NURSE LICENSURE EXAMINATION TEST 3-A
Mrs. Salazar, Salazar, 50 years old, has chronic respiratory respiratory illness. During her home home visit, she complained complained that she often has difficulty of
Situation 1:
breathing especially when she does household chores. 1. our supp support ortive ive respons response e would would be! be! "#et us see what ma$es you so.% a. b. "& should refer you to the health center.% "'his feeling is common at your age.% c. d. "Did you ta$e your prescribed ()* medications+% . -hich of the followi following ng criteria criteria would would you most consider consider when communica communicating ting with with your patients! patients! )esponsive c. )elevance a. b. redibility d. Simplicity /. 'his is an an eample eample of therapeuti therapeutic c communi communicatio cation! n! a. iving treatment promptly b. 2elping patient accept diagnosis c. 3ust being available to the patient d. 4nsuring comfort of patient caused by pain . -hich of the the following following is is most helpful helpful when when communicati communicating ng with a depressed depressed patient patient!! listening to needs of patient patient a. 6ctive listening b. Sensitive to non7verbal needs cues 8eeping communication open c. d. 4ncouraging verbalization of concern 5. 'his communi communicatio cation n techni9ue techni9ue will will more li$ely li$ely transmit transmit your your message message to your patient! patient! a. -ritten notes b. Sign language c. 'hrough patient:s watcher d. ;ace7to7face ommunicable disease disease remains a ma
Situation 2:
=. 'he control control of any communic communicable able disease disease depends depends to a large large measure measure upon the followi following, ng, ecept! ecept! effective control measures measures a. 6pplication of effective b. *ature of the disease itself 8nowledge of appropriate technology c. d. Discipline of health providers >. ;irst ;irst line line of defense defense of the the body against against infecti infection on is! a. (hysical fitness b. ;ull immunization c. 6n intact s$in d. (ersonal hygiene ?. -hich of of the followi following ng statement statements s on brea$ing brea$ing the chain chain of infect infection ion is true+ true+ a. 4very lin$ in the chain of infection can be interrupted b. 6 virulent virulent agent can resist resist disinfection disinfection 'he mode of direct contact is often direct entry c. d. 6n inappropriate portal portal of entry will will not support infection @.
*ewborn babies babies have limited ability ability to produce antibodies, antibodies, hence, immunization should not be given earlier than! months c. / months a. b. 1 month d. = wee$s
10. 2ealth education in in the prevention and control control of communicable communicable disease is a vital vital component to! to!
a. b. c. d.
Situation 3:
2elp individual cope with the illness )educe ris$ of eposure Modify ris$ behavior Diminish psychosocial stress
6ling eleste, your newly admitted patient, appears anious and fearful.
11. -hen initiating interaction with your patient, which of the following is appropriate! "& am your nurse today.% a. b. "#et us tal$ about your problem.% "-hat:s in your mind today.% c. d. "& am at your service.% 1. 'hese are characteristic behaviors demonstrating good nurse7patient relationship, ecept! a. onsistent b. Spontaneous c. Defensive d. Sincere 1/. 'his is an outcome of a meaningful nurse7patient relationship! (atient feels comfortable a. b. (atient accepts illness diagnosis (atient greets nurse c. d. (atient ta$es medications 1. 6 techni9ue of "putting yourself in others shoes% is! a. Sympathy c. 6pathy d. 'elepathy b. 4mpathy 15. 6t the end of the initial phase of interaction, you epect the patient to! Share her feelings a. b. 4press gratitude c. )espect you d. omply with treatment Situation 4!
6ling loria brought her first7born child. 6nna who is ? wee$s old to a local center where you wor$. 'he mother wants to register her child in the immunization of your center. 1=. 'he principles of vaccine administration are stated in the following, ecept! a. Divided doses decrease the ris$ of side effects b. 6 child with cerebral palsy can receive immunization c. 'he ris$ of side effects from a vaccine is significantly less than the side effects from the disease d. Do not vaccinate if the child has been on chemotherapy 1>. 6ctive as contrasted to passive immunization is described by the following statements, ecept! (roduce immediate immunity a. b. *one of these c. 6n eample is tetanus toic administration d. 'here is stimulation of antibody production by the body itself 1?. Aefore the administration of D(' vaccine, the following considerations should be ta$en! a. 6ll of these b. D(' may be given at = months or at years of age c. 6dministration of the pertusis component beyond years of age 1@. ;or other specific vaccines, the things to consider isBare the following! a. &nactive polio vaccine is preferred over oral polio7vaccine b. 'he rubella vaccine may be given to pregnant patients c. Aeyond / months of age, it is ideal to do tuberculosis testing before A administration d. 6ll of these. 0. Aaby 6na should have received the following vaccines! A, D(', C(E a. b. D(', C(, MM)
c. d.
