1 NURSING PRACTICE I SET A ________________________________________________________________________ NURSING PRACTICE I Foundation of PROFESSIONAL Nursing Practice

GENERAL INSTRUCTIONS: 1 T!is test "oo#$et contains 1%% test &uestions ' Read INSTRUCTIONS TO E(A)INEES *rinted on +our ans,er s!eet - S!ade on$+ one .1/ "o0 for eac! &uestion on +our ans,er s!eets T,o or 1ore "o0es s!aded ,i$$ in2a$idate +our ans,er 3 A4OI5 ERASURES 6 T!is is PRC property. Unaut!ori7ed *ossession8 re*roduction8 and9or sa$e of t!is test is punishable by law. Per RA 898 .

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INSTRUCTIONS: 1 5etac! one .1/ ans,er s!eet fro1 t!e "otto1 of +our E0a1inee I59Ans,er S!eet Set ' :rite t!e su";ect tit$e !Nursin" Pra#ti#e I$ on t!e "o0 *ro2ided - S!ade Set <o0 =A> on +our ans,er s!eet if +our test "oo#$et is Set A? Set <o0 =<> if +our test "oo#$et is Set <

)ULTIPLE C@OICE
1 Nurse Su7ie is ad1inistering 1':%% P) 1edication in :ard 3 T,o *atients !a2e to recei2e Lano0in :!at s!ou$d Nurse Su7ie do ,!en one of t!e c$ients does NOT !a2e a reada"$e identification "andA A As# t!e c$ient if s!e is )rs Santos %. As& the #lient his na'e C As# t!e roo1 1ate if t!e c$ient is )rs Santos 5 Co1*are t!e I5 "and ,it! t!e "ed tag ' Li7ette8 a !ead nurse in a surgica$ unit8 !ears one of t!e staff nurses sa+ t!at s!e does not touc! an+ c$ient assigned to !er un$ess s!e *erfor1s nursing *rocedures or conducts *!+sica$ assess1ent To guide t!e staff nurse in t!e use of touc!8 ,!ic! of t!e fo$$o,ing ,ou$d "e <EST res*onse of Li7etteA A =Use touc! ,!en t!e situation ca$$s for it> %. !Tou#h ser(es as a #onne#tion between the nurse an) the patient$. C =Use touc! ,it! discretion> 5 =Touc! is used in *!+sica$ assess1ent> - Bou are as#ed to teac! t!e c$ient8 )r La*u78 ,!o !as rig!t sided ,ea#ness t!e use of a cane :!ic! o"ser2ation ,i$$ indicate t!at )r La*u7 is using t!e cane correct$+A A. The #ane an) one *oot or both *eet are on the *loor at all ti'es < @e ad2ances t!e cane fo$$o,ed "+ t!e $eft $eg C C$ient #ee*s t!e cane on t!e rig!t side a$ong t!e ,ea# $eg 5 C$ient $eans to t!e $eft side ,!ic! is stronger 3 George8 a 3- +ear o$d e0ecuti2e is sc!edu$ed for cardiac "+*ass surger+ :!i$e "eing *re*ared for t!e surger+8 !e sa+s to t!e nurse =I a1 not going to !a2e t!e surger+ I 1a+ die "ecause of t!e ris# > :!ic! res*onse "+ t!e nurse is 1ost a**ro*riateA A =:it!out t!e surger+ +ou ,i$$ 1ost $i#e$+ die sooner > < =T!ere are a$,a+s ris#s in2o$2ed ,it! surger+ > C =T!ere is a c$ient in t!e ot!er roo1 ,!o !ad successfu$ surger+ and +ou can ta$# to !i1 > +. !This 'ust be (ery *ri"htenin" *or you. Tel 'e how you *eel about the sur"ery.$

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6 A c$ient is ordered to ta#e Lasi08 a diuretic8 to "e ta#en ora$$+ dai$+ :!ic! of t!e fo$$o,ing is an a**ro*riate instruction "+ t!e nurseA

