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1
Mary, a high school student, is currently admitted in the AB Ward.She complains of intense abdominal pain, bloating, and alternate periods of constipation and diarrhea. She reports that she felt it recently before taking an examination. Laboratory studies showed no findings present in the abdomen. Nurse Anne can infer that the patient is having:
Irritable Bowel Syndrome
2
Nurse Anne is aware that the management for the patient Mary's symptoms are focused on proper stress management, exercise, and appropriate diet. The following should NOT be included in the patient's diet, EXCEPT:
Oatmeal
3
Dumping syndrome occurs in which of the following patients? Select all that apply 1. Patients who had Bilroth 1 or 2 2. Patient who had a vagotomy 3. Patient who's currently on tube feeding 4. Patient who had a colectomy
123
4
Patient Rensie was transferred to the medical-surgical ward after a Bilroth II procedure. Nurse Jovy would suspect dumping syndrome if the patient showed which of the following early signs or symptoms,EXCEPT?
Headache
5
In order to prevent Patient Rensie to have recurring episodes of dumping syndrome, Nurse Jovy should:
Let the patient lie down in left side Wing position
6
Which of the following tests would confirm the patient diagnosis of HIV?
Western Blot
7
Patient Mamon is admitted with a recent history of sexual intercourse with a person positive with HIV. Which of the following are signs and symptoms of Acute stage of HIV?
Mild fever, headaches, sore throat
8
Handling a patient diagnosed with HIV requires which type of precaution?
Standard precaution
9
Which of the following patient exposure would most likely affect the nurse if the patient's HIV diagnosis is suspected but not confirmed?
Needlestick injury with the needle and syringe with the patient's blood
10
Nurse Twinnie is giving IV medications to the patient when she is suddenly pricked by the needle. The patient was diagnosed with HIV upon admission. Nurse Twinnie will know if she acquired the virus when she will have which diagnostic test?
EIA
11
The following are risk factors associated with development of cervical cancer, EXCEPT:
Late age of first sexual intercourse
12
Patient Bubbles is currently admitted on suspected cervical cancer.Which of the following would indicate possible signs and symptoms that may support the diagnosis?
Light bleeding or watery vaginal discharge
13
Francis, a 34-year-old male, went to the clinic complaining of intense joint pain in the fingers of the hands and feet. He claims to have recently been in a boodle fight with his family and he ate a lot of fried tilapias. The nurse suspects which of the following?
Gouty arthritis
14
The following are appropriate pharmacological management for patients with gout, EXCEPT:
Metoprolol
15
Patient Aristotle diagnosed with gout is currently experiencing pain in the left great toe and is given oral Ibuprofen to manage the pain. Which of the following assessment should Nurse Socrates observe that might necessitate intervention?
Black tarry stools
16
Patient Danilo who is confined in the hospital for a 3 weeks for multiple chronic illnesses develops acute gouty arthritis. As he takes multiple medication for his illnesses, Nurse Fen would warrant immediate intervention if the patient decided to take which of the following medication?
Furosemide
17
An upcoming hip repair for Gina's surgical procedure and is questioned by the nurse in the pre-admission screening lab. According to the client, a desire to donate her own blood in the approaching surgery. The nurse ought to:
Notify the office of the surgeon.
18
Which of the following clients should the nurse anticipate receiving a request for single-donor platelets?
a patient getting several platelet transfusions.
19
Lorno, a 72-year-old patient has active rectal bleeding and has been admitted. He has undergone cross-matching and typing for two packed red blood cell (RBC) units. Ten minutes after being admitted, he passes out while getting up to use the bedside toilet. The nurse alerts the medical professional, who promptly orders a unit of blood. What kind of packed RBCs should the nurse anticipate being utilized for an urgent transfusion?
O negative
20
Which test outcome should the nurse examine to determine whether blood from two distinct donors is compatible?
Indirect Coombs
21
Causes of a hemolytic transfusion response that may lead to hemolytic shock include
Rh or ABO incompatibility
22
The client is having blood transfusion therapy, and the nurse is taking care of them. What clinical signs should the nurse look for to suspect a hemolytic reaction to transfusion? 1. Headache 2. Tachycardia 3. Hypertension 4. Apprehension 5. enlarged neck veins 6. Sense of impending doom
1246
23
Due to an acute hemolytic transfusion reaction, a client's red blood cell transfusion was stopped. Which of the following tactics should the nurse do to reduce the likelihood of such a reaction the BEST?
