FUNDA Q & A
Concepts of Man and His Basic Human Needs 1.) The theory on man as a Biopsychosocial and Spiritual being by Sister Callista Roy
conceptualizes the following EXCEPT:
A.) Man, as a biologic being is like all other men B.) Man, as a psychologic being is like no other man
C.) Man, as a social being is like some other men
D.) Man, is a spiritual being only when he professes that he believes in God
Ans: D
>According to the theory on Man as
Biopsychosocial and Spiritual Being, all men are spiritual by nature. This is because of the will and intellect; virtues of faith, hope, and charity, and the belief of existence of supreme power who guides man’s faith and destiny
2.) Which of the following is NOT a characteristic of an open system?
A.) It is self-sufficient and is totally isolated from other systems
B.) It exchanges matter, energy or information with the environment
C.) It allows sustaining elements to enter the system to nourish it
D.) It is easily affected by changes in other systems
Ans: A
>An open system needs to exchange matter, energy and information. It is interrelated and interdependent with other systems
3.) Which aspect of man’s nature is
demonstrated by making a choice therapeutic regimen reluctantly?
A.) Limited and unlimited nature
B.) Mature nature with core of immaturity C.) A creature of indecisiveness
D.) Rational and logical, yet irrational at times Ans: C
> Man is a creature of indecisiveness. He is always at the crossroad of choosing
4.) Body image is:
A.) The way a person appears and his style of grooming
B.) The way the person looks at a certain age C.) The way a person pictures/perceives his appearance and function and how he compares himself with others.
D.) A body with complete parts and functions Ans: C
>Body image is the way a person perceives his appearance and function
5.) The nursing diagnosis Body Image
Disturbance is most likely to be written for which of the following persons?
A.) A patient with above the knee amputation B.) A patient with second degree burns C.) A quadriplegic patient
D.) A person entering the health care system after moving from wellness to illness
Ans: D
>A person entering a health care system most likely would experience alteration in body image
6.) The nurse should assess the activity tolerance of the patient with which of the following conditions?
A.) Diabetes mellitus B.) Diarrhea
C.) Anemia D.) Kidney stones Ans: C
>Activity intolerance is an appropriate nursing diagnosis for a client with anemia. IN anemia, there is low oxygen-carrying capacity of the blood, so the client experiences weakness and fatigue
7.) According to Maslow’s hierarchy of needs, which of the following is a basic physiologic need after oxygen?
A.) Water
B.) Freedom from infection C.) Love and belongingness D.) Self-esteem
Ans: A
>Water is next to oxygen in the hierarchy of physiologic needs for survival
8.) Mrs. Sy, diagnosed with cancer of the breast, is scheduled to undergo chemotherapy. How should the nurse deal with the topic of hair loss with client?
A.)Discuss about hair loss as it occurs
B.)Provide reading material about chemotherapy C.)Acknowledge that hair loss may be a difficult side effect and explore the patient’s feeling about this
D.) Give the patient information about head scarf, hats or wigs
Ans: C
>Focusing on the feelings of the client regarding hair loss is therapeutic. Discussing about wigs, headscarf, and hats will be dealt with later 9.) The following are characteristics of basic human needs EXCEPT:
A.) Priorities are uniform to all individuals B.) Needs may be met in different ways C.) Needs are interrelated
D.) Needs may be deferred Ans: A
>Priorities vary from individual to individual, according to stage of growth and development, life situations and other factors
10.) Which of the following needs is considered by the nurse when she implements reverse isolation for the client with leukemia? A.) Physiologic need
B.) Safety and security C.) Love and belongingness D.) Self esteem
Ans: B
>The client with leukemia has low resistance to infections. Protecting him from infection by implementing reverse or protective isolation technique meets his need for safety and security 11.) Who among the following clients should be attended first by the nurse?
A) The client with cough and colds B.) The client with pain on the chest C.) The client with fever due to infection D.) The client who is for discharge Ans: B
>The client with pain on the chest should be attended first by the nurse because he needs to be assessed and managed immediately before severe problem occurs. The clients with signs and symptoms of infections may be dealt with after those without infections to prevent contamination. The client for discharge would require longer nursing time for health teachings, and may be dealt with later
Concepts of Health and Illness
12.) The following are concepts of health: 1...) Health is a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity
2.) Health is the ability to maintain balance 3.) Health is the ability to maintain the internal environment
4.) Health is the integration of all parts and subparts of an individual A.) 1,2,3 B.) 1,3,4 C.) 2,3,4 D.) 1,2,3,4 Ans D
1-WHO concept of health
2-Walter Cannon’s concept of health on homeostasis
3-Claude Bernard’s concept of health on internal milieu
4- Neuman’s concept of health on integration of parts and subparts of an individual
13.) The theorist who advocates that health is the ability to maintain dynamic equilibrium is: A.) Claude Bernard
B.) Walter Cannon C.) Hans Selye D.) Martha Rogers ANS: B
> Walter Cannon advocates that health is the ability to maintain dynamic equilibrium (homeostasis)
14.) The “Health-Illness Continuum Theory” describes which of the following:
1.) The effect of environment to well-being and illness
2.) High level wellness is achieved if a person is able to function independently
3.) Precursor of illness may be hereditary, environmental and behavioral factors
4.) The relationship between agent, host and environment A.) 1,2,3,4 B.) 1,3,4 C.) 1,2,3 D.) 2,3,4 ANS: C
> 1,2,3 Dunn’s “Health-illness Continuum Theory” describes the following:
1.) The effect of environment to well-being and illness
2.) High level wellness is achieved if a person is able to function independently
3.) Precursor of illness may be hereditary, environmental and behavioral factors
15.) Which of the following statements is not true is high-level wellness?
A.) It is applicable only to healthy individuals
B.) It is the ability to perform activities of daily living
C.) It connotes maximizing one’s potentialities D.) It is the ability to perform self-care
ANS: A
> The statement which is NOT TRUE in high level wellness is that, it is applicable only to healthy individuals. High level wellness is applicable to both the well and the ill, as long as one maximizes his potentialities and functions independently
16.) Mrs. De Guzman had been diagnosed to have hypertension since 15 years ago. Since then, she had maintained low sodium diet, to control her blood pressure. This practice is viewed as:
A.) Her superstitious belief B.) Her cultural belief C.) Her personal D.) Her health belief ANS: D
> Health belief of an individual influences his/her preventive health behavior. Health beliefs may be influenced by individual perceptions, modifying factors, perceived benefits of preventive actions and perceived barriers to preventive actions
17.) The “Role Performance Model” of health views that:
A.) Health is the absence of signs and symptoms of disease
B.) Health is successful adaptation
C.) Health is the ability to perform one’s work or job
D.) Health is realization of one’s potential ANS: C
> The “Role Performance Model” of health by Smith views that health is the ability to perform one’s societal roles such as one’s work or job 18.) Mr. Salvador practices excessive alcohol intake. This is considered as which type of precursor to illness?
A.) Behavioral factor B.) Environmental factor C.) Hereditary factor D.) Genetic factor ANS: A
> Taking alcohol excessively is a behavioral precursor of illness. Other behavioral factors that may lead to illness are as follows: cigarette smoking, poor diet, sedentary lifestyle, poor hygiene, inadequate rest and sleep, excessive worry and tension,etc
19.) A person who may or may not be affected by disease is: A.) Agent B.) Carrier C.) Victim D.) Host ANS: D
> A host is an individual who may or may not be affected by disease
20.) Health promotion activities are directed to achieve the following:
1. Increasing level of wellness 2. Improving quality of life
3. Relying on health care personnel to maintain health
4. Promoting healthful lifestyle A.) 1,2,4 B.) 2,3,4 C.) 1,2,3 D.) 1,2,3,4 ANS: A
> 1,2,4 Health promotion activities are directed to achieve the following:
1.) Increasing level of wellness 2.) Improving quality of life 3.) Promoting healthful lifestyle
Furthermore, health promotion involves the principles of self responsibility for one’s health 21.) Which of the following behaviors is not expected when a client assumes the sick role? A.) The client seeks for sick leave
B.) The client consults a physician because of headache and perceived fever
C.) The client takes medications as prescribed by the physician
D.) The client ignores his dizziness, with the hope that it will be relieved spontaneously ANS: D
> Ignoring signs and symptoms of a disease is not a sick role behavior. Sick role emphasizes that the person: is not held responsible for his condition ; is excused from social roles; is obliged to get well as soon as possible; is obliged to seek for competent help, i.e. seeking advice of health professionals for validation of real illness, explanation of symptoms and reassurance or prediction of outcome
Health and Illness- Asepsis and Infection Control 22.) Which of the following situations may cause droplet transmission of microorganisms?
