is reviewing patient's record for physician's order after having an acute attack of
meniere's disease. Which of the following physician's order would the nurse question?
A. Diphenhydramine (Benadryl)
B. Ambulation three times daily – problems with balance → risk for injury
C. Diazepam (Valium)
D. Low sodium diet

8. When caring for Mr. Santos, the priority diagnosis would focus on:
A. Therapeutic regimen
B. Nutrition
C. Self-care measures
D. Safety measures

9. Mr. Santos would probably complain which of the following? Mark only one oval.
A. Pain upon pulling the tragus
B. Tenderness over the mastoid area
C. Bilateral hearing loss
D. Vertigo and nausea

SITUATION: Nurse Donna is assigned in Coronary Care Unit of PH where she is dealing
with clients with various heart disorders. As part of the assessment, knowledge of ECG
reading is essential for Nurse Donna to provide competent and effective nursing care.

10. Nurse donna is watching the cardiac monitor, and a client's rhythm suddenly suddenly
changes. These are no P waves: instead there are fibrillatory waves before each QRS complex.
How should nurse donna correctly interpret the client's heart rhythm?
A. Atrial fibrillation
C. Ventricular tachycardia
B. Sinus tachycardia
D. Ventricular fibrillation

11. Nurse Donna notes that a client with sinus rhythm has a premature ventricular contraction
that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with
no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How
would nurse donna interpret this rhythm?
A. Atrial Fibrillation
B. Asystole
C. Ventricular fibrillation
D. Ventricular tachycardia

12. The appearance of U wave in a patient's ECG tracing should alert the nurse to check the
laboratory values for:
A. Hypernatremia
B. Hypokalemia
C. Hyperkalemia
D. Hyponatremia

13. Nurse donna is watching the cardiac monitor and notices that the rhythm suddenly changes.
There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over
100 beats per minute. Nurse donna determines that the client is experiencing which of the
following dysrhythmias?
A. Sinus tachycardia
B. Ventricular fibrillation
C. Ventricular tachycardia
D. Premature ventricular contractions
SITUATION: Specific surgical interventions may be done when lung cancer is detected
early. You have important peri-operative responsibilities in caring for patients with lung
cancer.

14. Which of the following observations indicates that the closed chest drainage system is
functioning properly?
A. Absence of bubbling in the suction control bottle
B. Less than 25 ml drainage in the drainage bottle
C. Fluctuating movement of fluid in the long tube of water-seal bottle during inspiration
D. Intermittent bubbling through the long tube of the suction control bottle

15. Following thoracic surgery, you can BEST help GH to reduce pain during deep breathing
and coughing exercise by:
A. Splinting the patient's chest with both hands during the exercises
B. Administering the prescribed analgesic immediately prior to exercises
C. Providing rest for six hours before exercises
D. Placing the patient on his/her operative side during exercises

16. GH is scheduled to have lobectomy. The purpose

of closed chest, drainage following lobectomy is:
A. Expansion of the remaining lung
B. Facilitation of coughing
C. Prevention of mediastinal shift
D. Promotion of wound healing

17. What should you do as a nurse when the chest tubing is accidentally disconnected?
A. Reconnect the tube
B. Change the tubing
C. Notify the physician
D. Clamp the tubing

18. During the immediate postoperative period following a pneumonectomy, deep tracheal
suction should be done with
extreme caution because:
A. The remaining normal lung needs minimal stimulation
B. The patient will not be able to tolerate coughing
C. The tracheobronchial trees are dry
D. The bronchial suture line may be traumatized

SITUATION: Radiation therapy is another modality of cancer manazement. With emphasis on

multidisciplinary management you have important responsibilities as nurse.
19. Christian is admitted with a radiation-induced thrombocytopenia. As a nurse you should
observe the following
symptoms:
A. Petechiae, ecchymosis, epistaxis
C. Headache, dizziness, blurred vision
B. Weakness, easy fatigability, pallor
D. Severe sore throat, bacteremia, hepatomegaly

20. Christian is receiving external radiation therapy and he complains of fatigue and malaise.
Which of the following nursing interventions would be most helpful for christian?
A. Tell him that sometimes these feelings can be psychogenic
B. Refer him to the physician
C. Reassure him that these feelings are normal
D. Help him plan his activities

21. What interventions should you include in your care plan?

A. Inspect his skin for petechia, bruising, Gl bleeding regularly
B. Place Christian on strict isolation precaution
C. Provide rest in between activities
D. Administer antipyretics if his temperature exceeds 38 C

22. What nursing diagnosis should be of highest priority?

A. Impaired tissue integrity
B. Activity intolerance
C. Knowledge deficit regarding thrombocytopenia
D. Ineffective tissue perfusion, peripheral, cerebral, cardiovascular

SITUATION: Nurse Mara is performing an assessment to Andrew, a 34 year old car racing
enthusiast, after sustaining severe head injury following car accidents. She is utilizing
the Glasgow Coma Scale in assessing the neurologic status of Andrew.

23. Nurse Mara is assessing Andrew's eye opening response. She will give what score when
Andrew responds only to pain?
A. 1
B. 2
C. 3
D. 4
24. Nurse Mara understands the Glasgow coma scale scoring when she states which of the
following statements?
A. GCS is not a tool for assessing a client's response to stimuli
B. GCS scores range from 3 (normal) to 15 (deep coma)
C. Peripheral stimulation is more accurate than central stimulation when assessing GCS
D. The smaller the GCS score, the deeper the coma

25. Nurse Mara is assessing the motor functions of Andrew. She would plan to use which of the
following to test Andrew's peripheral response to pain?
A. Sternal rub
B. Nail bed pressure
C. Pressure on the orbital rim
D. Squeezing the sternocleidomastoid muscle

26. Nurse Mara would give what GCS score if Andrew's eyes open in response to pain, has no
verbal response, and has
decerebrate posturing?
A. 3
B. 5
C. 7
D. 9

SITUATION: Nurse Claire is assigned to the ward caring for patients with disturbances in the
endocrine system.

27. Mang Tenoryo was diagnosed with primary aldosteronism. Upon taking the V/S by Nurse
Claire, the blood pressure is elevated and the nurse knows that it is caused by:
A. Excessive secretion of aldosterone from adrenal cortex
B. Excessive secretion of insulin by the pancreas
C. Too much parathormone released by the parathyroid gland
D. Increased level of circulating epinephrine and nor-epinephrine from adrenal medulla
28. Nurse Claire is performing physical assessment to patient Y who has been diagnosed with
acromegaly and she noted the following characteristics of this disease except:
A. Enlarged hands and feet
B. Distorted facial features
C. Increasing height
D. Ulnar nerve entrapment the elbow

29. A patient is seeking consult to the hospital and complains of significant weight loss over the
last month though her appetite has been ravenous. She was diagnosed with grave's disease. /
HYPERTHYROIDISM The nurse is aware that the patient may exhibit the following
manifestations except:
A. Constipation
B. Tachycardia
C. Mild tremors
D. Nervousness

30. Patient Y is now being treated with octreoride acetate (sandostatin). The nurse knows that
the side effect of this drug is:
A. Abdominal pain
B. Constipation
C. Diarrhea
D. Drowsiness

SITUATION: Care of clients with tracheostomy is often a challenge to beginning nurse.