A Re*ort to t!e *!+sician t!e effects of t!e 1edication on urination %. Ta&e the 'e)i#ine early in the 'ornin" C Ta#e a fu$$ g$ass of ,ater ,it! t!e 1edicine 5 )easure fre&uenc+ of urination in '3 !ours C Nurse G$enda gets a ca$$ fro1 t!e neig!"or ,!o te$$s !er t!at !is - +ears o$d daug!ter !as "een 2o1iting and !as fe2er and as#s for ad2ice :!ic! of t!e fo$$o,ing is t!e 1ost a**ro*riate action of t!e nurseA A O"ser2e t!e c!i$d for an !our If t!e c!i$d does not i1*ro2e8 refer to t!e *!+sician in t!e neig!"or!ood %. Re#o''en) to brin" the #hil) i''e)iately to the hospital C Assess t!e c!i$d8 reco11end o"ser2ation and ad1inister aceta1ino*!en If s+1*to1s continue8 "ring to t!e !os*ita$ 5 Te$$ t!e neig!"or to o"ser2e t!e c!i$d and gi2e *$ent+ of f$uids If t!e c!i$d does not i1*ro2e8 "ring t!e c!i$d to t!e !os*ita$ D :i$fred8 -% +ears o$d 1a$e8 ,as "roug!t to t!e !os*ita$ due to in;uries sustained fro1 a 2e!icu$ar accident :!i$e "eing trans*orted to t!e (Era+ de*art1ent8 !e stra*s accidenta$$+ "ro#e and t!e c$ient fe$$ to t!e f$oor !itting to !is !ead In t!is situation8 t!e nurse is: A not res*onsi"$e "ecause of t!e doctrine of res*ondent su*erior < free fro1 an+ neg$igence t!at caused !ar1 to t!e *atient C. liable alon" with the e'ployer *or the use o* a )e*e#ti(e e,uip'ent that har's the #lient 5 tota$$+ res*onsi"$e for t!e neg$igence F :!i$e going on e2ening round8 Nurse Edna sa, )rs Pascua$ 1editating and after,ards started singing *ra+erfu$ !+1ns :!at is t!e <EST res*onse of EdnaA A Ignore t!e incidence < Re*ort t!e incidence to t!e !ead nurse C. Respe#t the #lient-s a#tions as this pro(i)es stru#ture an) support to the #lient 5 Ca$$ !er attention so s!e can go to s$ee* G A c$ient as#s for ad2ice on $o, c!o$estero$ food Bou ad2ise t!e c$ient to eat t!e fo$$o,ing: A C!ic#en $i2er8 co, $i2er8 eggs %. .ean bee* an) por&/ e"" ewhite/ *ish C <a$ut8 sa$ted eggs8 duc# and c!ic#en egg 5 Por# $ie1*o8 co, "rain8 $ungs and #idne+ 1% T!e code of et!ics for nurses !as an inter*retati2e state1ent t!at *ro2ides: A continuit+ of care for t!e i1*ro2e1ent of t!e c$ient %. "ui)e *or #arryin" out nursin" responsibilities that pro(i)e ,uality #are an) *or the ethi#al obli"ation o* the pro*ession C standards of care in carr+ing out nursing res*onsi"i$ities 5 identica$ care to a$$ c$ients in an+ setting 11 :!ic! of t!e fo$$o,ing situations ,ou$d *ossi"$+ cause a nurse to "e sued due to neg$igenceA A. Nurse "a(e a #lient wron" 'e)i#ation/ an) an hour later/ #lient #o'plaine) o* )yspnea < :!i$e *re*aring a 1edication8 t!e nurse notices t!at instead of 1 ta"$et8 s!e *ut t,o ta"$ets into t!e c$ientHs 1edicine cu* C As t!e nurse ,as a"out to ad1inister 1edication8 t!e c$ient &uestioned ,!+ t!e 1edication is sti$$ gi2en ,!en in fact t!e *!+sician discontinued it 5 Nurse ad1inistered ' ta"$ets of ana$gesic instead of 1 ta"$et as *rescri"ed Patient noticed t!e error and co1*$ained

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1' Bour nurse su*er2isor as#s +ou ,!o a1ong t!e fo$$o,ing c$ients is 1ost susce*ti"$e to getting infection if ad1itted to t!e !os*ita$A A 5ia"etic c$ient t+*e'