A.) Facing a clients who is coughing and sneezing within a distance of 3 feet B.) Eating contaminated shell fish
C.) Puncture from intravenous needle removed from a client with hepatitis B
D.) Exposure to flood water Ans: A
> Facing client who is coughing and sneezing most likely would cause droplet transmission of microorganisms
23.) Which of the following is most effective practice by caregivers and family, when caring for a client with low resistance to infection due to cancer.
A.) Allow two visitors only, at a time B.) Wash hands frequently
C.) Wear masks in the client’s room at all times D.) Meticulous cleaning of the client’s room ANS: B
> Handwashing is the most effective practice to prevent transfer of microorganisms
24.) The primary why the faucet is considered as contaminated is:
A.) It is located in unsterile area B.) Many people are using it C.) It is frequently used D.) It is opened by dirty hands ANS: D
> The faucet is considered contaminated primarily because it is opened by dirty hands 25.) The nurse enters the room of the client on airborne precautions due to tuberculosis. Which
of the following are appropriate actions by the nurse?
1. She wears the mask, covering the nose and mouth
2. She washes her hands before and after removing gloves, after suctioning the client’s secretions
3. She removes gloves and mask before leaving the client’s room
4. She discards contaminated suction catheter tip in a trash can found in the client’s room A.) 1 and 2
B.) 1 and 3 C.) 1,2 and 3 D.) 1,2,3, and 4 ANS: D
> 1,2,3, and 4 the mask should cover the nose and mouth snugly. The hands should be washed before and after removing gloves. Gloves and mask should be removed before leaving the client’s room, to contain the microorganism within the client’s unit. Contaminated articles like suction catheter should be discarded in a trash can found in the client’s room to prevent contamination of the outside environment. 26.) A 14-yar old male is to be admitted to the unit due to high fever related to influenza. With whom among the following clients should be placed together in the room?
A.) The 12-year old male client who had undergone appendectomy
B.) The 12-year old female with flu C.) The 12-year old boy with flu D.) The 12- year old boy with leukemia ANS: C
> Clients infected with the same type of
microorganism may cohabitate . The gender and the age of the clients should also be considered. Clients of the same gender and approximately of the same age group will stay together well 27.) After caring for a client with extensive body burns, the nurse performs which of the following actions when removing protective wear?
A.) Remove, mask, gown, gloves, cap and shoe cover
B.) Remove gloves, mask, gown, cap and shoe cover
C.) Remove gown, mask, gloves, cap and shoe cover
D.) Remove cap and shoe cover, mask, gloves, gown
ANS: B
> To remove protective wear, peel off gloves first, then the mask, gown cap and shoe cover. This is to prevent contamination of skin by the contaminated gloves
28.) When discarding used needle and syringes, which of the following is appropriate nursing action?
A.) Remove needle from the syringe and discard them in separate containers
B.) Recap needle, then discard the needle still attached to the syringe into a container
C.) Discard the uncapped needle and syringe into a container
D.) Break the needle, then discard syringe into a container
> Discard the uncapped needle and syringe into a leak-proof, puncture-proof container. This is to prevent needle puncture of self. Universal precaution: NEVER RECAP NEEDLE 29.) When performing surgical hand scrub, which of the following nursing actions ensure prevention of contamination?
1. Keep fingernails short, clean, without nail polish
2. Open faucet with knee or foot control
3. Keep hands above elbows when washing and rinsing
4. Wear cap, mask, and shoe cover after hand scrub A.) 1,3,4 B.) 1,2,3 C.) 1,2,4 D.) 2,3,4 ANS: B
> 1,2 and 3- Surgical hand scrub involves the following actions: Keep fingernails short, clean, without nail polish, open faucets with knee or foot control; keep hands above elbows when washing and rinsing. Cap, mask, shoe cover should be worn before hand scrub, to prevent contamination of the scrubbed hand
30.) When removing gloves, which of the following is inappropriate nursing action? A.) Wash gloved hands first
B.) Peel off gloves inside out
C.) Use glove-to-glove, skin-to-skin technique D.) Remove mask and gown before removing gloves
ANS: D
> When removing gloves, it is inappropriate to remove mask and gown first before gloves. Appropriate nursing actions are: wash gloved hands first, peel off gloves inside out; use glove-to-glove, skin-to-skin techniques. Remove gloves first, followed by the mask, gown, cap, and shoe cover
31.) When pouring sterile solution, the nurse performs which of the following actions correctly?
A.) Hold bottle 6 inches above receptacle on the sterile field
B.) Remove cap of bottle and place it with the underside lid down on a flat surface
C.) Return excess solution from sterile receptacle to the bottle
D.) Place the bottle of sterile solution within the sterile field
ANS: A
> When pouring sterile solution, hold bottle 6 inches above receptacle on the sterile field. Cap of the bottle should be placed with underside lip up, on a flat surface. Excess solution should not be returned to the bottle because this is
considered contaminated. The bottle of the sterile solution should be placed outside the sterile field because the outside part of the bottle is nonsterile. Remember, sterile field/object should come in contact with sterile objects only, to maintain sterility.
STRESS, ADAPTATION,HOMEOSTASIS
32.) Which of the following does not characterize stress?
A.) Stress is a nervous energy
B.) A single stress does not cause a disease C.) Stress in inherent to life
D.) Stress may be protective but at times problematic
ANS: A
> This is an incorrect statement because stress is not a nervous strategy; it is a
psychophysiologic response
33.) Adaptive responses of man to stressors are characterized by the following:
1. They are attempts to maintain equilibrium 2. They are fairly uniform in all individuals 3. They are limitless
4. They are always adequate to overcome stressors A.) 1 and 2 B.) 1 and 3 C.) 1 and 4 D.) 2 and 4 ANS: B
> 1 and 3 adaptive responses are attempts to maintain equilibrium and they are not limitless 34.) The first manifestation of inflammation is: A.) Heat
B.) Redness C.) Swelling D.) Pain ANS: B
> The first manifestation of inflammation is redness. This is due to increased blood flow to the area affected
35.) The primary cause of pain at the site of inflammation is:
A.) Release of bradykinin B.) Injury to nerve endings
C.) Compression of local nerve endings by edema fluids
D.) Impaired circulations ANS: C
> The primary cause of pain at the site of inflammation is the compression of local nerve endings by edema fluids
36.) The client is in stress because he was told by the physician that he needs to undergo surgery for removal of tumor in his stomach. Which of the following are effects of activation of the sympatho-adreno-medullary response in the client? 1. Constipation 2. Urinary frequency 3. Hypoglycemia 4. Increased BP A.) 1 and 2 B.) 1 and 3 C.) 2 and 3 D.) 1 and 4 ANS: D
>1 and 4- Effects of SAMR are due to release of norepinephrine and epinephrine. These include constipation and increase BP
37.) The client is on NPO since midnight, as preparation for blood test. Adreno-cortical response is activated. Which of the following is an expected response?
A.) Low BP
B.) Decrease urine output C.) Warm, flushed, dry skin D.) Low serum Na levels
ANS: B
> Adreno-cortical response involves release of aldosterone that leads to retention of sodium and water. This results to decreased urine output 38.) The client fell from the stairs, and had twisted her ankle. The injury caused inflammation of the ankle. The nursing
interventions for the inflamed ankle would least likely include which of the following?