The following questions will test your knowledge on tracheostomy and its related care:

31. You know that when rendering tracheostomy care, the priority consideration is always to
keep the airway patent and also to prevent infection at the site. The nurse knows that the
technique used in rendering tracheostomy care is:
A. Disinfectant
B. Clean
C. Medical
D. Sterile

32. Prior to the suctioning or removal of the inner cannula, the nurse knows that the client is
prepared and positioned in:
A. Semi Fowlers position
B. High Fowler
C. Left side lying
D. Sims

33. In cleaning the inner cannula or other parts of the tracheostomy tube, the best cleansing
medium are:
A. Hydrogen peroxide and sterile NSS
B. Povidone iodine & sterile NSS
C. Alcohol & sterile NSS
D. Alcohol & Hydrogen peroxide

34. Which of the following is NOT true with regards to securing the tracheostomy?
A. The cuff provides sufficient securing
B. The tracheostomy can be stapled in place
C. The tracheostomy can be sutured in place
D. Tie or Velco are used to generally secure tracheostomy around the client

35. The nurse is performing health education activities for Sally Mendoza, a 40 year old teacher
with insulin dependent Diabetes Milletus
A. Draw insulin from the vial of clear insulin first
B. Draw insulin from the vial of the immediate acting insulin first
C. Fill both syringes w/ the prescribed insulin dosage, shake the bottle vigorously
D. Withdraw the intermediate actine insulin before withdrawing the short acting insults
36. Sally complains of nausea, vomiting, diaphoresis and headache. Which of the following
nursing interventions are you
going to carry out first:
A. Withhold the client's next insulin injection
B. Test the client's blood glucose level
C. Administer Tylenol was ordered
D. Offer juice, gelatine & chicken bouillon

37, Upon asessment of hbalc of Mrs. Mendoza, The nurse has been informed of a 9% hbaic
result. In this case, she wil teach the patient to:
A. Prevent and recognize hyperglycemia
C. Take adequate food and nutrition
B. Avoid infection
D. Prevent and recognize hypoglycaemia

38. Sally administered regular insulin at 7AM and the nurse must instruct Sally to avoid exercise
around:
A. Between 9 to 11 AM
B. After 8 hours
C. Between 8 AM to 9AM
D. In the afternoon after lunch

39. Sally was brought at the emergency room after 4 month because she fainted in her school.
The nurse should monitor which of the following test to evaluate the overall therapeutic
compliance of a diabetic patient?
A. Ketone levels
B. Fasting blood glucose
C. Urine glucose level
D. Glycosylated hemoglobin — 3 MONTHS Compliance
SITUATION: Rene, 55 years old, was admitted to the hospital with chief complaints of raspy, low
pitched voice and lump in the neck. After several diagnostic procedures, the physician
diagnosed Rene with Laryngeal cancer.

40. Which of the following factors predispose Rene, the most for development of laryngeal
cancer?
A. Smoking and alcoholism
B. Familial predisposition
C. Gender
D. Age

41. Following laryngectomy, which of the following position should the nurse place the post-op
patient?
a. Supine with head flat on bed
b. Semi-fowler
c. Supine with pillow
d. Side lying

42. In promoting alternative communication methods in patient who underwent laryngectomy,

the best method that can be utilized is the use of:
a. Hand gesture
b. Picture board
c. magic slate
d. call bell

SITUATION: Five year old Alvin has been admitted to the pediatric unit with a tentative
diagnosis of nephritic syndrome

43. At Alvin's last PE when he was 3 years old, his BP was 95/50 mmH PR 110 bpm and his
weight was 15 kg. Which of the following current assessment findings would the nurse report to
help him confirm the diagnosis?
A. BP 200/70 mmHg
B. Weight 18 kg
C. PR 110 bpm
D. Temp 38 C

44. Prednisone is prescribed for Alvin. The nurse can evaluate its effectiveness by:
A. Checking his BP every four hours
B. Testing his urine for glycosuria
C. Weighing him morning before breakfast
D. Observing him for behavioural changes
SITUATION: You are assigned in the Medical-Surgical Ward and frequently encounter client's
charts with ABG results attached. Knowledge of acid-base imbalances and their interpretation is
essential in order to provide competent and effective nursing care to these clients.

45. You review the arterial blood gas of a client. The results indicate respiratory acidosis. Which
of the following values would indicate that this acid-base imbalance exists?
A. pH OF 7.48
B. pH of 7.30
C. PaCO2 of 32 mmHg
D. HCO3 of 20 mEg/L

46. A client is admitted to the hospital, abg result are pH 7.37, paCO243, HCO3 23. You will
interpret this result as:
A. Respiratory acidosis, uncompensated
B. Normal ABG result
C. Metabolic acidosis, partially compensated
D. Metabolic alkalosis partially compensated

47. The following ABG results are on the client's chart pH 7.40, paCO2 43, HCO3, 23. Which of
the following correctly reflects the above results?
A. Metabolic alkalosis partially compensated
C. Metabolic alkalosis partially compensated
B. Respiratory alkalosis compensated
D. Normal ABG result

48. Nurse Joan is accurate when she states, which of the following may exacerbate fluid volume
deficit?
b. Lasix
c. Propranolol
d. Lactated Ringer's solution

49. Nurse Joan expects to find which of the following assessment data that is consistent with
fluid volume deficit?
A. Bounding pulse
B. Crackles
C. Tachycardia
D. Oliguria

SITUATION: As a nurse researcher, you must have a very good understanding of the common
terms and concepts used
in research.

50. A small scale version or trial run designed to test the methods to be used in larger, more
rigorous study is referred to as
A. Pilot study
B. Parent study
C. Panel stud
D. Prospective study

51. The type of research design, which involves an intervention but lacks randomization is
known:
A. True experiment
B. Quasi experimental
C. Non experimental
D. Retrospective study

52. Which of the following is the most important criterion in the selection of the research
problem?
A. Delimitation of the study
B. Significance of the study
C. Research instrument availability
D. Limitation of the researcher

53. The statement "Migration of Filipino nurses affect the health care delivery system of the
country." is an example of a/an:
A. Hypothesis
B. Assumption
C. Theory
D. Variable

54. In an experimental study, the researcher:

1. Manipulates at least an independent variable
2. Controls other relevant variables
3. Observes the effect of one or more variable
4. Involves only one group
A. 1 and 3
B. 1,2 and 3
C. 1,2 and A
D.1,2,3and4

SITUATION: The kidneys have very important excretory, metabolic, erythropoietic

function. Any disruption in the kidney's function can cause disease. As a nurse it is
important that you understand the rationale behind the treatment regimen used.