Situation 5!
D('E, C(1, MM) A, D(' C(1
oals of maternal and infant care.
1. ecile D., 5 years old, wor$s as a senior corporate secretary of a big firm, visits the clinic. She is months pregnant with her first child. ecille feels that there is a conflict between self7actualization through her wor$ and through parenting. (rior setting health care plans, the nurse needs to consider! a. ;inancial and social status b. Aoss:s attitude towards her c. ecille:s educational bac$ground d. ulture and family structure . During this initial interaction, the nurse assesses for what might be the needed support, such as factors that can influence the couple:s ways of reacting to stress as! a. ;amily networ$ b. *ature of ecille:s
, /, 1, , /
c. 1, /, d. 1,
Mrs. Sison, /0 years old, tuberculosis patient, is one of the recipients of the Short ourse hemotherapy FSG drugs. 2er appointment to ta$e her supply of drugs was / days ago but she failed to come. 'his is the third month of treatment. Situation 6:
=. ou plan to visit Mrs. Sison in order to! a. 6dvise her to consult the physician for changes in her treatment b. hec$ whether she is no longer coughing so that she can terminate her treatment c. inform her to have another sputum eamination basis for continuing treatment d. motivate her to collect her drugs regularly >. ou will eplain to Mrs. Sison that the treatment of tuberculosis depend on! a. )est and hospitalization b. Special diet c. )est d. Huality and duration of chemotherapy ?. 6s part of your preparation for the home visit to Mrs. Sison, you review the minor signs of adverse reactions to the S drugs and these are! ;atigue or wea$ness and vomiting a. b. #oss of appetite, nausea, vomiting, wea$ness, rashes and fever
c. d.
#oss of appetite, nausea and vomiting )ashes or itchiness and fever
@. 6 yellowish discoloration of the s$in and eyeballs of a patient ta$ing S drugs is a sign to discontinue ta$ing the! a. 6ll the S drugs and refer patient to physician for evaluation b. )ifampicin and pyrazinamide for one wee$ (yrazinamide and refer to physician c. d. )ifampicin and refer patient /0. &n you scheduled visit to Mrs. Sison, you will also advise her to bring her school children without A to the health center for! a. hest I7ray b. Sputum eamination c. 'uberculin testing d. A vaccination 'he nurse conducts proper assessment of patient and consider eisting policies and guidelines in the provision of treatment. Situation 7:
/1. 'he nurse recognizes the following signsBsymptoms of chic$en po! )ashes which passes through stages of macules, papules and vesicles and are more abundant on a. the face and etremities b. )ashes which begin on the head and nec$ and spreads caudally )ed blotchy rashes which appears on the /rd and >th day c. d. )ashes which begin on the trun$ and spread peripherally and are more abundant on covered parts of the body /. hic$en po is contagious! a. 6fter the appearance of the rashes b. ;rom onset of the catarrhal stage up to the third day of the rash ;rom as early as 1 to days before the rashes appear until the lesions have crusted c. d. ;rom the onset of the rashes until the lesions have dried up //. 'he following nursing intervention is not appropriate for a child with chic$en po! a. ive aspirin for fever b. -ash rashes with soap and water to reduce secondary infection c. 6pply calamine lotion to the lesions to decrease pruritus d. 6dvise to $eep fingernails short /. 4lena is a newly diagnosed leprosy patient who will be treated under the multidrug therapy FMD'G. MD' consist of the following! a. Dapsone, lamprene and rifampicin b. &soniazid, pyrazinamide and rifampicin c. #amprene, purazinamide and rifampicin d. holor9uine, prima9uine and lamprene /5. 'he supervised dose of the MD' drugs is given in the health center! twice a month c. daily a. b. one a wee$ d. once a month Situation ?! arding, 50 years old, has been admitted to the hospital with a diagnosis of cirrhosis of the liver. 2e has dependent edema and is complaining of
. 'he primary cause of cirrhosis of the liver is! malnutrition a.