A.) Elevate the ankle with pillow support
B.) Apply warm compress over the ankle for the first seventy-two hours
C.) Apply compression bandage over the ankle D.) Administer anti-inflammatory drug as ordered by the M.D.
ANS: B
> Application of warm compress over an inflamed body part for the first 72hours of injury is not included in the nursing interventions for inflammation. Cold compress is preferably applied during the first 72hours to cause vasoconstriction and prevent/reduce swelling. 39.) Which of the following events characterize the GAS stage of Alarm?
A.) Fight-or-flight response is activated B.) The person regains homeostasis C.) Adaptive mechanisms fail
D.) Levels of resistance are increased ANS: A
> During the GAS stage of Alarm, fight-or-flight response is activated
40.) The client is a 57 year old male who works as a traffic officer. He is exposed to sunlight from morning until afternoon. Which of the following is considered as a physiologic adaptive mode of the client?
A.) He learns to interpret different traffic signs B.) He sees to it that he wears his uniform as dignified as a policeman does
C.) He develops dark skin
D.) He learns the skill of giving traffic directions to drivers and pedestrian
ANS: C
> Development of dark skin due to prolonged exposure to sunlight, is an example of physiologic adaptive mode
41.) The first protective cells launched at the site of tissue injury are the:
A.) Basophils B.) Eosinophils C.) Monocytes D.) Neutrophils ANS: D
> Neutrophils are the first protective cells launched at the site of injury to perform phagocytosis
Therapeutic Communication
42.) Therapeutic nurse-patient relationship is described as follows:
1. It is based on friendship and mutual interest 2. It is a professional relationship
3. It is focused on helping the patient solve problems and achieve health-related goals 4. It is maintained only as long as the patient requires professional help
A.) 1,2,3 B.) 1,2,4 C.) 2,3,4 D.) 1,3,4 ANS: C > 2,3,4- Nurse-patient relationship is a professional relationship, it is a helping
relationship; it is maintained only as long as the patient requires professional help. It is not based on friendship and mutual interest.
43.) During the working phase of therapeutic relationship, the nurse performs the following activities EXCEPT:
A.) Reviews the client’s medical record B.) Establishes a contract with the client regarding expectations and responsibilities C.) Decides with the client on mutually agreed upon goals
D.) Discusses with the client on time frame of the relationship
ANS: A
> Reviewing the client’s medical record is an activity done during the pre-interaction phase of the therapeutic nurse-patient relationship. All the other choices are performed during the working phase
44.) The client has been scheduled to undergo surgery for removal of tumor in her right breast. Which of the following manifestations indicate that she is experiencing mild anxiety?
A.) She has increased awareness of the environment details
B.) She focuses on selected aspect of her illness C.) She experiences incongruence of thoughts, feelings and actions
D.) She experiences random motor activity ANS: A
> Increased awareness of the environment details is a manifestation of mild anxiety
45.) Which of the following nursing interventions would least likely be effective when dealing with a client with aggressive behavior?
A.) Approach in calm, direct manner
B.) Provide opportunities to express feelings C.) Maintain eye contact with the client D.) Isolate the client from other clients ANS: D
> Isolating the client who manifests aggressive behavior would be ineffective intervention. This may further agitate him. Providing outlets, like physical activities will be more effective, to divert the client’s energy
46.) The client express fear that God will not be supportive and might be punitive. He is
experiencing which of the following responses? A.) Spiritual pain
B.) Spiritual anger C.) Spiritual anxiety D.) Spiritual loss ANS: C
>Spiritual anxiety is expression of fear that God will not be supportive and might be punitive 47.) 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?” B.) “Of course, you’re everything.”
C.) “That’s not true.”
D.) “You should not feel that way.” ANS: A
> Attempts to translate into feelings is a
therapeutic technique of communication. Using denial (B), disagreeing (C), and advising (D), are non-therapeutic techniques of communication. 48.) The client verbalizes that he is very anxious that the diagnostic tests he had undergone might reveal he has cancer. Which of the following is most appropriate nursing intervention?
A.) Tell the client not to worry unnecessarily, until the results are in.
B.) Ask the client to express feelings and concerns with regards to outcome of the tests C.) Reassure the client that everything will be alright
D.) Advise the client to divert his attention by watching television or reading newspaper ANS: B
> Exploring the client’s feelings and encouraging evaluation encourage verbalization by the client and therefore promote therapeutic nurse-client relationship. Reassuring (A and C), advising (D), are non-therapeutic techniques of
communication
49.) Which of the following statements clearly defines therapeutic communication?
A.) Therapeutic communication is an
interactional process which is primarily directed by the nurse
B.) Therapeutic communication is conveys feelings of warmth, acceptance and empathy from the nurse to a patient in a relaxed atmosphere
C.) Therapeutic communication is a reciprocal interaction based on trust and aimed at
identifying patient needs and developing mutual goals
D.) Therapeutic communication is the
assessment component of the nursing process ANS; C
> Therapeutic communication is a reciprocal interaction based on trust and aimed at
identifying patient needs and developing mutual goals.
50.) Which of the following concepts is most important in establishing therapeutic nurse-patient relationship?
A.) The nurse must fully understand the patient’s feelings, perceptions and reactions before goals can be established
B.) The nurse must be a role model for health-fostering behaviors
C.) The nurse must recognize that the patient may manifest maladaptive behavior during illness
D.) The nurse needs to understand that the patient may test her before he can accept and trust her
ANS: D
> In establishing therapeutic nurse-patient relationship, the nurse needs to understand that the patient may test her before he can accept and trust her
51.) Which communication skill is most effective in dealing with covert communication?
A.) validation B.) Listening C.) Evaluation
D.) Clarification ANS: A
> Validation is required for covert
communication. Only the patient can describe what he wants to convey through covert communication.
52.) Which of the following are qualities of good recording?
1. Brevity
2. Completeness and chronology 3. Appropriateness 4. Accuracy A.) 1,2 B.) 3,4 C.) 1,2,3 D.) 1,2,3,4 ANS: D
> 1,2,3 4- Good recording is characterized by brevity, completeness and chronology, appropriateness and accuracy.
53.) All of the following chart entries are correct EXCEPT:
A.) Complained of chest pain
B.) Chest pain relieved after administration of NTG sublingually
C.) Able to ambulate to the bathroom without assistance
D.) Vital signs 120/84 82, 18 ANS: D
> Recording of vital signs should be
T,PR,RR,BP. So the recording of vital signs letter D is incorrect. The rest are correct chart entries. 54.) The accepted method for signing a nurse’s note is:
A.) J.C./R.N.
B.) Juan Cruz, Clinical Instructor C.) Juan Cruz
D.) Juan D. Cruz, R.N. ANS: D
> The accepted method of signing a nurse’s notes is writing one’s full name n script and affixing R.N. to signify one’s status as a registered nurse
55.) Which of the following teachings methods is most appropriate for teaching a diabetic client on self-injection of insulin?
A.) Detailed explanations B.) Demonstration C.) Use of pamphlets D.) Filmstrip
ANS: B
> Demonstration is the best teaching strategy for psychomotor skills like self-injection of insulin. 56.) the most important characteristic of effective nurse-patient relationship is that:
A.) It is growth-facilitating
B.) It is base on mutual understanding C.) It fosters hope and confidence D.) It involves primarily emotional bond ANS: A
> The most important characteristic of effective nurse-patient relationship is that, it is growth-facilitating for the nurse and the patient
57.) Which of the following statements is most likely to promote a client’s compliance in performing post-operative deep breathing, coughing and turning exercises?
A.) “You will be given adequate medication is these exercises will cause you pain.”
B.) “Deep breathing, coughing and turning exercises will promote good breathing, body circulation. This will prevent complications.” C.) “These exercises will promote maximum respiratory ventilation, prevent thrombophlebitis and atelectasis.”