55. PL, in acute renal failure is admitted to the nephrology unit. The period of oliguria usually
fasts for about 10 days.
Which assessment parameter for kidney function will you use during the oliguric phase?
A. Urine output of less than 400 ml 24/hours
B. Urine output directly related to the amount of IV fluid infused
C. Urine output of 30-60 ml/hour
D. No urine output, kidneys in a state of suspension

56. As you are caring for PL who has acute renal failure, one of the collaborative interventions
you are expected to do
start hypertonic glucose with insulin and sodium bicarbonate to prevent:
A. Hyperkalemia
B. Hypercalcemia
C. Hypokalemia
D. Hypernatremia

57. Ben is 42 years old with chronic renal failure. An arteriovenous fistula was created for
hemodialysis in his left arm.
What diet instructions will you need to reinforce prior to his discharge?
A. Monitor fruit intake
B. Drink plenty of fluids
C. Restrict your salt intake
D. Be sure to eat meat every meal

58. Ben is also advised not to use salt substitute in the diet because:
A. Salt substitutes contain potassium w/ must be limited to prevent arrhythmias
B. Fluid retention is enhanced when salt substitutes are included in the diet
C. Limiting salt substitutes in diet prevents a buildup of waste product in the blood
D. A substance in the salt substitute interferes w/ fluid transfer across the membrane

SITUATION: As a nurse you need to anticipate the occurrence of complications of stroke

so that life threatening situation can be prevented.
59. Candy is admitted to the hospital with signs and symptoms of stroke. Her glasgow coma
scale is 6 on admission. A central venous catheter was inserted and an I.V. Infusion was
started. As a nurse assigned to candy, what will be your priority goal?
A. Prevent skin breakdown
C. Preserve muscle function
B. Promote urinary elimination
D. Maintain patent airway

60. Knowing that for a comatose patient hearing is the last sense to be lost, as jane's nurse,
what should you do?
A. Tell her family that probably she can't hear them
B. Tell her family who are in the room not to talk
C. Talk loudly so that Candy can hear you
D. Speak softly then hold her hands gently

61. Which among the following interventions should you consider as the highest priority when
caring for june who has hemi-paresis secondary to stroke?
A. Place June on an upright lateral position
B. Apply anti-embolic stockings
C. Perform range of motion exercise
D. Use hand rolls or pillows for support

62. Irene, age 40 was admitted to the hospital with a severe headache, stiff neck and
photophobia. She was diagnosed with a subarachnoid hemorrhage secondary to ruptured
aneurysm. While waiting for surgery, you can provide a therapeutic environment doing which of
the following?
A. Placing her bed near the window
B. Honouring her request for a television
C. Dimming the light in her room
D. Allowing the family visiting privileges

63. When performing a neurologic assessment on Wally, you can find that his pupils fixed and
dilated. This infected that
he:
A. Is permanently paralyzed
C. Is going to be blind because of trauma
B. Probably has meningitis
D. Has received a significant brain injury

SITUATION: The body has regulatory mechanism to maintain the needed electrolytes.
However there are conditions/surgical interventions that could compromise life. You
have to understand how management of these conditions is done.
64. You are caring for Nida who is scheduled to undergo total thyroidectomy because of a
diagnosis of thyroid cancer.
Prior to total thyroidectomy, you should instruct Nida to:
A. Perform range of motion exercises on the head and neck
B. Apply gentle pressure against the incision when swallowing
C. Cough and deep breathe every 2 hours
D. Support head with the hands when changing position

65. As Nina's nurse, you plan to set up emergency equipment at her bedside following
thyroidectomy. You should include:
A. An airway and breathing tube
B. A tracheotomy set and oxygen
C. A crush cart with bed board
D. Two ampoules of sodium bicarbonate

66. Which of the following nursing interventions is appropriate after a total thyroidectomy?
A. Place the pillows under your patient's shoulder
B. Raise the knee-gatch to 30 degrees
C. Keep your patient in a high-fowler's position
D. Support the patients head and neck with pillows

67. If there is an accidental injury to the parathyroid gland a thyroidectomy, which of the
following might Nida's develop postoperatively?
A. Cardiac arrest
B. Dyspnea
C. Tetany → hypocalcemia
D. Respiratory failure

68. After surgery Nina develops peripheral numbness, tingling and muscle twitching and spasm.
What would you anticipate to administer?
A. Magnesium sulphate
B. Potassium iodine
C. Calcium gluconate
D. Potassium chloride

SITUATION: In a client with wide-spread colon cancer, a colectomy is the surgical

procedure of choice instead of an abdominal perineal resection.

69. When should the teaching about ileostomy care begin?

A. Immediately after the operation when the anesthesia is wearing off
B. 72 hours after the operation
C. When readiness and interest is observed
D. As soon as the patient admitted
70. Which of the following indicates a need for further teaching in client's with ileostomy?
A. "I am expecting a change in my diet"
B. "I can remove the appliance during sleep"
C. "I can still swim"
D. "I am prone to dehydration"

71. The nurse will expect that the stool of the client after ileostomy will be:
A. Mushy
B. Spicy
C. Liquid
D. Soft

72. An expert nurse in the field of colostomy and ileostomy is called a/an:
A. Enterostomal therapy nurse
B. Nurse oncologist
C. Ostomy nurse
D. Nurse enterostomist

SITUATION: The nurse is handling patients with hematologic aberrations.