< C$ient ,it! c!ronic o"structi2e *u$1onar+ disease .COP5/ C. Client with se#on) )e"ree burns 5 C$ient ,it! *soriasis 1- )r C!ris )artine7 !as "een confined for t!ree da+s @is ,ife !e$*ed ta#e care of !i1 and !e !as o"ser2ed !er to "e =too in2o$2ed> in !is care @e co1*$ained to t!e !ead nurse a"out t!is :!ic! of t!e fo$$o,ing ,ou$d "e t!e <EST res*onse of t!e nurseA A =5onHt ,orr+ I ,i$$ ca$$ t!e attention of +our ,ife > < =Bour ,ife is ;ust tr+ing to !e$* "ecause s!e is ,orried a"out +ou > C. !0hat are your thou"hts about your wi*e-s in(ol(e'ent in your #are1$ 5 =Bour ,ife can assist +ou ,e$$ in +our care and reco2er+ > 13 T!e nurse is in t!e !os*ita$ canteen and !ears t,o staff nurses ta$#ing a"out t!e c$ient confined in Roo1 C1' T!e+ 1entioned !is na1e and discussed detai$s of !is condition :!ic! of t!e fo$$o,ing actions s!ou$d t!e nurse ta#eA A. Approa#h the two nurses an) tell the' that their a#tions are inappropriate espe#ially in a publi# pla#e < :ait ti$$ t!e nurses finis! t!e discussion and re*ort t!e situation to t!e su*er2isor C Sa+ not!ing to a2oid e1"arrassing t!e staff nurses 5 Re1ain &uiet and ignore t!e discussion 16 T!e son of )r Rosario8 a DC +ear o$d 1an8 re*orts to t!e nurse in t!e co11unit+ !ea$t! center t!at !is fat!er !as "een getting out of "ed at nig!t and ,a$#s around t!e !ouse in t!e ear$+ !ours of t!e 1orning causing !i1 to fa$$ and in;ure !i1se$f :!ic! instruction ,ou$d +ou gi2eA A A**$+ restraints during nig!t !ours on$+ < Ad2ise !os*ita$i7ation to *re2ent future accidents C Iee* a radio or T4 for co1*an+ and to orient t!e c$ient +. 2a(e so'eone #he#& on the #lient *re,uently at ni"ht SITUATI3NA. Situation Pre*aration and ad1inistration of 1edications is a nursing function t!at cannot "e de$egated It is i1*ortant t!at t!e nurse !as a dee* understanding of t!is res*onsi"i$it+ t!at is 1eant to sa2e *atientHs $i2es 1C Bou are to ad1inister an intra1uscu$ar in;ection to 5u$ce8 1 J +ear o$d gir$ T!e 1ost a**ro*riate site to ad1inister t!e drug is: A dorso g$utea$ region C. (astus lateralis < 2entra$ forear1 5 g$utea$ region 1D An infant is ordered to recei2e 6%%1$ of 56NSS for '3 !ours T!e intra2enous dri* is running at C% dro*s91inute @o, 1an+ dro*s *er 1inute s!ou$d t!e f$o, rate "eA A C% dro*s *er 1inute C -% dro*s *er 1inute < 4 )rops per 'inute 5 16 dro*s *er 1inute 1F Fo$$o,ing surger+8 @enr+ is to recei2e '% 1E& .1i$$ie&ui2a$ent/ of *otassiu1 c!$oride to "e added to 1%%% 1$ of 56: to run for F !ours T!e intra2enous infusion set is ca$i"rated at '% dro*s *er 1i$$i$iter @o, 1an+ dro*s *er 1inute s!ou$d t!e rate "e to infuse 1 $iter of 56: for F !oursA A 54 )rops C C% dro*s < '% dro*s 5 -' dro*s

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1G )r Lagro is to recei2e 1 $iter of 56LR to run for 1' !ours T!e dro* factor of t!e I4 infusion set is 1% dro*s *er 1inute A**ro0i1ate$+ !o, 1an+ dro* *er 1inutes s!ou$d t!e I4 "e regu$atedA A 67 5 )rops C 1%E1' dro*s < 1DE1F dro*s 5 16E1C dro*s '% T!e *!+sician ordered Ne1"uta$ Na gr (( T!e "ott$e contains 1%%1g9ca*su$e @o, 1an+ ca*su$e ,i$$ "e ad1inistered to t!e c$ientA A 1 ca*su$e C. 4 #apsule