D.) “Your cooperation during these exercises will determine the rate of your recovery.”
ANS: B
> Giving information is a therapeutic technique of communication, like giving explanation on the benefits that a client will experience from deep breathing, coughing and turning exercises during the postop period
58.) When using printed material to teach diabetic patient about foot care, the nurse should:
A.) Read the material to the patient B.) Allow the patient to read the material
C.) Give the material to a family member to read the patient
D.) Read the material to evaluate its clarity, accuracy and effectiveness
ANS: D
> Reading materials to be distributed to clients should be evaluated by the nurse, for clarity, accuracy and effectiveness
59.) The patient asks the nurse, “ Do you think, I have the cancer?” The most appropriate
response of the nurse is:
A.) “I will refer you to your doctor.”
B.) “If I were you, I will not worry unnecessarily C.) “You sound concerned about what the doctor may find.”
D.) “You will undergo different tests before cancer can be diagnosed.”
ANS: C
> Focusing on client’s feeling is therapeutic 60.) The patient is scheduled for
proctosigmoidoscopy. She says she is nervous. The most appropriate response to be made by the nurse is:
A.) “You need not worry. You have the best doctor in the hospital.”
B.) “I don’t blame you for feeling that way. If I were in your position, I would feel the same.” C.) “Why do you feel that way? Don’t you trust God?”
D.) “You sound really upset. Would you like to sit and talk about it?
ANS: D
> Focusing on client’s feeling is therapeutic 61.) Which of the following behavior should the nurse recognize when caring for elderly patients?
A.) Most elderly resent being cared for by people not related to them
B.) Many elderly patients need support in maintaining their independence
C.) Elderly patients refuse to change old habits D.) Most elderly are unable to learn new skills ANS: B
> Maintaining independence among elderly is essential to maintain their ego integrity
62.) The nurse can best evaluate that the patient is learning by:
A.) His ability to repeat what was taught B.) A desired change in his behavior C.) Verbal acknowledgements that he understands
D.) His ability to get a good score from a questionnaire
ANS: B
> The best evidence that learning has taken place is an observable desired change in the client’s behavior
63.) Therapeutic communication begins with: A.) Giving initial care
B.) Showing empathy C.) Interacting with patient D.) Knowing your patient ANS: D
> Therapeutic communication begins with knowing the client
64.) Which of the following responses is appropriate when a patient requests to be discharged at once?
A.) “I will notify the supervisor about your request.”
B.) “You can only be discharged after the doctor has given a medical clearance.”
C.) “I will notify your doctor, so I can inform him about your request.”
D.) “I understand your request but please sign this special form.”
ANS: C
> Discharge from the hospital requires
physician’s order. Reassuring the client that his desire to go home will be conveyed to the M.D. is therapeutic
65.) From your admission interview of a patient, you obtained a history of allergies. You can best communicate this information by:
A.) Placing allergy alert in kardex B.) Writing in the patient’s chart C.) Informing his attending physician D.) Observation of the patient’s behavior ANS: C
> Informing the attending physician about the client’s allergies is the best way to communicate the information. Merely placing the information in the kardex, writing in the patient’s chart, will not ensure that the physician will be properly informed about the patient’s allergy
66.) Which of the following techniques can be most helpful in assessing the degree of distress and discomfort of a newly admitted patient? A.) Review the nurse’s notes
B.) Performing physical assessment C.) Active listening on what the patient says D.) Observation of the patient’s behavior ANS: C
> Active listening on what the patient says will be most helpful in assessing the degree of distress and discomfort her is expressing. Only the patient will be able to describe his distress and discomfort, because these are subjective data. 67.) Which of the following factors will least likely facilitate learning of a patient?
A.) Motivation to learn
B.) Active participation in the learning activity C.) Influencing the client to change his health beliefs
ANS: C
> Influencing the client to change his health beliefs will least likely facilitate his learning. Learning takes place more easily if the new leaning is closely related to previous learning like health beliefs.
68.) Which of the following principles must be given consideration by the nurse when giving patient teaching to an elderly client/
A.) Use audio-visual aids to facilitate learning B.) Provide opportunity for independence to learn
C.) Provide lecture for at least 2 hours D.) Proceed from complex to simple material ANS: B
> An elderly client learns best if he is given opportunity for independence to learn. Audio-visual aids may be ineffective among elderly because of possible visual and hearing impairment. Elderly have short attention span, so providing lecture for at least 2 hours is ineffective. Proceeding from simple to complex material facilitates learning; not complex to simple material.
Stages of Growth and Development: Adulthood 69.) The development task of the young adult according to Erikson is:
A.) Identity vs. Role confusion B.) Intimacy vs. Isolation C.) Generativity vs. Stagnation D.) Ego Integrity vs. Despair Ans: B
70.) The following are characteristics of a middle —aged adult EXCEPT:
A.) There is a sense of stability and consolidation
B.) The person becomes more oriented and career-oriented
C.) The person is more family oriented and career-oriented
D.) The person is more concerned with adhering to laws that protect the welfare and rights of others.
Ans: C
71.) The aging process which is characterized by severe mental deterioration is:
A.) Senility B.) Senescence C.) Gerontology D.) Geriatrics Ans: A
72.) The rate of Living Theory of Aging conceptualizes that:
A.) Changes in replication of DNA –RNA are the causes of aging
B.) Aging is caused by a change in the immune system
C.) The body is like a machine, parts wear out and the machine breaks down
D.) The faster one lives, the sooner one ages and dies
Ans: D
73.) The Disengagement Theory of aging believes that:
A.) Human beings are mortal and must eventually leave their place and role in society B.) One must constantly struggle to remain functional
C.) Persons will remain the same unless external and internal factors stimulate change D.) NOTA
Ans: A
74.) Which of the following is inappropriate nursing action for the elderly when providing hygienic practices and skin care?
A.) Provide daily bath
B.) Use mild, superfatted soap C.) Use body lotion
D.) Change position frequently Ans: A
75.) The following are appropriate nursing actions for the elderly with hearing impairment EXCEPT:
A.) Speak clearly, in well-enunciated words B.) Use normal tone of voice
C.) Repeat instructions as needed
D.) Increase loudness of voice when speaking Ans: D
76.) Which of the following colors is difficult to be distinguished by an elderly? A.) Red B.) Green C.) Purple D.) Blue Ans: C
77.) Which of the following enhances drug toxicity among elderly?
A.) Less acute vision
B.) Decreased renal function C.) Altered memory
D.) Diminished sense of taste Ans: B
78.) Which of the following should be include in the nursing care plan of an elderly?
A.) Provide health teachings in several brief sessions
B.) Provide recreational activities like needleworks
C.) Make decisions for the client
D.) Use audio-visual aids when providing health teachings
Ans: A
79.) Which of the following may be a primary reason why an elderly finds it difficult to comply
with low sodium diet?
A.) The patient had been used to taking salty foods in his younger years
B.) The patient experiences diminished sense of taste
C.) The patient has decreased absorption in the GI tract
D.) The patient experiences decreased peristalsis
Ans: B
80.) The following are true in the human sexuality of the elderly EXCEPT:
A.) There is minimal change in amount of sexual response
B.) There is cessation of sexual activity among elderly
C.) There is increased refractory periods in male D.) There is reduced vaginal lubrication
Ans: B
81.) The following are characteristics of an elderly who has achieved ego integrity EXCEPT: A.) Views life with sense of wholeness and satisfaction from past accomplishments B.) Accepts death as completion of life C.) Experiences serenity and shares wisdom D.) He wishes to live life longer to correct past mistakes
Ans: D
82.) According to Kohlberg’s theory on moral development, relationships are based on: A.) Mutual trust
B.) Mutual satisfaction of needs C.) Mutual approval of each other D.) Mutual beliefs
Ans: A
83.) According to Havighurst’s theory on
developmental tasks, the following are tasks of a 65-year old person EXCEPT:
A.) Adjusting to retirement and reduced income B.) Adjusting to decreasing Physical strength and health
C.) Establishing an explicit affiliation with one’s age group
D.) Adjusting to aging parents Ans: D
84.) Which of the following will help maintain the self-esteem of an elderly client?