73. Increase blood viscosity in polycythemia vera may lead to the following conditions, EXCEPT:
A. Blurred vision
B. Angina
C. Claudication
D. Thrombophlebitis - causes vaso occlusion not thrombophlebitis

74. The nurse is aware that the most definite diagnostic test for iron deficiency anemia (IDA) is:
A. Complete blood count (CBC)
B. RBC indices
C. Bone marrow aspiration
D. Hematocrit

75. The patient was prescribed with iron supplements, the nurse knows that the patient has
correct understanding when
A. I will take it early in the morning
B. I will take it on an empty stomach
C. I will take it on a full stomach
D. I will take it 15 minutes before meals

76. The nurse takes highest priority for which of the following nursing diagnosis in caring for
patient with anemia?
A. Imbalance nutrition, less than body requirement
B. Fatigue, activity intolerance
C. Ineffective tissue perfusion
D. Ineffective therapeutic regimen

77. The nurse is caring for Joan,45 years old, diagnosed with polycythemia vera. The nurse
knows that in polycythemia
vera:
A. The erythrocyte and leukocyte counts are elevated while the platelet counts is low
B. The erythrocyte count is low while leukocyte and platelet counts are elevated
C. The erythrocyte, leukocyte and platelet counts are elevated
D. The erythrocyte, leukocyte and platelet counts are low

78. Ace is in the post anesthesia care unit following a colorectal resection. He has an IV of
dextrose 5% lactated ringers solution. Upon assessment you observe that he is exhibiting
sudden onset of crackles in the lungs, most respiration and tachypnea. Which of the following
will you do first?
A. Notify anaesthesiologist
B. Increase 02 flow rate
C. Place Fowler's position → promote lung expansion and compensatory
D. Reduce IV Rate

79. As a head nurse of the unit, which of the following sources should you take into
consideration when making effective assignments for the next shift?
A. Seniority preference
C. Personality status
B. Recent performance evaluation
D. Client classification data

80. A child is receiving vincristine (oncovin) as a part of the chemotherapy protocol. The nurse
should monitor the child for untoward reactions affecting the:
A. Emotional status
B. Neurological status
C. Respiratory status
D. Cardiovascular status

81. You are reviewing the laboratory result of Claire who has rheumatoid arthritis. Which
laboratory result should you expect to find?
A. Increase platelet count
B. Altered blood urea nitrogen (BUN) and creatinine levels
C. Electrolyte imbalance
D. Elevated erythrocyte sedimentation rate (ESR)

82. Mrs. Waudnell is receiving total parental nutrition (TP). If you will evaluate her nutritional
status, which of the following indicators will tell you that TN was effective?
A. Laboratory work up
B. Adequate hydration
C. Weight gain
D. Diminish episode of nausea and vomiting

83. Studies have shown that the incidence of hodgkin's disease is common among young
adults, juana 20-year old approaches you and tells you "I am worried about the mass on my
neck." What should you do as a nurse?
A. Tell her there is nothing to worry if it does not bother her
B. Palpate Juana's neck and explain the possible cause
C. Tell her Hodgkin's disease is common among young adults
D. Tell her to see a doctor

84. As a nurse, you accidentally administer 40 mg of propranolol (inderal) to a client instead of

10 mg. Although the client exhibits no adverse reactions to the larger dose. You should:
A. Complete an incident report
B. Call the hospital attorney
C. Inform the client's family
D. Do nothing because the client's condition is stable

85. Which of the following appear abnormal on an EKG when ischemia and injury occur in the
myocardium?
A. QRS interval
B. ST segment and T wave
C. P wave
D. PR interval

86. From an ECG reading, a QRS complex represents:

A. Ventricular repolarization
B. Ventricular depolarization
C. End of ventricular depolarization
D. Atrial depolarization

87. Which of the following represents ventricular repolarization?

A. T wave
B. ST segment
C. QRS complex
D. PR interval

88. It is important that the nurse measures intervals of QRS complex. Which of the following
represent the normal interval of the QRS complex?
A. Greater than 0.20 sec
B. 0.20 sec
C. 0.10 sec
D. 0.12 to 0.20 sec
89. Albert is admitted with a radiation induced thrombocytopenia. As a nurse you should
observe the following symptom:
A. Petechiae, ecchymosis, epistasis
C. Headache, dizziness, blurred vision
B. Weakness, easy fatigability, pallor
D. Severe sore throat, bacteremia, hepatomegaly

90. Andrea's physician gives an order of mannitol 0.25 g/kg IV bolus for increased ICP. This is
given to:
A. Promote cerebral-tissue fluid movement
B. Promote renal perfusions
C. Correct acid-base imbalances
D. Enhanced renal excretion of drugs

91. Pain in the older persons required careful assessment because they:
A. Are expected to experience chronic pain
B. Experienced reduce sensory perception
C. Have increase sensory perception
D. Have a decreased pain threshold

92. Frank admitted to the intensive care unit with a diagnosis of acute respiratory distress
syndrome. When assessing Frank vou would expect to find:
A. An altered mental status
B. Hypertension
C. A lowered rate of breathing
D. Tenacious secretion

93.Frank's respiratory status necessities intubations and positive pressure ventilation. Your most
immediate nursing intervention for Frank at this time would be to:
A. Facilitate Frank's verbal communication
B. Maintain sterility of the ventilation system
C. Assess his response to the equipment
D. Prepare him for emergency surgery

94. The WHO analgesic ladder provides the health professional with:
A. Pharmacologic and non-pharmacologic pain management choices
B. General pain management choices based on level of pain
C. Non pharmacologic interventions based on level of pain
D. Specific pain management choices based on severity of pain.

95. When caring for a client who has had a total hip replacement, the nurse should position the
client's affected limb in:
A. Abduction and flexion
B. Adduction and internal rotation
C. Abduction and extension
D. Abduction and external rotation

96. When assessing hemorrhage after a client has a total hip replacement, the most important
nursing action would be:
A. Measure the girth of the thigh
B. Check the vital signs every four hours
C. Examine the bedding under the client
D. Observe ecchymosis at the operative site

97.When planning the discharge for a client who has had a total hip replacement, the nurse
should include encouraging the client to avoid:
A. Climbing stairs
B. Stretching exercises
C. Sitting in a low chair
D. Lying prone for at least 30 minutes

98. Which assessment would be most supportive of the nursing diagnosis, impaired skin
integrity related to purulent wound drainage?
A. Heart rate of 88 bpm
B. Dry and intact wound dressing
C. Oral temperature of 38.8 C
D. Wound healing by first intention

99. Vince has been placed in buck's extension traction. The nurse can provide for counter
traction to reduce shear and friction:
A. Providing an overhead trapeze
B. Slightly elevating the foot of the bed
C. Using footboard
D. Slightly elevated the head of the bed

100. To determine the status of the client's carotid pulse the nurse should palpate:
A. Below the mandible
B. In the lateral neck region
C. At the anterior neck, lateral to the trachea
D. along the clavicle at the base of the neck

SIMULATION 5 NURSING PRACTICE 5

CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS (PART C)

SITUATION: A vehicle hits some pedestrians while waiting for a bus ride. Some of the
victims suffered injuries in the different parts of their bodies. The victims were brought to
the nearby hospital. One of the victims, Rose, was confirmed to have a fractured left arm.