b. c. d.
alcoholism physical damage of the liver eposure to infection
/?. ;oods usually omitted from the diet of arding with cirrhosis of the liver are! whole grain cereals a. b. mil$ products cereal products c. d. rich gravies and sauces /@. arding develop ascites. 'his is caused by! a. pulmonary failure b. portal obstruction c. capillary obstruction d. arterial obstruction 0. lay colored stool are caused by! improper utilization of itamin $ by the body a. b. the absence of bile salts in the feces the absence of bile pigments in the feces c. d. faulty diet Situation @! Mr. Aen, /5 years old, underwent cholycystectomy and was brought to the ward with '7tube and *'. 1. &mmediately, you connect the nasogastric tube to the suction apparatus. &n this case, you should be observant for any indication of! a. metabolic acidosis b. tetany c. metabolic al$alosis d. cardiac arrest . *' tube was removed days after surgery and he began to have diarrhea. D5 in #B) 1 liter and D5 *SS 1 #iter was ordered for intravenous infusion. &f each bottle has to run for 1 hours, how many drops will be there in one minute+ a. / gtts. . 0 gtts. D. 50 gtts. b. 1 gtts. /. &f his diarrhea persists and not controlled right away, he might develop! metabolic acidosis a. b. metabolic al$alosis cardiac arrest c. d. tetany . ou cautioned him that if intravenous infusion is regulated faster than the prescribed rate, he may be apt to have! respiratory overload a. b. metabolic acidosis cardiac arrest c. d. tetany 5. 2e has been informed the rationale of his having &.. transfusions following are the sings of dehydration, ecept! a. sun$en eyeballs b. concentrated urine puffy eyelids c. d. thirst Situation 10:
abriel, 1? years old, is suffering from asthma after he returned home from mountaineering.
=. Jpon auscultation, you hear! dull sound on the affected area a. b. wheezing sound murmur sound c.
d.
gurgling sound
>. -hich of these manifestations is not epected to occur! Aradycardia a. b. 6pprehension 'achypnea c. d. ool and moist s$in ?. &nitially, the doctor order aminophylline /50 mg S'6', psuh with 10cc of D5K -. Drug on hand is 500 mgB5cc a vial. 2ow many cc of the drug will you aspirate! 1.5 cc a. b. /.0 cc /.5 cc c. d. .5 cc @. Cne toic effect of aminophylline! a. *ystagmus b. )inging of the ears c. ardiac arrest d. ardiac arrhythmias 50. 'he priority of your nursing care is! administration of aminophylline a. b. force fluid inta$e give bronchodilator c. d. $eep the bed elevated Situation 11:
Ms. ;elisa, 1@ years old and single, the only child is scheduled for mastectomy.
51. ou are her nurse. -hich of these is not included in your preoperative care! instructing eercises that will benefit her postoperatively a. b. allay her fear about the surgery giving health teaching to client and relatives regarding surgery c. d. giving him health teaching what to do when discharged 5. ou informed her that the most common breast tumor occurring in young women is! a. ;ibrocystic c. ynecomastia d. ;ibroadenoma b. (apilloma 5/. -hich of these wor$7up is not related to her surgery! A c. A.'. a. b. Jrinalysis d. .'. 5. -hich of these activities should you encourage her to do in early 6.M. prior to the surgery! a. sign of the consent for the surgery b. ta$e a bath c. sponge bath only d. ta$e her temperature 55. 2ow would you allay herBtheir fear for the surgery+ 'ell herBthem that! your doctor is the best in town, he does all $inds of surgery a. b. your doctor is the topnotcher in the board eamination for medicine that would ma$e him very capable to conduct the surgery c. your doctor is a thoracic surgeon and have a lot of breast surgery d. your doctor will specialize in breast surgery Ms. #iza, /5 years old, is eperiencing intermittent abdominal pain for the past few days. 2er physician recommends "Stat% eploratory laparatomy after the blood eamination. Situation 12:
5=. (reoperative medications were ordered. -hich of these drugs is given to suppress salivation! Aenadryl a. b. Scopolamine Demerol c.
d.