A.) Provide as much independence as possible, with consideration to safety
B.) Assist the client to accept the need for seeking help in making decisions and judgments C.) Do hygiene measures for the elderly to promote sense of well-being
D.) Plan for routine activities of daily living to be followed by the client
Ans: A
85.) The following are appropriate nursing actions to prevent postural hypotension in an elderly patient EXCEPT:
A.) Advise to get out of bed gradually B.) Instruct to have a daily fluid intake of 3 glasses a day
C.) Advise to avoid straining at stool
D.) Advise to avoid bending down and suddenly standing up again
Ans: B
86.) Which of the following is not appropriate nursing intervention for an elderly with osteoporosis?
A.) Include milk and dairy products in diet B.) Take large amounts of protein-rich and salty foods
C.) Have regular exercise
D.) Wear rubber-soled, low heeled shoes that grip well
Ans: B
87.) The following are nursing interventions to minimize confusion among elderly?
A.) Use touch to convey concern
B.) Have clocks or calendars in the environment C.) Keep a routine of activities of daily living D.) All of theses
Ans: D
88.) The following nursing interventions are appropriate in the prevention of pressure sores among bedridden elderly patient EXCEPT: A.) Massage bony prominences
B.) Apply alcohol on the skin
C.) Apply cornstarch over the bedlinens D.) Elevate head of bed at 45 to 90 degree angle
Ans: B
89.) Florence Nightingale conceptualizes that
nursing is:
A.) The act of utilizing the environment of the patient to assist him in his recovery
B.) Assisting the individual, sick or well, in the performance of those activities contributing to health, preventing illness and rehabilitating the sick or disabled
C.) A humanistic science dedicated to compassionate concern with maintaining and promoting health, preventing illness and rehabilitating the sick or disabled
D.) A unique profession in that it is concerned with all the variables affecting an individual’s response to stressors.
Ans: A
90.) Which of the following nursing theorists
conceptualizes that all persons strive to achieve self-care?
A.) Sister Callista Roy B.) Dorothea Orem C.) Dorothy Johnson D.) Jean Watson
Ans: B
91.) Which of the following nursing theorists
introduced Transcultural Nursing Model?
A.) Imogene King B.) Dorothea Orem C.) Dorothy Johnson D.) Madeleine Leininger Ans: D
92.) The most important communication skill
to be developed by the nurse manager except.
A.) Performing bedside nursing B.) Assertiveness
C.) Questioning D.) Attentive Listening Ans: D
93.) Which of the following moral theories is
based on respect for other humans and belief that relationships are based on mutual trust?
A.) Erikson’s Theory B.) Kolberg’s Theory C.) Freud’s Theory
D.) Schulman and Mekler’s Theory Ans: B
94.) The caregiver role of the nurse
emphasizes:
A.) Implementing nursing care measures B.) Providing direct nursing care
C.) Recognition of needs of clients
D.) Observation of the client’s responses to illness
Ans: C
95.) The nurse takes the patient’s advocate
role when she;
A.) Defends the rights of the patient B.) Intercedes on behalf of the patient C.) Refers the patient to other services D.) Works with the significant others Ans: A
96.) The manager role of the nurse is best
demonstrated when she:
A.) Plans nursing care with the patient B.) Intercedes on behalf of the patient C.) Refers the patient to other services D.) Works with the significant of others Ans: B
97.) All of the following are primary
responsibilities of the nurse manager EXCEPT
A.) Performing bedside nursing
B.) Coordinating and delegating patient care C.) Setting standards of performance D.) Designating staff schedules
Ans: A
98.) The four concepts common to nursing
that appear in each of the current conceptual models
A.) Person, Nursing, Environment, Medicine B.) Person, Health, Nursing, Support System C.) Person, Environment, Health, Nursing D.) Person, Environment, Psychology, Nursing Ans:C
99.) Which of the following is not a subjective data? A.) Dizziness B.) Chest pain C.) Anxiety D.) Bluish discoloration Ans: D
100.) The following are specific activities during evaluation EXCEPT:
A.) Collecting data
B.) Performing nursing interventions C.) Measuring goal attainment
D.) Revising or modifying the care plan Ans: B
Funda Part 2 --Nursing
Process--1.) Which of the following is incorrect statement of nursing diagnosis?
A.) High risk for ineffective airway clearance related to pneumonia
B.) High risk for injury related to dizziness C.) Constipation related to decreased activity and fluids as manifested by small, hard, formed stool every three days
D.) Anxiety related to insufficient knowledge regarding surgical experience
ANS: A
> is incorrect statement of nursing diagnosis (refer to NANDA, appendix A). B,C and D are correct statement of nursing diagnosis.
2.) Which of the following would NOT be a basis for establishing priorities in client care?
A.) Actual problems take precedence over potential concerns
B.) Attend to equipment and contraptions first, such as IV fluids, urinary catheter, drainage tubes, before the client
C.) Airway should always be given highest priority
D.) Clients with unstable condition should be given priority over those with stable conditions. ANS: B
> Attend to client first before equipment. A, C and D are basis for establishing priorities in client care
3.) Which of the following is an incorrect statement of outcome procedure? A.) Ambulates 30 feet with cane before discharge
B.) Discusses fears and concerns regarding the surgical procedure during preoperative teaching C.) Demonstrates proper coughing technique after the teaching session
D.) Reestablishes normal pattern of bowel elimination
ANS: D
> Outcome criteria should be specific,
measurable, attainable, realistic and time-bound. A, B and C are correct statements of outcome criteria
--Assessing
Health--4.) The primary factor responsible for body heat production is: A.) Metabolism B.) Release of thyroxine C.) Thyroxine output D.) Muscle activity ANS: A
> The primary factor responsible for body production is metabolism
5.) The heat-regulating center is found in the: A.) Medulla oblongata
B.) Thalamus C.) Hypothalamus D.) Pons
ANS: C
> The heat-regulating center is found in the hypothalamus
6.) A process of heat loss which involves the transfer of heat from one surface to another is: A.) Radiation
B.) Conduction
C.) Convection D.) Evaporation ANS: B
> Conduction is the process of heat loss which involves the transfer of heat from one surface to another
7.) The following statements are true about body temperature EXCEPT:
A.) Core body temperature measures the temperature of deep tissues
B.) Highest body temperature is usually reached between 8:00 P.M. to 12:00 M.N.
C.) Elderly people are at risk of hypothermia due to decreased thermoregulatory controls and decreased subcutaneous fats
D.) Sympathetic response stimulation decreases body heat production
ANS: D
> Is incorrect statement about body temperature. Sympathetic nervous system releases
norepinephrine which increases metabolic rate, thereby increases body heat production.
8.) The client with fever had been observed to experience elevated temperature for few days, followed by 1 to 2 days of normal range of temperature. The type of fever he is experiencing is:
A.) Intermittent fever B.) Relapsing fever C.) Remittent fever D.) Constant fever ANS: B
> Relapsing fever is “on-and-off” fever
9.) Which of the following is NOT an appropriate nursing action when taking oral temperature? A.) Wash the thermometer from the bulb to the stem before use
B.) Place the thermometer under the tongue directed towards the side
C.) Take oral temperature for 2-3 minutes D.) Take oral temperature using a thermometer with pear-shaped bulb
ANS: D
> Is not appropriate nursing action when taking oral temperature. Thermometer with pear-shaped or rounded bulb is used for rectal temperature-taking
10.) The following are contraindications to oral temperature taking EXCEPT:
A.) Dyspnea B.) Diarrhea C.) Nasal-packing D.) Nausea and vomiting ANS: B
> Diarrhea is not a contraindication for oral temperature-taking
11.) Which of the following nursing actions is inappropriate when taking the rectal
temperature?