1. Cast was applied on Rose left arm. In assessing the neurovascular status of the client, which
of the following assessment findings should be reported to the physician?
A. Swelling of the fingers
B. Pain on the left arm
C. Nail bed capillary refill time of 10 seconds
D. Skin abrasions on the edges of the plaster cast

2. Miranda a psychiatric client is to be discharged with orders for haloperidol (haldol) therapy.
When developing a teaching plan for discharge, the nurse should include cautioning the client
against:
A. Driving at night
B. Staying in the sun
C. Ingesting wines and cheeses
D. Taking medications containing aspirin

3. To prevent complications when a child is in Buck's Traction, the nurse should:

A. Provide high fiber small meals
B. Clean the pin sites as necessary
C. Assess the skin and circulator disturbances
D. Clean the extremity and keep the skin dry

4. One of the victims, a 55 year old woman, sustained hip fracture. Prior to surgery, a Buck's
extension traction is to b applied. The rationale of traction is primarily based on the
understanding that Buck's extension action:
A. Allows reduction of the fracture site for bone healing
B. Reduces muscle spasm and helps to immobilize the fracture
C. Secure the facture site o prevent damage to the muscle tissues
D. Secures the fracture site for rigid immobilization

A nurse was interested to the study the research question. "What are the differences and
similarities between aggressive and non-aggressive cognitively impaired, elderly,
institutionalized people?"

5. The type of study conducted is:

A. Descriptive-Comparative design
C. Quasi-experimental-non equivalent design
B. Experimental-Pretest-post-test design
D. Correlational, Retrospective design

6. The average age of the respondents was 85. This represents:

A. The youngest participant is 85 ears old
B. The sum ages divided by total number of participants
C. The oldest participant is 85 years old
D. Most of the participants are 85 years old

7. The review of literature included reference to retrospective studies. Such studies have the
advantages EXCEPT:
A. Possibility of memory bias and distortion of fact
B. Data are inexpensive to obtain
C. There is much material available
D. It is easy to get data
8. Investigation of cognitively impaired individual presented some ethical dilemmas. Which of
the following protocol would be considered unethical?
A. Verbal permission from the subject is unnecessary
B. Recording interaction with the elderly with their permission
C. Data coded and recorded solely by the investigator
D. A written consent from the institution and a significant other

9. A semi-structured interview was conducted. This means that:

A. Interviewer is free to probe beyond a number of specific major questions
B. Interview is conducted precisely in the same manner
C. Subject is allowed to express without any suggestion from interviewer
D. Interview is not held to any specific question

SITUATION: The patient who is depressed will undergo electroconvulsive therapy.

10. Inform consent is necessary for the treatment for involuntary clients. When this cannot be
obtained permission may be taken from the:
A. Doctor
B. Chief Nurse
C. Next of Kin/guardian
D. Social worker

11. After ECT, the nurse should do this action before giving the client fluids, food or medication.
A. Assess the gag reflex
B. Take vital signs
C. Assess the sensorium
D. Check oxygen saturation with a pulse oximeter

12. The preparation of a patient for ECT is ideally most similar to preparation of a patient for:
A. General anesthesia
B. X-ray
C. Electroencephalogram
D. Electrocardiogram

13. Which of the following is a side effect which you will need to discuss with the patient?
A. Robot like stiffness
B. Hemorrhage within the brain
C. Encephalitis
D. Confusion disorientation and short term memory loss

14. Studies on biological depression support electroconvulsive therapy as mode of treatment.

A. The treatment serves as a symbolic punishment for the client who feels guilty and worthless
B. ECT is seen as a life threatening experience and depressed patients mobilized all their body
C. ECT relieves depression physiologically by increasing the nor-epinephrine level
D. ECT produces massive brain damage which destroys the specific area containing memories

SITUATION: Mental retardation is an increasingly common childhood disorder that impairs

learning.

15. Which of the following is true regards to Mild Mental Retardation?.

A. Trainable can reach up to 2nd grade and can reach he maturity of a 7 year old
B. Requires total care throughout life, mental age of a young infant
C. Educable, can reach up to 6th grade and has maturity of a 12 year old
D. Custodial and barely trainable
16. The child was classified as having an IQ of 55. This is said to be:
A. Severe mental retardation
B. Moderate mental retardation
C. Mild mental retardation
D. Profound mental retardation

17. Mental retardation is?

A. A delay in normal growth and development caused by an inadequate environment
B. A severe lag in neuromuscular development and motor abilities
C. Requires total care throughout life, mental age of a young infant
D. A lack of development of sensory abilities

18. An important principle for the nurse to follow in interacting with retarded children is:
A. Treat the child according to his developmental level
B .Provide an environment appropriate to their developmental task as scheduled
C. Treat the child according to his chronological age
D. If the appears contented, his needs are being met

19. A child with an IQ of 35-49 is:

A. Barely trainable
B. Trainable
C. Requiring total care
D.Educable

SITUATION: Elena, 82 year old widow, has been observed to be irritable, demanding and
speaking louder than usual. She would prefer to be alone and take her meals by herself;
minimized receiving visitors at home and no longer bother to answer telephone calls
because deterioration of her hearing. She was brought by her daughter to the geriatric
clinic for assessment and treatment.

20. A nursing diagnosis for Elena is:

A. Sensory deprivation
C. Cognitive impairment
B. Social isolation
D. Ego despair

21. The nurse will assist Elena and her daughter to

plan goal which is:
A. Adjust to the loss of sensory and perceptual function
B. Increase her self-esteem to maintain authoritative role
C. Accept the steady loss of hearing that occurs with aging
D. Participate in conversation and other social situation

22. The daughter understood the following ways to assist Elena to meet her needs and avoiding
which of the following?
A. Speaking distinctly and slowly
B. Speaking at eye level
C. Using short simple sentence
D. Allowing to take her meals alone

23. The nurse counsel Elena's daughter that Elena's becoming very proud and tendency to
become aggressive is a/an:
A. Attempt to maintain authoritative role
B. Beginning indifference to the world around her
C. Overcompensation for hearing loss
D. Behavior indicative of unresolved repressed conflict of the past

SITUATION: Sammy, a 45 year old father of 7, has been diagnosed with Alcoholism.

24. Which of the following is the drug of choice to ease the withdrawal symptom of an alcoholic
client?
A. Disulfiram
B. Librium
C. Naltrexone
D. Flumazenil
25. Alcohol are said to have problems during the
A. Oral stage
B. Phallic stage
C. Anal stage
D. Genital stage

26. Blood alcohol level is the best evidence of alcohol use. It should be withdrawn as soon as
possible within 24 hours. A level that indicates intoxication is at least a. 0.15
b. 0.25
c. 0.20
d. 0.10

27. The nurse in the substance abuse unit is trying to encourage a client to attend Alcohol
Anonymous meeting. When the client ask the nurse what he must do to become a member, the
nurse should respond:
A. Your physician must refer you to this program
B. You must bring along friends who will support you
C. Admit that you are powerless over alcohol & that need help
D. You must first stop drinking
28. A client hospitalized with fractures of the right femur and humerus, sustained in a motorcycle
accident. Police suspect the client was intoxicated at the time of the accident. Laboratory test
reveals a blood alcoholic level of 0.20 (200 mg/dl). The client later admits to drinking heavenly
for years. During hospitalization, the client periodically complains of tingling and numbness in
the hands and feets. The nurse realizes that these symptoms probably result from:
A. Thiamine deficiency
B. Triglyceride build up
C. Acetetate accumulation
D. Below normal potassium level

SITUATION: Autoimmune disorders usually have a slow, progressive course, requiring

the nurse to manage symptoms and facilitate patients and families, understanding of the
disease process.