alium
5>. &n preparing preoperative patient li$e #iza, which of these is given the last priority to be accomplished /0 minutes before the scheduled time! Signing of consent for suregery a. b. iving preoperative medications &nstructing the parents to empty the bladder c. d. 'a$ing vital signs 5?. -hich of the following techni9ues is best applied to minimize pain when as$ing post7operative patient do coughing eercise! Support her abdomen with a small pillow a. b. over her mouth when coughing Support her chest with your hand c. d. (ut her in fowler%s position with $nee fleed 5@. (ost operative order is 1 bottle of D5K in water 500 cc with 1 ampule Solucortef incorporated to run for 10 hours using a microdrop tubing. ;ind the number of drops per minute! 100 gtts c. ?0 gtts a. b. gtts d. 0 gtts =0. #iza made 9ueries to the charge nurse during the rounds, when will her stitches to remove+ our answer is! a. *ormally > days after surgery b. *ormally / days after operation c. 6lternating stitches will be removed after four days d. 'wo wee$s from now Situation 1/! Mrs. hing, a mother of siblings, sought consultation in the hospital because of fatigability,
=/. -hat will you do before administering the prescribed II&&& gtts for #ugol:s solution! a. 6llow the solution to cool before giving b. 6dminister it with a straw Mi it with about a glass of water c. d. hec$ the amount of drops desired =. ou as$ed as soon as she regained consciousness from thyroidectomy primarily to assess the evidence of! a. 'hyroid storm b. Mediastinal shift c. Damage of the laryngeal nerve d. 'etany =5. Should you chec$ for hemorrhage, how will you do it! Slip your hand under the nape of her nec$ a. b. -atch for hypotension c. 6pply nec$ collar to prevent hemorrhage d. Cbserve the dressing if soa$ed in blood
Situation 1! Mrs. Ccampo, age 50, complains of severe on and off headache, which started si months after her husband, died in vehicular accident! ==. 'he physician orders various diagnostic tests for Mrs. Ccalmpo:s problem to!
a. b. c. d.
)ule our organic pathology Satisfy her psychosocial need Decrease her aniety onfirm to the patient that her symptom is real
=>. 6fter a thorough assessment, the nurse concluded Mrs. Ccampo:s problem is! a. Self esteem disturbance b. &mpaired ad0. 6niety as a sub1. ;or suspicious patients, activities involving higher level of concentration are provided because of one of the following rationales. 'hese patients! a. *eed to be challenged by this type of activities b. #ose interest if not given this type of activities c. -ill have lesser need for acting out d. -ill have less time for delusion thin$ing >. &n a nurse patient relationship, more therapeutic interaction occur at this phase! Crientation c. (re7interaction a. b. -or$ing d. 'ermination >/. Schizoprenic patients fre9uently eperience what type of hallucination+ a. 6uditory c. Clfactory d. 'actile b. isual >. 6 young woman, Monina, suffers from headache every time she is confronted with a problem. Mr. )ecto identifies one of the following as appropriate nursing diagnosis! a. Moderate aniety b. &mpaired communication c. 6ltered health maintenance d. 8nowledge deficit >5. -hen a withdrawn patient says she does not want to tal$ the nurse says! an you tell me what have been going on with you a. b. ou seem to be upset, what are you thin$ing right now+ -hy do you feel this way+ c. d. &t is all rightL & would li$e to spend time with you. -e don:t have to tal$ Situation 1=! Mang arlo age >, is a widower with moderate 6lzheimer:s disease was brought to the 2ome for the aged by his married daughter. Cn admission, she says to the nurse, "& never thought this would happen to us.% & really feel guilty about bringing him here. & can:t bear to be part with him%.