< 1 J ca*su$e 5 J ca*su$e Situation 4 T!e nurse su*er2isor is o"ser2ing t!e staff nurses in !er !os*ita$ to see !o, &ua$it+ of care *ro2ided to c$ients can "e i1*ro2ed '1 T!e nurse su*er2isor is not satisfied ,it! t!e "ed "at! t!at is *ro2ided "+ Nurse Art!ur To i1*ro2e t!e care *ro2ided to t!e *atients in t!e unit "+ Nurse Art!ur8 t!e nurse su*er2isor s!ou$d: A te$$ t!e nurse !o, to gi2e "ed "at!s correct$+ < as# anot!er staff nurse to do "ed "at!s instead C *ro2ide a 1anua$ to "e read on gi2ing "ed "at!s +. brin" the sta** nurse to a #lient-s roo' an) )e'onstrate '' T!e staff nurse discusses ,it! t!e no2ice nurse t!e t+*e of ,ound dressing t!at is "est to use for a c$ient Toget!er8 t!e+ o"ser2e !o, ,e$$ t!e dressings a"sor" t!e drainage In ,!at ste* of t!e decision 1a#ing *rocess are t!e+A A Testin" options C 5efining t!e *ro"$e1 < Considering effects on resu$ts 5 )a#ing fina$ decisions '- To c!ec# if t!e nurses under !er su*er2ision use critica$ t!in#ing8 )rs 5a2id o"ser2es if t!e nurses act res*onsi"$+ ,!en at ,or# :!ic! of t!e fo$$o,ing actions of t!e nurse de1onstrates t!e attitude of res*onsi"i$it+A A T!in#ing of a$ternati2e 1et!ods of nursing care < S!aring ideas regarding *atient care C. 8ollowin" stan)ar)s o* pra#ti#e 5 P$anning ot!er a**roac!es for *atient care '3 T!e nurse ,!o 1a#es c$inica$ ;udg1ent can "e de*ended u*on to i1*ro2e t!e &ua$it+ of care of c$ients Nurse Ku$ie uses suc! good c$inica$ ;udg1ent ,!en s!e gi2es *riorit+ care to t!is c$ient: A Ro1an8 a c$ient ,!o is a1"u$ator+ and for surger+ to1orro, %. A post operati(e #lient/ Rey/ who has a bloo) pressure o* 99:;9 ''2" C )r A"ad8 a c$ient ,!o needs instructions for !o1e 1edications 5 Fred8 a c$ient ,!o recei2ed *ain 1edications 6 1inutes ago '6 A good nursing care *$an is de*endent on a correct$+ ,ritten nursing diagnosis It defines a c$ientHs *ro"$e1 and its *ossi"$e cause T!e fo$$o,ing is an e0a1*$e of a ,e$$ ,ritten nursing diagnosis: A Acute *ain re$ated to a$tered s#in integrit+ secondar+ to !+sterecto1+ < E$ectro$+te i1"a$ance re$ated to !+*oca$ce1ia C. Altere) nutrition relate) to hi"h *at inta&e se#on)ary to obesity 5 Ino,$edge deficit re$ated to *roctosig1oidosco*+ Situation 6 Bou are ta#ing care of )rs Le+"a8 CC +ears o$d8 ,!o is ter1ina$$+ i$$ ,it! o2arian cancer stage I4 'C :!en caring for a d+ing c$ient8 +ou ,i$$ *erfor1 ,!ic! of t!e fo$$o,ing acti2itiesA A Encourage t!e c$ient to reac! o*ti1a$ !ea$t! < Assist c$ient *erfor1 acti2ities of dai$+ $i2ing

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C. Assist the #lient towar)s a pea#e*ul )eath 5 )oti2ate c$ient to gain inde*endence 'D T!e c$ient *re*ares for !er e2entua$ deat! and discusses ,it! t!e nurse and !er fa1i$+ !o, s!e ,ou$d $i#e !er funera$ to $oo# $i#e and ,!at dress s!e ,i$$ use T!is c$ient is in t!e stage of: A a##eptan#e C denia$ < reso$ution 5 "argaining 'F T!e nurse is to ad1inister 5e1ero$ 6% 1g I) to )rs Le+"a 5e1ero$ is a2ai$a"$e in a 1utidose 2ia$ $a"e$$ed 1%% 1g91$ and 4istari$ co1es in an a1*u$e $a"e$$ed 6% 1g91$ Bou are to gi2e t!e "ot! 1edications in one in;ection Bou ,i$$: A. with)raw the 'e)i#ation *ro' the (ial *irst then *ro' the a'pule < in;ect air into t!e 2ia$8 t!en into t!e a1*u$e

C in;ect air into t!e a1*u$e8 as*irate t!e desired dose8 t!en into t!e 2ia$ 5 ,it!dra, 1edication fro1 t!e a1*u$e t!en fro1 t!e 2ia$ 'G :!en gi2ing 5e1ero$ 6% 1g fro1 a 1u$tidose 2ia$ $a"e$$ed 1%% 1g91$ and 4istari$ 6% 1g91$ fro1 an a1*u$e $a"e$$ed 6% 1g91$8 ,!at is t!e tota$ 2o$u1e t!at +ou ,i$$ in;ect to t!e c$ientA A ' 1$ C. .; 'l < 1 1$ 5 1 D6 1$ -% )rs Le+"a is e1aciated and is at ris# for de2e$o*ing ,!ic! *ro"$e1 in s#in integrit+A A <$isters C. Pressure sores < Reddening of t!e s#in 5 Pustu$es Situation 5 Bou are assigned to ,or# in an ort!o*edic ,ard ,!ere c$ients are e0*ected to !a2e *ro"$e1s in 1o"i$it+ and i11o"i$it+ -1 Ra1i$Hs rig!t $eg is in;ured and Nurse Iaren !as to 1o2e !i1 fro1 t!e "ed to , ,!ee$ c!air :!ic! of t!e fo$$o,ing is t!e a**ro*riate nursing action of Nurse IarenA A Put t!e c$ient on t!e edge of t!e "ed and *$ace t!e ,!ee$c!air at !er "ac# < Face t!e c$ient and *$ace t!e ,!ee$c!air on !er $eft side C Put t!e c$ient on t!e edge of t!e "ed and *$ace t!e ,!ee$c!air on t!e ot!er side of t!e "ed +. Put the #lient on the e)"e o* the be) an) pla#e the wheel#hair on the #lient-s le*t si)e -' Car$o !as to "e 1aintained on a dorsa$ recu1"ent *osition :!ic! of t!e fo$$o,ing s!ou$d "e *re2entedA A adduction of t!e s!ou$der < Latera$ f$e0ion of t!e sternoc$eido1astoid 1usc$e C. 2ypere<tension o* the &nees 5 Anterior f$e0ion of t!e $u1"ar cur2ature -- Kose*! *refers to "e in !ig! fo,$erHs *osition 1ost of t!e ti1e T!e nurse s!ou$d *re2ent ,!ic! of t!e fo$$o,ingA A. Posterior *le<ion o* the lu'bar #ur(ature < Interna$ rotation of t!e s!ou$der C E0terna$ rotation of t!e !i* 5 Adduction of t!e s!ou$der -3 Ant!on+ as#s to "e assisted to 1o2e u* t!e "ed :!ic! of t!e fo$$o,ing s!ou$d Nurse 5iana do firstA A )o2e t!e *atient to t!e edge of t!e "ed near t!e nurse %. A)=ust the be) to *lat position C Loc# t!e ,!ee$s of t!e "ed 5 Raise t!e "ed rai$s o**osite t!e nurse