29. The cause of multiple sclerosis is in area of ongoing research. The most common effect of
autoimmune is:
A. Lesion at the myoneural junction
B. Demyelination of the brain & spinal cord
C. Excessive thing on neurons
D. Paralysis in the feet then goes to the lung

30. Autoimmune nervous system disorders include the following EXCEPT:

A. Creutzfeldt-Jakob disease
B. Myasthenia gravia
C. Guillan barre's syndrome
D. Multiple sclerosis
31. The patient with myasthenia gravis has undergone tensilon test. The test shows myasthenia
crisis. The nurse must prepare:
A. Atropine sulfate
B. Neostigmine
C. Levodopa
D. Baclofen

32. The client has multiple sclerosis. The primary symptoms most commonly reported are:
A. Posis, diplopia, generalized weakness
B. Fatigue, fasciculation and failure of respiratory muscles
C. Ascending paralysis and diminished reflexes of lower extremities
D. Fatigue, depression, diplopia

SITUATION: A nurse assigned in the neurologic unit is taking care of clients with varying
degrees of degenerative disorders.

33. When planning for nursing care for Mr. Joe who has Parkinson's disease. Which of the
following goals would be
MOST appropriate?
A. To start rehabilitations as much as possible
C. To treat the disease
B. To improve muscle tone
D. To maintain optimal body function
34. Mr. Joe with myasthenia gravis is having difficulty speaking. What communication, strategies
should the nurse avoid when interacting with Mr. Joe?
A. Encouraging the clients to speak quickly
B. Using paper and pencil in communicating with the client
C. Repeating what the client says for better understanding
D. Encouraging the client to speak quickly

35. On his second day of hospitalization Mr. Joe was able to stand and is having difficulty
swallowing and talking. Which of the following is the priority of the nurse in assisting Mr. Joe?
A. To prevent decubitus ulcer
B. To prevent bladder distention
C. To prevent contracture
D. To prevent aspiration pneumonia

36. For the past 10 years, Anna 45 years old has had multiple sclerosis. Client with multiple
sclerosis experience many different symptoms. As part of the rehabilitation planned for Anna,
the nurse suggested therapy and hobbies to help her.
A. Establish routine
B. Strengthen muscles coordination
C. Develop perseverance and motivation
D. Establish good health habits

37. A wife of a 72 year old male with a diagnosis of Alzheimer's disease begins to cry and tells
the nurse. "I could not understand my husband anymore he has changed drastically". Which of
the following responses of the nurse is MOST appropriate?
A. "The physician and the staff will make sure that your husband will be comfortable and safe
here"
B. This has been difficult time for you. Let us walk and find a quiet place where we can
talk"
C. "He will soon recover in his condition."
D. "You need not to worry; we are doing the best we could."

38. The priority intervention in caring for patient with seizure disorders is:.
A. Improving coping mechanisms
B. Reducing fear of seizures
c. Preventing injury
D. Providing patient and family education

39. You are reviewing the guidelines for seizures care. Which of the following nursing care
during a seizure is incorrect?
A. Ease the patient to the floor, if possible
B. Loosen constrictive clothing
C. Protect the head with a pad to prevent injury
D. Attempt to pry open jaws that are clenched in a person

40. The patient has a series of generalized seizures that occurred without full recovery of
consciousness between attacks lasting for 30 minutes. The nurse document this as:
A. Status epilepticus
B. Petit mal seizures
C. Tonic-clonic seizure
D. Atonic seizure

41. The patient has a series of generalized seizures that occurred without full recovery of
consciousness between attacks lasting for 30 minutes. The nurse document this as:
A. Status epilepticus
B. Petit mal seizures
C. Tonto-clonic seizure
D. Atonic seizure

SITUATION: Christian, age 36, is admitted to the psychiatric unit in an acute manic episode of
Bipolar Disorder.

42. Which of the following nursing care is appropriate after a seizure event?.
A. Keep the patient on side-lying position
B. Place bed in highest position possible with two to three side rails up and padded
C. Orient the patient upon awakening
D. Use calm persuasion and gentle restraint when the patient becomes agitated

43. Christian disruptive behavior in the unit has been increasingly annoying other clients. Which
of the following would the nurse do?
A. Set limits in his behavior and be consistent in approach
B. Make a grid structured plan that he will have to follow
C. Ignore his behavior
D. Tell him that he is annoying other clients and isolate him in his room

44. Christian's condition is a disturbance of:

A. Sensorium
B. Cognition
C. Central nervous system
D. Affect

45. The defense mechanism utilized by manic patients to cover up depression is:
A. Displacement
B. Denial
C. Compensation
D. Reaction formation
46. Christian approaches you and says, "I have been awarded Top salesman of the Year. My
boss will come and celebrate with me." You know for a fact that this is not true. Christian is
demonstrating a delusion of:
A. Achievement
B. Reference
C. Influence
D. Grandeur

SITUATION: Mang Edgar, a 39-year-old farmer, unmarried had been confined in the
National Center of Mental Health for three years with a diagnosis of schizophrenia.

47. A relevant nursing diagnosis for clients with auditory hallucination is:
A. Sensory perceptual alteration
B. Altered thought process
C. Impaired social interaction
D. Impaired verbal communication

48. During mealtime, Edgar refused to eat, telling that the food was poisoned. The nurse should:
A. Ignore his remark
B. Offer him food in his own container
C. Show him how irrational his thinking is
D. Respect his refusal to eat

49. The most common defense mechanism used by a paranoid client is:
A. Displacement
B. Suppression
C. Rationalization
D. Projection
50. When Mang Edgar says to you, "the voices are telling me bad things again!" the best
response is:
A. "Whose voices are those?"
B. "I doubt what the voices are telling you."
C. "I do not hear the voice you say you hear."
D. "Are you sure you hear these voice?"

SITUATION: Mang Greg, age 72, is a widower with moderate Alzeimer's disease. He was
brought to the Home for the Aged by his married daughter. On admission, she says to the
nurse, "I never thought this would happen to us. I really feel guilty bringing him here. I
can't bear to part with him."