A.) Assist client to assume lateral position D.) Lubricate thermometer with water-soluble lubricant before use
C.) Hold the thermometer in place for 2 minutes D.) Instruct to strain during insertion of the thermometer
> Instructing client to strain during insertion of rectal thermometer is inappropriate. This may cause trauma to the anus.
12.) The following are correct nursing actions when taking the radial pulse EXCEPT: A.) Put the palms downward
B.) Use the thumb to palpate the artery C.) Use two to three fingertips to palpate the pulse at the inner wrist
D.) Assess the pulse rate, rhythm, volume and bilateral equality
ANS: B
> Using the thumb when palpating pulse is incorrect nursing action. The thumb has strong pulsation and the nurse might be counting her own pulse, instead of the client’s pulse
13.) The difference between the systolic pressure and the diastolic pressure is: A.) Apical rate
B.) Cardiac rate C.) Pulse deficit D.) Pulse pressure ANS: D
> Pulse pressure is the difference between systolic pressure and diastolic pressure. 14.) When measuring the blood pressure, the following are nursing considerations EXCEPT: A.) Ensure that the client is rested
B.) Use appropriate size of BP cuff
C.) Initiate and deflate BP cuff 2-3 mm Hg/sec D.) Read upper meniscus of mercury
ANS: D
> Reading the upper meniscus of mercury will yield inaccurate BP reading. BP reading is done by noting the level of the lower meniscus of the mercury.
15.) The process involved in the exchange of gases in the lungs is:
A.) Diffusion B.) Osmosis
C.) Hydrostatic pressure D.) Oncotic pressure ANS: A
> Diffusion is exchange of gases from an area of higher pressure to an area of lower pressure. 16.) The primary respiratory center is: A.) Medulla oblongata
B.) Pons
C.) Carotid and aortic bodies D.) Proprioceptors
ANS: A
> The primary respiratory center is the medulla oblongata. It contains the central
chemoreceptors that are stimulated by high levels of carbon dioxide in the blood
17.) Which of the following primarily affects BP? A.) Age
B.) Stress C.) Gender D.) Obesity ANS: B
> Stress is the primary factor that affects BP, because of release of norepinephrine by the sympathetic nervous system.
18.) The following are social data about a client EXCEPT:
A.) Patient’s lifestyle B.) Religious practices
C.) Family home situation D.) Usual health status ANS: A
> Patient’s lifestyle is not a social data
19.) The systematic manner of collecting data about the client by listening to body sounds with the use of stethoscope is:
A.) Inspection B.) Palpation C.) Percussion D.) Auscultation ANS: D
> Auscultation is listening to body sounds with the use of stethoscope
20.) The following are appropriate nursing actions when performing physical health examination to a client EXCEPT:
A.) Ensure privacy of the client throughout the procedure
B.) Prepare the needed articles and equipment before the procedure
C.) Assess the abdomen following this sequence: right lower quadrants
D.) When assessing the chest, it is best to place the client in side lying
ANS: D
> This is incorrect nursing action. The best position when assessing the chest is sitting or upright position. This allows assessment of the anterior and posterior chest
21.) Which of the following is inappropriate nursing action when collecting clean-catch midstream urine specimen for routine urinalysis? A.) Collect early morning, first voided specimen B.) Do perineal care before collection of specimen
C.) Collect 5-10 mls of urine D.) Discard the first flow of urine ANS: C
> This is inappropriate nursing action. For routine urinalysis, 3-50 mls of urine specimen is required to yield accurate results
22.) Which of the following nursing actions is incorrect when performing Benedict’s test? A.) Collect 24-hour urine specimen
B.) Ensure that Benedict’s solution remains unchanged after heating it
C.) Add 8-10 drops of urine
D.) Interpret that the urine is negative for glucose when the color remains blue ANS: A
> This is incorrect nursing action. When performing Benedict’s test, collect second-voided urine specimen
23.) Heat and acetic acid test is done to determine
A.) Presence of albumin in the urine B.) Presence of glucose in the urine C.) Presence of ketones in the urine D.) Presence of RBC in the urine ANS: A
> Heat and acetic acid test is done to determine presence of albumin in the urine.
24.) Which of the following is correct nursing action when collecting urine specimen from a client with indwelling urethral catheter? A.) Collect urine specimen from the urinary drainage bag
B.) Detach the catheter from the connecting tube C.) Use sterile needle and syringe to aspirate urine specimen from the drainage port
D.) Flush the catheter with sterile NSS before collection of urine specimen
ANS: C
> When collecting urine specimen from a client with indwelling urethral catheter, collect urine specimen by using sterile needle and syringe to aspirate urine specimen from the drainage port. 25.) The following are independent nursing interventions for a febrile client EXCEPT:
A.) Administer paracetamol 500 mg. tab every 4 hours PRN for temperature 38.5 C
B.) Increase fluid intake C.) Promote bed rest
D.) Keep the client’s clothing clean and dry ANS: A
> Administration of antipyretic to a febrile client is dependent nursing intervention, (not
independent nursing intervention)
---Basic Human Needs: Oxygenation----26.) The common opening between the respiratory and digestive system is: A.) Pharynx
B.) Larynx C.) Trachea D.) Bronchus ANS: A
> The common opening between the respiratory and digestive system is the pharynx
27.) The right lung has: A.) 2 lobes
B.) 3 lobes C.) 4 lobes D.) 5 lobes ANS: B
> The right lung has 3 lobes
28.) The amount of air that remains in the lungs after forceful exhalation is:
A.) Functional residual capacity B.) Residual volume
C.) Tidal volume D.) Minute volume ANS: B
> The amount of air that remains in the lungs after forceful exhalation is residual volume 29.) Cheyne-Stokes breathing is:
A.) Slow, shallow respirations which result to inadequate alveolar ventilation
B.) Difficulty of breathing in reclining position C.) Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea
D.) Shallow breaths interrupted by apnea ANS: C
> Cheyne-stokes breathing is marked waxing and waning of respirations from very deep to very shallow breathing and temporary apnea 30.) The best position to promote maximum lung expansion is: A.) Supine B.) Retractions C.) Noisy breathing D.) Semi fowler’s ANS: D
> The best position to promote maximum lung expansion is Semi-Fowler’s
31.) The characteristic manifestation of airway obstruction is: A.) Bradypnea B.) Retractions C.) Noisy breathing D.) Tachypnea ANS: C
> The characteristic manifestation of airway obstruction is noisy breathing.
32.) The following are appropriate nursing interventions to promote normal respiratory function EXCEPT:
A.) Adequate fluid intake B.) Minimize cigarette smoking
C.) Deep breathing and coughing exercises D.) Frequent change of position among bedridden clients
ANS: B
> This is inappropriate nursing intervention to promote respiratory function. Appropriate is avoid or quit cigarette smoking, not just to minimize it
33.) The initial manifestations of hypoxemia are A.) Restlessness, tachycardia
B.) Dizziness, faintness
C.) Headache, blurring of vision D.) Dyspnea, retractions ANS: A
> The initial manifestations of hypoxemia are restlessness and tachycardia
34.) The following are appropriate nursing actions when performing percussion, vibration and postural drainage, EXCEPT:
A.) Verify doctor’s order
B.) Perform the procedure before meals and at bedtime
C.) provide good oral hygiene after the procedure
D.) Each position during postural drainage should be assumed for 30 minutes
ANS: D
> This is inappropriate nursing action during chest physiotherapy. Appropriate is to assume each position during postural drainage for 10 to 15 minutes
35.) Which of the following nursing actions is inappropriate when providing steam inhalation therapy?
A.) Check doctor’s order
B.) Cover the eyes with moist washcloth C.) Place the spout 3-4 inches away from the patient’s nose
D.) Place the patient in semi-fowler’s position ANS: C
> This inappropriate nursing action when providing steam inhalation therapy. Appropriate is to place the spout at least 12 inches from the patient’s nose.