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-6 :!ic! of t!e fo$$o,ing su**orti2e de2ices can "e used 1ost effecti2e$+ "+ Nurse Arno$d to *re2ent e0terna$ rotation of t!e rig!t $egA A San)ba"s C Pi$$o, < Fir1 1attress 5 @ig! foot "oard Situation ; > As +ou "egin to ,or# in t!e !os*ita$ ,!ere +ou are on *ro"ation8 +ou are tas#ed to ta#e care of a fe, *atients T!e c$ients !a2e 2aried needs and +ou are e0*ected to *ro2ide care for t!e1 -C An a1"u$ator+ c$ient )r Losi1o8 is "eing *re*ared for "ed :!ic! of t!e fo$$o,ing nursing actions *ro1ote safet+ for t!e c$ientA A Turning off t!e $ig!ts to *ro1ote rest and s$ee* < Instructing t!e c$ient a"out t!e use of ca$$ s+ste1 C. Raisin" the si)e rails 5 P$acing t!e "ed in !ig! *osition -D )i##a8 a '6 +ear o$d fe1a$e c$ient8 is ad1itted ,it! rig!t $o,er &uadrant a"do1ina$ *ain T!e *!+sician diagnosed t!e c$ient ,it! acute a**endicitis and an e1ergenc+ a**endecto1+ ,as

*erfor1ed T,e$2e !ours fo$$o,ing surger+8 t!e *atient co1*$ained of *ain :!ic! of t!e fo$$o,ing is t!e 1ost a**ro*riate nursing diagnosisA A I1*aired 1o"i$it+ re$ated to *ain secondar+ to an a"do1ina$ incision < I1*aired 1o2e1ents re$ated to *ain due to surger+ C I1*aired 1o"i$it+ re$ated to surger+ +. Se(ere pain relate) to sur"ery -F Bou are *re*aring a *$an of care for a c$ient ,!o is e0*eriencing *ain re$ated to incisiona$ s,e$$ing fo$$o,ing $a1inecto1+ :!ic! of t!e fo$$o,ing s!ou$d "e inc$uded in t!e nursing care *$anA A. En#oura"e the #lient to lo" roll when turnin" < Encourage t!e c$ient to do se$fEcare C Instruct t!e c$ient to do dee* "reat!ing e0ercises 5 A1"u$ate t!e c$ient in ,ard *re1ises e2er+ t,ent+ 1inutes -G )r Lo7ano8 6% +ear o$d e0ecuti2e8 is reco2ering fro1 se2ere 1+ocardia$ infarction For t!e *ast - da+s8 )r Lo7anoHs !+giene and groo1ing needs !a2e "een 1et "+ t!e nursing staff :!ic! of t!e fo$$o,ing acti2ities s!ou$d "e i1*$e1ented to ac!ie2e t!e goa$ of inde*endence for )r Lo7anoA A In2o$2ing fa1i$+ 1e1"ers in 1eeting c$ientHs *ersona$ needs < )eeting !is needs ti$$ !e is read+ to *erfor1 se$fEcare C Pre*aring a da+ to da+ acti2it+ $ist to "e fo$$o,ed "+ c$ient +. In(ol(in" ?r. .o@ano in his #are 3% )r Ernest Lo*e7 is ter1ina$$+ i$$ and !e c!oose to "e at !o1e ,it! !is fa1i$+ :!at nursing action are "est initiated to *re*are t!e fa1i$+ of )r Lo*e7A A Ta$# ,it! t!e fa1i$+ 1e1"ers a"out t!e ad2antage of sta+ing in t!e !os*ita$ for *ro*er care %. Pro(i)e support to the *a'ily 'e'bers by tea#hin" ways to #are *or their lo(e) one C Con2ince t!e c$ient to sta+ in t!e !os*ita$ for *rofessiona$ care 5 Te$$ t!e c$ient to "e ,it! !is fa1i$+ Situation A > )+rna8 a researc!er8 *ro*oses a stud+ on t!e re$ations!i* "et,een !ea$t! 2a$ues and t!e !ea$t! *ro1otion acti2ities of staff nurses in a se$ected co$$ege of nursing