51. Initially, the nursing diagnosis would be:

A. Impaired communication
C. Altered thought process
B. Impaired social interaction
D. Altered family process

52. To guide the nurse in planning activities for Mang Greg, the nurse should prioritize soliciting
which information?
A. Support system from the significant others
B. Coping mechanism
C. Routine activities at home
D. The extent of memory impairment

53. One morning, Mang Greg has difficulty putting his pajamas. In Alzeimer's disease, this is
known as:
A. Aphasia
B. Agnosia
C. Apraxia
D. Anomia

54. The nurses therapeutic response to Mang Greg's daughter is:

A. "You have indeed made a sound decision. Your father needs a professional care which you
cannot provide at home."
B. "Why are you feeling guilty bringing him here?"
C. "I know that this has been a difficult time for you. You seemed trouble about bringing
him here."
D. "You have done well everything for your father. Do not be upset. We will take care of him

55. One morning Mang Carlo has difficulty putting his pajamas. In Alzeimer's disease, this is
known as:
A. Aphasis
B. Agnosia
C. Apraxia
D. Anomia

56. Carlo appears to be awake and restless throughout the night. Which of the following is the
medication you are expecting to be given:
A. Diazepam (Valium)
C. Imipramine (Tofranil)
B. Chlorpromazine (Thorazine)
D. Lithium (Lithane)

SITUATION: Celina, age 25, a ramp model, suddenly became blind after her boyfriend
broke off with her. A thorough workup did not reveal any pathological findings.

57. The defense mechanism commonly used by these clients is:

A. Proiection
B. Rationalization
C. Repression
D. Sublimation

58. The loss or alternation of physical functioning without organic cause but is an expression of
a psychological needs is known as:
A. Somatization
B. Depersonalization
C. Hypochondriasis
D. Conversion

59. Initially, the relevant nursing diagnosis the nurse includes her care plan is:
A. Self-esteem disturbance
B. Impaired adjustment
c. Ineffective individual coping
D. Ineffective denial

60. An effective modality of treatment for Celina would be:

A. Milieu therapy
B. Systemic desensitization
C. Cognitive-behavioral
D.Psychopharmacology

SITUATION: Glaucoma is the leading cause of blindness in adults

61. Which of the following is NOT a risk factor for glaucoma?

A. Wearing a contact lenses
B. African American
C. Diabetes
D. Prolonged steroid use

62. Which of the following is NOT true in glaucoma examinations?

A. Perimetry is used to assess visual fields, giving clue to peripheral vision loss
B. Tonometry is used to assess IOP, greater than 21 mmg is suggestive of glaucoma
C. Opthalmoloscopy is used to inspect eye's optic nerve, redness of the optic nerve is
suggestive of glaucoma
D. Gonioscopy is used to measure the angle of the anterior chamber, a narrowed or close
chamber is suggestive of close angle glaucoma

63. How does diamox (Acetazolamide) decrease I0P?

A. It increases Aqueous Humor absorption
B. It opens the angle by causing pupil constriction
C. It decreases Aqueous Humor production
D. It opens the trabecular meshwork

64. Which of the following is a sign/symptom of glaucoma?

A. Floaters, curtains in vision
B. Hazy, cloudy vision
C. Headache, eye pain
D. Sudden loss of peripheral vision, halos around the lights

65. In clients with Sulfonamide/Sulfa allergies, which of the following is used to decrease I0P by
decreasing AH production?
A. Timolol, Betaxalol
C. Myasthenia gravis
B. Pilocarpine, Carbachol
D. Acetazolamide

SITUATION: Mr. Mark is brought to the hospital due to pain radiating to the hip and leg.
He is diagnosed with a herniated lumbar disk. He is scheduled for myelogram.

66. Mr. Mark is scheduled for lumbar laminectomy. Post operatively the nurse should:
A. Logroll the client with the help of another nurse
B. Inform the client that he should be in supine position
C. Assess the sensory loss in his legs
D. Instruct the patient to move from side to side

67. Trimethobenzamine hydrochloride (Tigan) was administered postoperatively. The action of

his drug is effective when it controls:
A. Nausea
B. Pain
C. Muscle spasm
D. Edema

68. After the procedure, the nurse must include which of the following nursing action in the
care?
A. Assess for movement and sensation of the lower extremity
B. Place the client in most comfortable position
C. Lying supine with heels flexed
D. Bed rest with bed elevated at 45 degrees

69. Mr. Mark, has to wear back brace. Which position is recommended when the brace is
applied?
A. Sitting position
B. Standing position
C. Lying on his side in bed
D. Supine position in bed – if stated “not recommended”

70. Mr. Mark is to ambulance for the first time following surgery. Which nursing action should be
BEST when the client begins to faint?
A. Get another nurse for help
B. Maneuver the client to a sitting position
C. Get back to his bed in side lying position
D. Assist the client to form a wide base support and lean against the nurse

SITUATION: The nurse is assigned in handling patient with Guillain-Barre Syndrome.

71. Nursing interventions in caring for patient with Guillain-Barre Syndrome are primarily geared
towards:
A. Improving respiratory function
B. Enhancing physical mobility
C. Providing adequate nutrition
D. Improving communication

72. The major cause of mortality in patients with Guillain-Barre Syndromes due to what
complication?
A. Pulmonary embolism
B. Respiratory failure
C. Cardiac dysrhythmias
D. Transient hypertension

73. The following are true regarding Guillain-Barre Syndrome except:

A. It is an autoimmune attack on the peripheral nerve myelin
B. It produces descending weakness with dyskinesia, hyporeflexia, and paresthesia
C. A history of viral illness may precipitate clinical presentation
D. It is more common in men than women

74. Nursing interventions to enhance physical mobility and prevent complications of immobility
include the following except:
A. Performing active range-of-motion exercises at least twice daily
B. Changing positions regularly
C. Administering anticoagulant agents as prescribed
D. Providing thigh-high elastic stockings

SITUATION: As a nurse researcher you must have a very good understanding of the
common terms of concept used in research.

75. The device or techniques an investigator employs to collect data is called:

A. Sample
B. Hypothesis
C. Instrument
D. Concept

76. Which of the following usually refers to the independent variables in doing research?
A. Result
B. Output
C. Cause
D. Effect

77. The information that an investigator collects from the subjects or participants in a research
study is usually called:
A. Hypothesis
B. Variable
C. Data
D. Concept

78. The recipients of experimental treatment are an experimental design or the individuals to be
observed in a non-experimental design are called:
A. Setting
B. Treatment
C. Subjects
D. Sample

79. The use of another person's ideas or wordings without giving appropriate credit results from
inaccurate or
inappropriate credited as one's own:
incomplete attribution of materials to its sources. Which of the following is refered to when
another person's idea is
A. Plagiarism
B. Assumption
C. Quotation
D. Paraphase

SITUATION: Judy is an 18-year-old 1st year college student. Her mother observed that
she is having problems relating with her friends. She is undecided about the future. she
has lost insight, lost interest in anything and complain of instant tiredness.