Before hanging the blood unit, the nurse confirms all client-identifying information in accordance with hospital practice.
24
Fandi, a 26 year old woman is undergoing blood transfusion, however, wrong blood matching and typing happened. Which is the first sign of hemolytic transfusion reaction?
Low Back Pain
25
Jana is brought to the ER with a BP of 70/45 and is diagnosed with septic shock. Which assessment would validate the diagnosis.
40.9 C temperature and a pulse rate of beats per minute 138
26
The most common and frequent cause of septic shock is infection with
Gram-Positive Bacteria
27
Which patient will not exhibit the expected assessment in response to septic shock?
Janji, taking Atenolol for Hypertension
28
The nurse checks the antenatal history of several patients in early labor. The following are factors documented in the history as having potential factors in increased risk for septic shock after delivery, except? A. Asian in descent B. During the third trimester, prenatal care was started. C. spontaneous membrane rupture 24 hours ago PinfoN D. A dietary examination revealed unhealthful eating patterns. E. prior usage of drugs during pregnancy F. prior two miscarriages
AF
29
Who amongst the following children should MM vaccine not be given?
Dondi who has HIV
30
After being given a dose of penicillin, the client experiences an anaphylactic reaction. Which nursing intervention for this client is of the utmost importance?
Maintain patent airway clearance
31
A 20-year-old patient who suffered a hornet sting is brought to the emergency room. Which signs point to an anaphylactic reaction in the patient? 1. Wheezing 2. Rhinorrhea 3. Urticaria A Localized Edema 5. Angioedema 6. Generalized pruritus
12356
32
Which of the following actions should the nurse perform first after providing first treatment to a patient who has asthma and is on the verge of anaphylaxis due to a medication hypersensitivity?
Administer bronchodilators as ordered
33
Which kind of hypersensitivity is related to anaphylactic shock?
Type I hypersensitivity.
34
Shena, a 45 year old female, has gouty arthritis. She is being treated with allopurinol. The client is taught by the nurse which action to do in the event of an acute attack occurs?
Add NSAID or colchicine to the treatment plan
35
Indomethacin therapy is explained to the client who has been diagnosed with acute gouty arthritis by Fiona, the community health nurse. When the client says what, does the nurse decide that more instruction is necessary?
“Whenever I need to relieve pain, I can take a pill"
36
Allopurinol 250mg PO daily was prescribed to patient Imelda. After 3 weeks of continued daily regimen, she decided to go back to the clinic. Which of the following statements by patient Imelda indicates that the teaching was effective?
l need to consume at least 8 glasses of water each day."
37
A patient with a gout diagnosis is given colchicine. Knowing that this drug should only be used in certain disorders, the nurse looks over the client's medical history.
Chronic Kidney Disease
38
The patient in a local community clinic is being treated by the nurse for gout. What laboratory result would the nurse anticipate seeing in the patient?
Uric acid: 9.0 mg/dL
39
The nurse is arranging for peritoneal dialysis to be administered to a child with hemolytic-uremic syndrome who has previously been anuric. What action should the nurse prepare to take?
Restrict fluid as prescribed
40
The nurse is explaining peritoneal dialysis to a client who has diabetes mellitus. The client is informed by the nurse that maintaining the prescribed dwell time for the dialysis is crucial due to the danger of this complication?
Hyperglycemia
41
An indwelling peritoneal catheter for peritoneal dialysis is present in the abdomen of a patient with chronic renal disease. The patient accidentally wets the abdominal dressing while taking a bath. What should the nurse do to ensure the client's safety the most effectively?
Change the dressing
42
Peritoneal dialysis is being carried out by a nurse, who injects 2 L of dialysate into the peritoneal cavity. Only 1 L of the solution is returned by the client after 30 minutes have passed. The nurse ought to?
Reposition the patient and have him roll from side to side
43
The client and family are being instructed by Nurse Irma about peritoneal dialysis, which will be carried out at home. The most important discharge instruction is
indicators that a peritoneal infection is present.
44
Kim Chay, an ER nurse, endorse patient Tibet a 40 yo female who is admitted to the hospital for high phosphorus level due to having End Stage Renal Disease. She is receiving continuous ambulatory peritoneal dialysis and her attending doctor ordered continued management during admission. Which of the following should nurse June, the ward nurse should do?