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31 In "ot! &uantitati2e and &ua$itati2e researc!8 t!e used of a fra1e of reference is re&uired :!ic! of t!e fo$$o,ing ite1s ser2es as t!e *ur*ose of a fra1e,or#A A Incor*orates t!eories into nursingHs "od+ of #no,$edge %. 3r"ani@es the )e(elop'ent o* stu)y an) lin&s the *in)in"s to nursin"-s bo)y o* &nowle)"e C Pro2ides $ogica$ structure of t!e researc! findings 5 Identifies conce*ts and re$ations!i*s "et,een conce*ts 3' )+rna need to re2ie, re$e2ant $iterature and studies T!e fo$$o,ing *rocesses are underta#en in re2ie,ing $iterature E(CEPT: A $ocating and identif+ing resources C. #lari*yin" a resear#h topi# < reading and recording notes 5 using t!e $i"rar+ 3- T!e *ri1ar+ *ur*ose for re2ie,ing $iterature is to: A organi7e 1ateria$s re$ated to t!e *ro"$e1 of interest < generate "road "ac#ground and understanding of infor1ation re$ated to t!e researc! *ro"$e1 of interest C se$ect to*ics re$ated to t!e *ro"$e1 of interest +. "ather #urrent &nowle)"e o* the proble' o* interest 33 In for1u$ating t!e researc! !+*ot!eses8 researc!er )+rna s!ou$d state t!e researc! &uestion as: A :!at is t!e res*onse of t!e staff nurses to t!e !ea$t! 2a$uesA

< @o, is 2aria"$e =!ea$t! 2a$ue> *ercei2ed in a *o*u$ationA C. Is there a si"ni*i#ant relationship between health (alues an) health pro'otion a#ti(ities o* the sta** nurses1 5 @o, do !ea$t! 2a$ues affect !ea$t! *ro1otion acti2ities of t!e staff nursesA 36 T!e *ro*osed stud+ s!o,s t!e re$ations!i* "et,een t!e 2aria"$es :!ic! of t!e fo$$o,ing is t!e inde*endent 2aria"$eA A Staff nurses in a se$ected co$$ege of nursing %. 2ealth (alues C @ea$t! *ro1otion acti2ities 5 Re$ations!i* "et,een !ea$t! 2a$ues and !ea$t! *ro1otion acti2ities Situation B > :!i$e ,or#ing in a tertiar+ !os*ita$8 +ou are assigned to t!e 1edica$ ,ard 3C Bour c$ient8 )r 5ia78 is concerned t!at !e can not *a+ !is !os*ita$ "i$$s and *rofessiona$ fees Bou refer !i1 to a: A Nurse su*er2isor C "oo##ee*ing de*art1ent < So#ial wor&er 5 *!+sician 3D )r )agno !as $ung cancer and is going t!roug! c!e1ot!era*+ @e is referred "+ t!e onco$og+ nurse to a se$fE!e$* grou* of c$ients ,it! cancer to: A re#ei(e e'otional support C *ro2ide financia$ assistance < to "e a *art of a researc! stud+ 5 assist ,it! c!e1ot!era*+ 3F A dia"etic !+*ertensi2e c$ient8 )rs Linao8 needs a c!ange in diet to i1*ro2e !er !ea$t! status S!e s!ou$d "e referred to a: A nutritionist C *!+sician < dietitian 5 1edica$ *at!o$ogist 3G :!en co$$a"orating ,it! ot!er !ea$t! tea1 1e1"ers8 t!e "est descri*tion of Nurse RitaHs ro$e is: A encourages t!e c$ientHs in2o$2e1ent in !is care < s!ares and i1*$e1ents orders of t!e !ea$t! tea1 to ensure &ua$it+ care