36.) To be effective, steam inhalation should be rendered for at least:
A.) 5-10 minutes B.) 15-20 minutes C.) 30-45 minutes D.) 60-70 minutes ANS: B
> To be effective, steam inhalation should be rendered for at least 15-20 minutes
37.) The correct pressure of the wall suction unit when suctioning an adult patient is:
A.) 95-110 mm Hg B.) 100-120 mm Hg C.) 50-95 mm Hg D.) 10-15 mm Hg ANS: B
> The correct pressure of the wall suction unit when suctioning an adult patient is 100-120 mm Hg
38.) Which of the following is inappropriate nursing action when performing oropharyngeal suctioning?
A.) Place the client in semi-fowler’s or lateral position
B.) Measure length of catheter from the tip of the nose to the earlobe.
C.) Lubricate suction catheter with alcohol D.) Apply suction during withdrawal of the suction catheter tip:
ANS: C
> When performing oropharyngeal suctioning, it is inappropriate to lubricate catheter with alcohol. Alcohol may irritate mucous membrane of airways. Appropriate is, use sterile water or sterile NSS.
39.) The maximum time for applying suction is: A.) 5-10 seconds
B.) 10-15 seconds C.) 15-20 seconds D.) 20-30 seconds ANS: B
> The maximum time for applying suction is 10 to 15 seconds. This is to prevent hypoxia 40.) To evaluate effectiveness of suctioning, the nurse should primarily:
A.) Auscultate the chest for clear breath sounds B.) Assess the respiratory rate
C.) Check the skin color D.) palpate the pulse rate ANS: A
> To evaluate effectiveness of suctioning, the nurse should primarily auscultate the chest for clear breath sounds
41.) The oxygen administration device preferred for patients with COPD is:
A.) Nasal cannula B.) Oxygen tent C.) Venturi mask D.) Oxygen hood ANS: C
> Venturi mask is the preferred device for oxygen therapy among clients with COPD. 42.) Which of the following is not to be included in the nursing interventions for a client receiving oxygen therapy?
A.) Place a “Non-smoking” sign at the bedside B.) Place the client in semi-fowler’s position C.) Place sterile water into the oxygen humidifier D.) Lubricate nares with oil to prevent dryness of the mucous membrane
ANS: D
> It is inappropriate to lubricate nares with oil when the client is receiving oxygen therapy. Oil ignites when exposed to compressed oxygen 43.) When assessing respiration, the nurse describes the following EXCEPT:
A.) Rhythm
B). Effort C.) Rate D.) Depth ANS: C
> When assessing respirations, the nurse should count the rate, not simply describe it.
44.) The small hair-like projections that line the tracheobronchial tree, which sweep out debris and excessive mucous from the lungs are called: A.) Cilia B.) Vibrissae C.) Macrophages D.) Goblet cells ANS: A
> Cilia are small hair-like projections that line the tracheobronchial tree
45.) The following are appropriate nursing diagnoses for clients with oxygenation problems: A.) Ineffective airway clearance related to tracheobronchial secretions
B.) Ineffective breathing pattern related to decreased energy and fatigue
C.) Impaired gas exchange related to altered oxygen-carrying capacity of the blood
D.) All of these ANS: D
> All of these (A,B, and C) are appropriate nursing diagnoses for clients with oxygenation problems.
---Basic Human Needs:
Nutrition----46.) The regulating center for fluid and food intake are located in their
A.) Thalamus B.) Hypothalamus C.) Medulla oblongata D.) Pons
ANS: B
> The regulating centers for food and fluid intake are found in the hypothalamus
47.) The enzyme that initiates digestion of starch in the mouth is:
A.) Amylase B.) Sucrase C.) Maltase D.) Lactase ANS: A
> The enzyme that initiates digestion of starch in the mouth is salivary amylase
48.) Which of the following structure prevents gastric reflux?
A.) Pyloric sphincter B.) Internal sphincter C.) Cardiac sphincter D.) Sphincter of Oddi ANS: C
> The cardiac sphincter also known as lower esophageal sphincter prevents gastric reflux 49.) Which of the following nutrients remains in the stomach for the longest period?
A.) Fats B.) Proteins C.) Carbohydrates D.) Water
ANS; A
> Fats remains in the stomach for 4 to 6 hours; carbohydrates for 1 to 2 hours; protein 3 to 4 hours
50.) The pancreatic enzyme which completes digestion of fats is A.) Amylase B.) Lipase C.) Trypsin D.) Rennin ANS: B
> Lipase is the pancreatic enzyme that completes digestion of fats
51.) Kwashiorkor is a condition characterized by: A.) Calorie deficiency
B.) Vitamin Deficiency C.) Protein deficiency D.) Mineral deficiency ANS: C
> Kwashiorkor is protein deficiency
52.) Which of the following is most effective nursing measures to relieve anorexia EXCEPT: A.) Provide small, frequent feedings
B.) Remove unsightly articles from the patient’s unit
C.) Provide three full meals a day D.) Provide good hygienic measures ANS: A
> Providing small frequent feedings is most effective nursing measure to relieve anorexia 53.) The following factors increase calorie requirements EXCEPT:
A.) Cold climate
B.) Activity and exercise C.) Fever
D.) sleep ANS: D
> Sleep reduces calorie requirement by 10 to 15% . A,B,and C are factors that increase calorie requirement.
54.) The following are good sources of calcium EXCEPT: A.) Cheese B.) Milk C.) Soy products D.) Carbonated drinks ANS: D
> Carbonated drinks are not sources of calcium. A,B and C are good sources of calcium.
55.) Which of the following is the richest source of iron? A.) Mongo B.) Milk C.) Malunggay leaves D.) Pechay ANS: A
> Among these choices, mongo (a legume) is the richest source of iron. The richest source of iron is liver, next is lean meat, then legumes, then green leafy vegetables
56.) Which of the following is a good source of vitamin A? A.) Eggs B.) Liver C.) Fish D.) Peanuts ANS: B
> Liver is very good source of fat-soluble vitamins (A,D,E,K)
57.) The following may be given to relieve nausea and vomiting EXCEPT:
A.) Dry toast
B.) Milk
C.) Cold cola beverage D.) Ice chips
ANS: B
> Milk does not relieve nausea and vomiting. A,B,C may relieve nausea and vomiting 58.) The most life threatening complication of vomiting is: A.) Aspiration B.) Dehydration C.) Fever D.) Malnutrition ANS: A
> The most life-threatening complication of vomiting is aspiration. It causes airway obstruction.
59.) The vomiting center is found in the ________. A.) Cerebellum B.) Hypothalamus C.) Medulla Oblongata D.) Cerebrum ANS: C
> The vomiting center in the Medulla Oblongata 60.) The best indicator of nutritional status of the individual is:
A.) Weight B.) Height
C.) Arm muscle circumference D.) Adequacy of hair
ANS: A
> The best indicator of nutritional status is the weight
61.) To assess the adequacy of food intake, which of the following assessment parameters is best used?
A.) Food preferences and dislikes B.) Regularity of meal times C.) 3-day diet recall
D.) Eating style and habits ANS: C
> Dietary diary e.g. 3-day diet recall, is the best assessment parameter for adequacy of food intake
62.) Prolonged deficiency of vitamin B12 leads to: A.) beriberi B.) Pernicious anemia C.) Pellagra D.) Peripheral neuritis ANS: B
> Prolonged Vit B12 deficiency results to pernicious anemia
63.) The vitamin necessary for absorption of calcium is: A.) Vit D B.) Vit A C.) Vit C D.) Vit E ANS: A
> Vit D promotes absorption of calcium 64.) Vit. K is necessary for:
A.) Bone and teeth formation
B.) Integrity of skin and mucous membrane C.) Blood coagulation
D.) Formation of RBC ANS: C
> Vit K is necessary for blood clotting. Prolonged deficiency of this vitamin leads to bleeding 65.) The following are signs and symptoms of dehydration EXCEPT:
A.) Weight loss
B.) Decreased urine output C.) Elevated body temperature D.) Elevated BP
ANS: D
> Elevated BP is not a sign of dehydration. A,B,C are signs and symptoms of dehydration. 66.) The client is experiencing hypokalemia. Which of the following should be included in his diet? A.) Banana B.) Milk C.) Cheese D.) Fish ANS: A
> Hypokalemia is low serum potassium level. Providing potassium-rich foods like banana and other fresh fruits is effective nursing intervention for this condition
67.) During insertion of NGT, which position is best assumed by the client?