Use sterile procedures and a permanent peritoneal catheter while weighing the patient at the same time each day
45
What medication is used to treat patients with anorexia nervosa?
Risperidone
46
The nurse wants to create a nursing diagnosis for a patient with anorexia nervosa. Which of the following would the priority nursing diagnosis?
Fluid and electrolyte imbalance
47
The nurse finds the patient doing push-ups and jumping jacks in her room. What should the nurse do?
Stop the patient and invite the patient for a walk
48
The female patient with anorexia nervosa would most likely have which of the following signs and symptoms regarding her menstrual cycle?
Amenorrhea
49
The following family dynamics would put adolescents at risk for anorexia nervosa except?
The parents have maladaptive communication with their child
50
Which of the following is not done by a patient with anorexia nervosa?
Recognize that their body image is abnormal
51
Situation: Patient Kirby is being assessed by the nurse for signs and symptoms of Bulimia. The nurse's assessment reveals a history of binging and purging for the last six months. The nurse continues with her assessment. During the assessment for patient Kirby, the nurse notices scrapes on patient Kirby's knuckles and knows that this sign is called?
Russel's sign
52
Situation: Patient Kirby is being assessed by the nurse for signs and symptoms of Bulimia. The nurse's assessment reveals a history of binging and purging for the last six months. The nurse continues with ner assessment. Patient Kirby would be most at risk for developing what electrolyte imbalance?
Hypokalemia
53
What is the criteria to be diagnosed for bulimia?
Binging and purging once a week for three month
54
Situation: Patient Fischl is in the psychiatric ward and has been undergoing treatment after being diagnosed with schizophrenia. Nurse Bennett has been assigned as patient Fischl's primary nurse. Patient Fischl presents with positive symptoms of schizophrenia. Nurse should expect the following statements except?
"I don't find my old hobbies as enjoyable as before"
55
Patient Fischl has been telling patient Bennett that there are feathers all over her body and makes her feel itchy. Which of the following should nurse Bennett do?
Assess patient Fischl for any physical problems causing the itch
56
Nurse Bennett reviewed patient Fischl's medication history and found out that she has been on anti-psychotics for nearly 6 months.Patient Fischl is at most at risk for what condition if she continues using her anti-psychotics?
Tardive dyskinesia
57
What neurotransmitter is affected in schizophrenia?
Dopamine
58
Patient Fischl has been taking Haloperidol, a first-generation anti-psychotic. Nurse Bennett knows that this drug class works by:
Decreasing dopamine
59
If patient Fischl's psychosis lasts for more than 1 month but subsides before 6 months, nurse Bennett would classify this as?
Schizophreniform
60
A few weeks after undergoing treatment, patient Fischl presents with avolition. Nurse Bennett knows that this is:
Lack of motivation
61
When providing health teaching to patient Fischl regarding her medications, nurse Bennett should instruct the following except?
Standing up immediately after laying down for a long time
62
Nurse Bennett noticed that patient Fischl presented with symptoms of extrapyramidal symptoms caused by her medications.Nurse Bennet will expect the following except?
Catatonia
63
Situation: Nurse Barbara is an emergency nurse and is experienced with handling patients with different levels of anxiety. One day, a road accident occurs and causes a surge of patients in the emergency room. A patient is brought in the emergency department who seems to be the only survivor in the vehicle she was in. Upon assessment, IM valium is ordered; nurse Barbara knows that this is given to patients with what level of anxiety?
Severe
64
Another patient is brought to the emergency department. Despite having a non-life threatening injury, the patient is found pacing and can only focus on answering a few of the assessment questions. What level of anxiety does the patient present?
Moderate
65
A patient comes to the emergency department with severe difficulty of breathing. The patient verbalizes that she hears a loud ringing in her ear, aggressive, and cannot focus nor answer any of the questions nurse Barbara is asking. What level of anxiety is this?
Panic
66
What neurotransmitter is affected in patients diagnosed with ~ anxietv disorders?
GABA
67
Nurse Barbara is preparing to establish rapport with a patient with severe levels of anxiety. Which of the following should she do initially?
Provide the patient with personal space
68
A patient comes to the hospital asking about his medications for ADHD. He asked what is the generic name for Ritalin as he cannot afford this brand of medication. The nurse would be correct to state which generic name?