8
C. she listens to the in)i(i)ual (iews o* the tea' 'e'bers 5 !e$*s c$ient set goa$s of care and disc!arge 6% Nurse Rita is successfu$ in co$$a"orating ,it! !ea$t! tea1 1e1"ers a"out t!e care of )r Linao T!is is "ecause s!e !as t!e fo$$o,ing co1*etencies: A. Co''uni#ation/ trust/ an) )e#ision 'a&in" < Conf$ict 1anage1ent8 trust8 negotiation C Negotiation8 decision 1a#ing 5 )utua$ res*ect8 negotiation and trust Situation 8 > T!e *ractice of nursing goes ,it! res*onsi"i$ities and accounta"i$it+ ,!et!er +ou ,or# in a !os*ita$ or in t!e co11unit+ setting +ou 1ain o";ecti2e is to *ro2ide safe nursing to +our c$ientsA 61 To *ro2ide safe8 &ua$it+ nursing care to 2arious c$ients in an+ setting8 t!e 1ost i1*ortant too$ of t!e nurse is: A. #riti#al thin&in" to )e#i)e appropriate nursin" a#tions < understanding of 2arious nursing diagnoses C o"ser2ation s#i$$s for data co$$ection 5 *ossession of in scientific #no,$edge a"out c$ient needs 6' Bou ensure t!e a**ro*riateness and safet+ of +our nursing inter2entions ,!i$e caring for 2arious c$ient grou*s "+: A creating *$ans of care for *articu$ar c$iente$e < identif+ing t!e correct nursing diagnoses for c$ients C. 'a&in" a thorou"h assess'ent o* #lient nee)s an) proble's 5 using standards of nursing care as +our criteria for e2a$uation 6- T!e effecti2eness of +our nursing care *$an for +our c$ients is deter1ined "+ A t!e nu1"er of nursing *rocedures *erfor1ed to co1fort t!e c$ient

< t!e a1ount of 1edications ad1inistered to t!e c$ient as ordered C t!e nu1"er of ti1es t!e c$ient ca$$s t!e nurse +. the out#o'e o* nursin" inter(entions base) on plan o* #are 63 Bou are assigned to )rs A1ado8 age 3G8 ,!o ,as ad1itted for *ossi"$e surge+ S!e co1*$ained of recurrent *ain at t!e rig!t u**er &uadrant of t!e a"do1en 1E' !ours after ingestion of fatt+ food S!e a$so !ad fre&uent "outs of di77iness8 "$ood *ressure of 1D%91%%8 !ot f$as!es :!ic! of t!e a"o2e s+1*to1s ,ou$d "e an o";ecti2e cueA A. %loo) pressure 'easure'ent o* B9: 99 < Co1*$aint of !ot f$as!es C Re*ort of *ain after ingestion of fatt+ food 5 Co1*$aint of fre&uent "outs of di77iness 66 :!i$e ta$#ing ,it! )rs A1ado8 it is 1ost i1*ortant for t!e nurse to: A sc!edu$e t!e $a"orator+ e0a1s ordered for !er %. )o an assess'ent o* the #lient to )eter'ine priority nee)s C te$$ t!e c$ient t!at +our s!ift ends after eig!t !ours 5 !a2e t!e c$ient sign an infor1ed consent Situation 9 > Ora$ care is an i1*ortant *art of !+gienic *ractices and *ro1oting c$ient co1fort 6C An e$der$+ c$ient8 F3 +ears o$d8 is unconscious Assess1ent of t!e 1out! re2ea$s e0cessi2e dr+ness and *resence of sores :!ic! of t!e fo$$o,ing is <EST to use for ora$ careA A $e1on g$+cerine C )inera$ oi$ < !+drogen *ero0ide +. Nor'al saline solution

9
6D :!en *erfor1ing ora$ care to an unconscious c$ient8 ,!ic! of t!e fo$$o,ing is a s*ecia$ consideration to *re2ent as*iration of f$uids into t!e $ungsA A. Put the #lient on a si)elyin" position with hea) o* be) lowere) < Iee* t!e c$ient dr+ "+ *$acing to,e$ under t!e c!in C :as! !ands and o"ser2e a**ro*riate infection contro$ 5 C$ean 1out! ,it! ora$ s,a"s in a carefu$ and an order$+ *rogression 6F T!e ad2antages of ora$ care for a c$ient inc$ude a$$ of t!e fo$$o,ing8 E(CEPT: A decreases "acteria in t!e 1out! and teet! %. re)u#es nee) to use #o''er#ial 'outhwash whi#h irritate the bu##al 'u#osa C i1*ro2es c$ientHs a**earance and se$fEconfidence 5 i1*ro2es a**etite and taste of food 6G A *ossi"$e *ro"$e1 ,!i$e *ro2iding ora$ care to unconscious c$ients is t!e ris# of f$uid as*iration to $ungs T!is can "e a2oided "+: A C$eaning teet! and 1out! ,it! cotton s,a"s soa#ed ,it! 1out!,as! to a2oid rinsing t!e "ucca$ ca2it+ < s,a""ing t!e inside of t!e c!ee#s and $i*s8 tongue and gu1s ,it! dr+ cotton s,a"s C use fingers ,ra**ed ,it! ,et cotton ,as!c$ot! to ru" inside t!e c!ee#s8 tongue8 $i*s and u1s +. su#tionin" as nee)e) while #leanin" the bu##al #a(ity C% Bour c$ient !as difficu$t+ of "reat!ing and is 1out! "reat!ing 1ost of t!e ti1e T!is causes dr+ness of t!e 1out! ,it! un*$easant odor Ora$ !+giene is reco11ended for t!e c$ient and in addition8 +ou ,i$$ #ee* t!e 1out! 1oistened "+ using: A sa$t so$ution C. petroleu' =elly < ,ater 5 1ent!o$ated oint1ent Situation 9 > Errors ,!i$e *ro2iding nursing care to *atients 1ust "e a2oided and 1ini1i7ed at a$$ ti1e Effecti2e 1anage1ent of a2ai$a"$e resources ena"$es t!e nurse to *ro2ide safe8 &ua$it+ *atient care C1 In t!e !os*ita$ ,!ere +ou ,or#8 increased incidence of 1edication error ,as identified as t!e nu1"er one *ro"$e1 in t!e unit 5uring t!e "rainstor1ing session of t!e nursing ser2ice