>=. 'he nurse:s therapeutic response to Mang arlo:s daughter is! "ou have indeed made a sound decision. our father needs professional care which you cannot a. provide at home% b. -hy do you feel guilty about bringing him here+% c. " & $now this has been difficult time for you, maybe it will be good if we tal$ for a while% d. " ertainly, you have done everything for your father. Don:t worry, he is going to receive ecellent care here% >>. &nitially, the nursing diagnosis would be! &mpaired communication a. b. &mpaired social interaction c. 6ltered family process d. 6ltered thought process >?. 'o guide him in planning nursing care for Mang arlo, the nurse should prioritize soliciting this information! Significant others a. b. oping mechanism )outine activities at home c. d. 4tent of his memory impairment >@. 'wo days after admission, Mang arlo was observed to be awa$e and restless most of the night. 6fter referral to the physician, this medication was ordered! a. Diazepam FvaliumG 10 mg 2.S b. hlorpromazine FthorazineG 10mg '&D c. &mipramine 2# FtofranilG /0 mg. CD d. #ithium ==0 mg. CD ?0. Cne evening, Mang arlo finds difficulty putting on his pa! 'essie, age 1?, a college student was referred for weight loss of ? lbs. Diagnosis! 6noreia nervosa. ?1. 'he most important goal for clients with eating disorders is! a. 'he client will develop a more satisfying relationship with others b. 'he client will develop a normal eating pattern c. 'he client will be able to identify and epress their own feelings and concerns d. 'he client will achieve a normal weight ?. 6ssessment data will most li$ely reveal that 'essie has! a. 6 strong desire to loo$ good and acceptable b. 6cademic and interpersonal problems in school c. 6 desire to maintain ideal weight d. Satisfactory mother child relationship ?/. 'o ensure compliance with the weight program, an effective nursing interventions is! a. Cbserve the amount of food that 'essie eats voluntarily b. 4plain the importance of a well b alanced diet c. -eigh 'essie the same time in light clothing d. 4plain to 'essie that weight gain will be slow and controlled ?. &f 'essie start to gain weight, it is important for the nurse to assess her mental status by observing signs of! Delusion c. 2allucinations a. b. 6niety d. depression ?5. 'he weight gaining intervention for 'essie is considered successful if she! a. 4presses delight in eating b. )ecognizes that she has abnormal eating pattern c. &s not choosy with the $ind of food she eats d. 6ccepts that the treatment is for her own good
Situation 1?! lenda /5 years old, has difficulty falling asleep, with poor appetite which started after bring terminated from wor$. ?=. 6 relevant information about this crisis is! &s not caused by a stressful event a. b. an result to personality disorganization an not lead to personal growth c. d. &s a pathological state ?>. 6n initial nursing diagnosis would be! a. 6ltered family process b. &mpaired ad
@0. -hen helping a person in crisis, it is helpful to remember that the one who solves the problem is the! a. *urse c. (sychiatrist d. ;amily b. lientBpatient Situation 1@! ivian, 5 years old pregnant woman was admitted sloppily dressed, with dirty hair, nail and appear greatly un$ept. 2er husband states that she has not eaten for days. Cn admissio, she sits motionless and mute. Diagnosis! Schizophrenia catatonia! @1. 6 distant feature of Schizophrenia catatonia is! a. Distractibility c. -ay fleibility d. Aizarre effect b. Stupor @. 6fter an initial assessment, nurse 6 identified one of the following nurse diagnosis! a. 6ltered thought process related to panic level of aniety b. &neffective individual coping related to lac$ of motivation to respond Self care deficit related to immobility c. d. &mpaired communication related to unclear communication @/. &n planning the care for a withdrawn patient li$e ivian. *urse 6 prioritizes! a. 4liminating physical contact with ivian b. 8eeping ivian in a 9uiet area c. &nitiating fre9uent, short, regular contact with ivian d. onstantly reinforcing reality @. 'o control the symptoms, the physician orders an psychotic medication, 'his is! &mipraminine hydrochlorideF'ofranilG a. b. ;ouetine hydrochlorideF(rozacG hlorpromazineF'horazineG c. d. DiazepamFaliumG @5. ivian is observed to be repeating the words of the nurse as illustrated by the following eample! *urse 6! ivian, come for your medication ivian! ivian, come for your medication 'his speech disturbance is $nown as!
a. b. c. d.
-ord salad lang association *eologism 4cholalia
Situation 0! 6ce, 1 years old, a cocaine user for two years, was admitted to the rehabilitation center. Cn admission, his blood pressure was 150B @0 with tachycardia and dilated pupils. @=. 'he sign and symptoms of admission are indicative of! ocaine withdrawal syndrome a. b. 6lcohol intoication ocaine intoication c. d. 6lcohol withdrawal syndrome @>. #ong term treatment program for drug addicts are best described as programs! onducted on an out patient basis to allow the persons to maintain their
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