A.) Low-Fowler’s B.) Semi-Fowler’s C.) High-Fowler’s D.) Lateral ANS: C
> During insertion of NGT, the patient is best placed in high-Fowler’s position with neck hyperextended until the tube is in the
oropharynx. Once the NGT is in the oropharynx, the client is instructed to flex the neck and swallow, as the tube is advanced.
68.) The length of NGT to be inserted is correctly measured;
A.) From the tip of the nose to the umbilicus B.) From the tip of the nose to the xiphoid process
C.) From the tip of the nose to the earlobe to the umbilicus
D.) From the tip of the nose to the earlobe to the xiphoid process.
ANS: D
> The length of NGT to be inserted is measured from the tip of the nose, to the earlobe, to the xiphoid process (N-E-X) which is approximately 50cm
69.) When inserting NGT, the neck should: A.) Flexed
B.) Hyperextend C.) Tilted to the left D.) In neutral position ANS: B
> When inserting NGT, the neck is initially hyperextended
70.) The most accurate method of assessing method of placement of NGT is:
A.) Aspiration
B.) Testing the pH of gastric aspiration C.) X-ray study
D.) Introduction of air into NGT and auscultate at the epigastric area.
ANS: C
> The most accurate method of assessing placement of NGT is through X-ray.
71.) Which of the following is inappropriate nursing action when administering NGT feeding? A.) Assist the client in Fowler’s position
B.) Introduce feeding slowly
C.) Place the feeding 24 inches above the point of insertion of NGT
D.) Instill 60mls of water into the NGT after feeding
ANS: C
> During NGT feeding, the height of the feeding is 12 inches above the point of NGT insertion, not 24 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may trigger nausea and vomiting.
72.) The primary purpose of gastrostomy is: A.) For feeding
B.) For drainage
C.) To prevent flatulence
D.) To prevent aspiration of gastric reflex ANS: A
> The primary purpose of gastrostomy is for feeding
73.) The most important nursing action before gastrostomy feeding is:
A.) Check VS
B.) Assess for patency of the tube C.) Measure residual feeding D.) Check for placement of the tube ANS: B
> The most important nursing action before gastrostomy feeding is to assess for patency of the tube. This is done by instilling 15-30 mls of water into the tube.
74.) The primary advantage of gastrostomy feeding is:
A.) It ensures adequate nutrition B.) It prevents aspiration
C.) It maintains integrity of gastro-esophageal sphincter
D.) It minimizes fluid-electrolyte imbalances ANS: C
> The primary advantage of gastrostomy feeding is, it maintains the integrity of gastro-esophageal sphincter ( cardiac sphincter) of the stomach 75.) Vit B3 (Niacin) deficiency leads to: A.) Pellagra
B.) Beriberi C.) Scurvy D.) Rickets ANS: A
> Vitamin B3 (Niacin) deficiency leads to pellagra
--Basic Human Needs: Bladder and Bowel & Elimination—
76.) Constipation is best described as: A.) Irregular passage of stool
B.) Passage of stool every other day C.) Passage of hard, dry stool D.) Seepage of liquid feces ANS: C
> Constipation is passage of hard, dry stool 77.) The accumulation of hardened, putty-like fecal mass at the rectum is
A.) Obstipation B.) Constipation C.) Tympanities D.) Fecal impaction ANS: D
> Fecal impaction is the accumulation of hardened, putty-like fecal mass at the rectum 78.) The following are appropriate nursing measures to relieve constipation EXCEPT: A.) Include fruits and vegetables
B.) Have adequate activity and exercise C.) Take laxatives at regular basis
D.) Answer immediately to the urge to defecate ANS: C
> Regular use of laxative is inappropriate nursing measures to relieve constipation 79.) Castor oil acts as a laxative by: A.) Providing chemical stimulation of the intestinal mucosa
B.) Softening the stool
C.) Increasing the bulk of the stool D.) Lubricating the stool
ANS: A
> Castor oil provides chemical stimulation to the intestinal mucosa, to increase peristalsis and promote defecation
80.) Which of the following foods should be avoided by the client prevent flatulence? A.) Fruit juice
B.) Cabbage C.) Meat D.) Fish ANS: B
> To prevent flatulence, avoid gas-forming foods like cabbage
81.) Which of the following antidiarrheal medications absorb gas or toxic substances from the bowel?
A.) Demulcent B.) Cabbage C.) Meat D.) Fish ANS: B
> Absorbent anti-diarrheal medications absorb gas or toxic substances from the bowel
82.) The most common-side effect of overuse of laxatives is:
A.) Diarrhea
B.) Nausea and vomiting C.) Constipation
D.) Flatulence ANS: C
> The most common side-effect of overuse of laxative is rebound constipation
83.) Which of the following should be included in the diet of the patient with diarrhea?
A.) Banana B.) Papaya C.) Pineapple D.) Avocado Ans: A
> Banana should be included in the diet of the client with diarrhea. It is rich in potassium and it replaces potassium losses due to diarrhea 84.) Which of the following fluids may be given to a client with diarrhea?
A.) Milk B.) Coffee C.) Tea D.) Gatorade ANS: D
> Gatorade may be given to a client with diarrhea because it is rich in potassium
85.) Which of the following laxative increases the bulk of the stool?
A.) Colace B.) Metamucil D.) Dulcolax D.) Duphalac ANS: B
> Metamucil increases bulk of the stool and it provides adequate mechanical stimulation for peristalsis
86.) The following are appropriate nursing measures to relieve diarrhea EXCEPT: A.) Provide high-fiber diet
B.) Promote rest
C.) Include banana in the diet D.) Avoid fatty or fried food ANS: A
> High fiber die stimulates peristalsis and therefore inappropriate for a client with diarrhea 87.) The following are solutions used as non-retention enema EXCEPT:
A.) Tap water
B.) Carminative enema C.) Normal Saline Solution D.) Fleet Enema
ANS: B
> Carminative enema is used for retention enema. A,C, and D are solutions used as non-retention enema
88.) The medication that relieves flatulence is: A.) Imodium (Loperamide)
B.) Plasil (Metochlopramide) C.) Prostigmin (Neostigmine) D.) Colace ( Na Docussate) ANS: C
> Prostigmin is cholinergic, so it stimulates peristalsis. It is used to relieve flatulence 89.) The best position of the adult client during enema administration is:
A.) Left lateral B.) Supine C.) Right lateral D.) Semi-Fowler’s ANS: A
> Left lateral position is the best position for the adult client receiving enema. This position facilitates the flow of the solution into the colon by gravity
90.) Which of the following is inappropriate nursing action during rectal tube insertion to relieve flatulence?
A.) Insert rectal tube for 3-4 inches B.) Use rectal tube size Fr.22-30
C.) Keep rectal tube in place for 45 minutes D.) Insert well-lubricated rectal tube in rotating motion
ANS: C
> Keeping the rectal tube in place for 45 minutes is inappropriate. Beyond 30 minutes rectal tube causes irritation of the mucous membrane in the rectal area.
91.) The following are correct nursing actions when administering enema EXCEPT:
A.) Provide privacy
B.) Introduce solution slowly
C.) Alternate NSS with tap water and soap suds D.) Increase the flow rate of the enema solution if abdominal cramps occur