80. After one week of antidepressant medication, Judy will manifests depression. The nurse
evaluates this is:
A. Unusual because action of antidepressant drug is immediate
B. Unexpected because the therapeutic effectiveness takes within a few days
C. Expected because therapeutic effectiveness takes 2-4 weeks
D. Ineffective result because perhaps the drug's dosage is inadequate

81. Judy continues to verbalize feeling sad and hopeless. She is not mixing well with other
clients. One of the nurse's important considerations for Judy INITIALLY is to:
A. Formulate a structured schedule so she is able to channel her energies externally
B. Let her alone until she feels like mingling with others
C. Encourage her to join socialization hours so she will start to relate with other clients.
D. Encourage result because perhaps the drug's dosage is inadequate

82. Which among the following is a tricyclic antidepressant drug?

A. Venlafaxine (Effexor)
B. Fluoxetine (Prozac)
C. Setraline (Zoloft)
D. Imipramine (Tofranill

SITUATION: Mike seeks psychiatric counseling for his ritualistic behavior of counting his
money as many as 10 times before leaving alone.

83. To be more effective, the nurse who care for persons with obsessive compulsive disorder
must possess one of the following qualities:
A. Compassion
B. Consistency
C. Patience
D. Friendliness

84. Obsessive compulsive disorder is BEST described by:

A. Uncontrollable impulse to perform act or ritual repeatedly
B. Persistent thoughts
C. Recurring unwanted and distributing thoughts alternating with a behavior
D. Pathological persistence of unwilled thought, feeling, or impulse

85. An initial appropriate nursing diagnosis is:

A. Impaired social interaction
B. Ineffective individual coping
C. Impaired adjustment
D. Anxiety; moderate

86. Person with OCD usually manifest:

A. Fear
B. Apathy
C. Suspiciousness
D.Anxiety

SITUATION: Maya, 1 ½ years old, is admitted to the hospital from the emergency room
with a fracture of the left femur due to a fail down a flight of stairs. Maya is placed on
Bryant's traction.

87. Maya is assessed to have no head injury. The bryant's traction is removed. A plaster of
Paris hip spica is applied. which of these findings is a concern for immediate attention that must
be reported to the physician immediately?
A. Maya is scratching the cast over her abdomen
B. The toes of Maya's foot blanch when the nurse applies pressure on them
C. Maya's cast is still damp
D. The nurse is unable to insert a finger under the edge of Maya's cast on her left foot

88. While on Bryant's traction, which of these observation of Maya and her traction apparatus
would indicate a decrease in the effectiveness of her traction?
A. Maya's buttocks are resting on the bed → should eb sligtly elevated
B. The traction weighs are hanging 10 inches above the floor
C. Maya's legs are suspended at a 90 degrees angle to her trunk
D. The traction rope move freely through the pulley

89. Part of discharge plan is for the nurse to give instructions about the care of Maya's cast to
the mother. Which of these statements indicates that the mother understood an important
aspect of cast care?
A. I will use white shoe polish to keep the cast neat
B. I will place the plastic sheeting around the perineal area of the cast
C. I will use cool water to wash the cast
D. I will reinforce cracked areas on the cast with adhesive tape

90. The nurse notes that the fall might also cause a possible head injury. She will be observed
for signs of increased intracranial pressure which include:
A. Narrowing of the pulse pressure - - should be widening
B. Vomiting → projectile vomiting
C. Periorbital edema
D. A positive Kemig's sign

91. The nurse counsel Maya's mother ways to safeguard safety while providing opportunities to
develop a sense of:
A. Trust
B. Initiative
C. Industry
D. Autonomy

SITUATION: As a nurse you are expected to participate in initiating or participating in the

conduct of research studies to improve nursing practice. You have to be updated on the
latest trends and issues affecting profession and the best practices arrived at by
profession.

92. In any research study where individual persons are involved it is important that an informed
consent for the study is obtained. The following are essential information about the consent that
you should disclose to the prospective subjects except:
A. Consent to incomplete disclosure
B. Descriptions of benefits, risks, and discomforts
C. Explanation of procedure
D. Assurance of anonymity and confidentiality

93. You are shown a Likert Scale that will be used in evaluating your performance in the clinical
area. Which of the following questions will you not use in critiquing the Likert Scale?
A. Are the techniques to complete and score the scale provided?
B. Are the reliability and validity of information on the scale described?
C. If the Likert Scale is to be used for a study, was the development process described?
D. Is the instrument clearly described?

94. You are interested to study the effects of medication and relaxation on the pain experienced
by cancer patients.
What type of variable is pain?
A. Dependent
B. Correlational
C. Independent
D. Demographic

95. You would like to compare the support system of patients with chronic illness to those with
acute illness. How will
you best state your problem?
A. A Descriptive Study To Compare The Support System Of Patients With Chronic Illness And
Those With Acute Illness In Terms Of Demographic Data And Knowlegde About Interventions
B. The Effect Of The Type Of Support System Of Patients With Chronic Illness And Those With
Acute Illness
C. A Comparative Analysis Of The Support System Of Patients With Chronic Illness And
Those With Acute Illness
D. A Study To Compare The Support System Of Patients With Chronic Illness And Those With
Acute Illness

96. You would like to compare the support system of patients with chronic illness to those with
acute illness. What type of research is this?
A. Correlational
B. Descriptive
C. Experimental
D. Quasi-experimental

97. The type of research that lacks manipulation but with control and randomization is called:
A. True-experimental
B. Quasi-experimental
C. Pre-experimental
D. Non-experimental
SITUATION: The global economic showdown has been identified as a probable reason for
the increase in the incidence of suicide.

98. Suicide risk assessment should consider all of the following factors, EXCEPT:
A. A client who is at high for suicide is one who plans a violent death and has the means to
carry it out.
B. Ambivalence is one of the most common characteristics of suicidal clients
C. Elderly suicidal clients are most likely to succeed on their first suicide attempt
D. Suicide risk increases as depression becomes more severe.

99. Which of the following behaviors indicates the greatest danger of suicide? The client
A. Reveals that the family member committed suicide in the past year
B. Has a history of previous suicide attempt
C. Has a definite plan to commit suicide
D. Expresses suicidal thought

100. The patient who is suicidal becomes hostile and is about to throw it. The nurse best
response is
A. Stop, sit on that chair
B. Stop, the security will be here
C. Stop, let us start our art therapy
D. Stop, put the chair down.