Methylphenidate hydrchloride s
69
As patient Furina's psychiatric nurse, the nurse knows that which of the following is the drug of choice for bipolar disorder?
Eskalith
70
Patient Furina mentions that her psychiatrist noticed that patient Furina's disorder was dysthymic in nature and asks what does it mean. The nurse would state that the disorder is marked by:
Persistent mild depression
71
When taking lithium, what precaution should the nurse give to Furina regarding sodium intake?
Maintain normal level of sodium
72
When should Furina have her lithium levels checked in the beginning of her treatment?
Once every three days
73
The nurse expects what potential electrolyte imbalance in a patient with Addison's Disease?
Hyperkalemia
74
The nurse educates the patient with Addison's Disease for lifelong therapy of?
mineralocorticoids
75
Priority health education for patients with adrenal insufficiency taking corticosteroids includes which of the following?
All of the above
76
All of the following are physical characteristics seen from a patient with Addison's disease, EXCEPT?
bipedal edema
77
A patient with an Addisonian crisis had undergone an ECG. Which of the following waves can be expected from a patient with Addison's Disease?
peaked T waves
78
The staff nurse is asking a student about the gland that is responsible for the secretion of corticosteroids in the human body. The student is correct when he/she answers:
adrenal cortex
79
The nurse expects which of the following findings in a patient with Cushing's Disease? 1. Hypotension 2. Hyperglycemia 3. Hypokalemia 4. Hypernatremia
2, 3, 4,
80
The following nursing diagnoses apply to a patient with Cushing's Disease, except?
Fluid Volume Deficit
81
Which additional assessment finding would lead the nurse to suspect that the client has Cushing's syndrome rather than obesity?
posterior neck fat pad and thin extremities
82
Which statement by the client indicates an understanding of the possible side effects of Prednisone therapy?
"I must take this medicine exactly as my doctor ordered it. I shouldn't skip doses."
83
There are 17 Sustainable Developmental Goals developed by the United Nations. Clean Water and Sanitation is under what number?
Six
84
A patient undergoes endotracheal intubation and positive pressure ventilation. The primary nursing responsibility of the nurse at this time is?
Assess the patient's response to the equipment
85
The primary responsibility of a community health nurse is:
Health teaching
86
You ensure the appropriateness and safety of your nursing interventions while caring for various client groups by:
making a thorough assessment of each client's needs and problems
87
Using Patricia Benner's stages of nursing expertise, you are an entry-level nurse. You will rank yourself as a/an?
Novice Nurse
88
The most appropriate nursing intervention to facilitate the client's acceptance of a change in body image would be to:
establish a therapeutic relationship
89
To provide safe, quality nursing care to various clients in any setting, the most important tool of the nurse is:
critical thinking to decide appropriate nursing actions
90
The Universal Health Care Act mandates the institutionalization of health technology assessment as a fair and transparent priority setting recommended to the DOH and PhilHealth. This act is also known as?
R.A. 11223
91
Policies and Standards for Bachelor of Science in Nursing Program are according to which of the following CHED memorandum order?
CMO No. 14 s. 2009
92
All of the following are included in the principles of Primary Health Care, except?
Accountability
93
Included in the elements of Primary Health Care is the Expanded Program on Immunization which requires infants/children to be administered with six-vaccine-preventable disease which includes all of the following, except?
Antirabies
94
Which of the following are considered as barangay health workers according to the Primary Health Care in the Philippines? 1. Health auxiliary volunteers 2. Traditional birth attendants 3. Public Health Nurse 4. Traditional Healers
1,2 and 4
95
Supply of essential drugs is also one of the elements of Primary Health Care, upon this, The Generics Act was established. This is under which Republic Act?
R. A. 6675
96
The 2 Core Principles of Primary Health Care are active partnership with the people and empowerment. Empowerment is to:
transfer knowledge, skills, and attitude
97
When planning care for a client diagnosed with Cushing's syndrome, the nurse would include which intervention to prevent a common complication of this disorder:
Monitoring glucose levels
98
The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. Which sign/symptom would the nurse observe with this electrolyte imbalance?
Cardiac dysrhythmias
99
A client receiving fludrocortisone acetate for the treatment of Addison's disease is monitored for what therapeutic response from this medication?
Promote electrolyte balance
100
A client is recently diagnosed with Cushing's Disease, and the nurse monitors the client for which manifestation most likely occurring with this diagnosis:
Mood Disturbances