de*art1ent8 *ro"a"$e causes ,ere identified :!ic! of t!e fo$$o,ing is *rocess re$atedA A interru*tions C $ac# of #no,$edge < use of unofficia$ a""re2iations +. *ailure to i)enti*y #lient C' )isco11unication of drug orders ,as identified as a *ro"a"$e cause of 1edication errors :!ic! of t!e fo$$o,ing is safe 1edication *ractice re$ated to t!isA A )aintain 1edication in its unit dose *ac#age unti$ *oint of actua$ ad1inistration < Note "ot! generic and "rand na1e of t!e 1edication in t!e )edication Ad1inistration )et!od C. 3nly o**i#ially appro(e) abbre(iations 'aybe use) in pres#ription or)ers 5 Encourage c$ients to as# &uestion a"out t!eir 1edications C- T!e !os*ita$ !as an ongoing &ua$it+ assurance *rogra1 :!ic! of t!e fo$$o,ing indicates i1*$e1entation of *rocess standardsA A. The nurses #he#& #lient-s i)enti*i#ation ban) be*ore "i(in" 'e)i#ations < T!e nurse re*orts ad2erse reaction to drugs C A2erage ,aiting ti1e for 1edication ad1inistration is 1easured 5 T!e unit !as ,e$$ 2enti$ated 1edication roo1

10
C3 :!ic! of t!e fo$$o,ing actions indicate t!at Nurse Kero1e is *erfor1ing outco1e e2a$uation of &ua$it+ careA A. Inter(iews nurses *or #o''ents re"ar)in" sta**in" < )easures ,aiting ti1e for c$ientHs *er nurseHs ca$$ C C!ec#s e&ui*1ent for its ca$i"ration sc!edu$e 5 5eter1ines ,!et!er nurses *erfor1 s#in assess1ent e2er+ s!ift C6 An order for a c$ient ,as gi2en and t!e nurse in c!arge of t!e c$ient re*orts t!at s!e !as no e0*erience of doing t!e *rocedure "efore :!ic! of t!e fo$$o,ing is t!e 1ost a**ro*riate action of t!e nurse su*er2isorA A Assign anot!er nurse to *erfor1 t!e *rocedure < As# t!e nurse to find ,a+ to $earn t!e *rocedure C Te$$ t!e nurse to read t!e *rocedure 1anua$ +. +o the pro#e)ure with the nurse Situation > )r KoseHs c!art is t!e *er1anent $ega$ recording of a$$ infor1ation t!at re$ates to !is !ea$t! care 1anage1ent As suc!8 t!e entries in t!e c!art 1ust !a2e accurate data CC )r KoseHs c!art contains a$$ infor1ation a"out !is !ea$t! care T!e functions of records inc$ude a$$ e0ce*t: A 1eans of co11unication t!at !ea$t! tea1 1e1"ers use to co11unicate t!eir contri"utions to t!e c$ientHs !ea$t! care < t!e c$ientHs record a$so s!o,s a docu1ent of !o, 1uc! !ea$t! care agencies ,i$$ "e rei1"ursed for t!eir ser2ices C educationa$ resource for student of nursing and 1edicine +. re#or)in" o* a#tions in a)(an#e to sa(e ti'e CD An ad2antage of auto1ated or co1*uteri7ed c$ient care s+ste1 is: A T!e nursing diagnoses for a c$ientHs data can "e accurate$+ deter1ined < Cost of confine1ent ,i$$ "e reduced C. In*or'ation #on#ernin" the #lient #an b easily up)ate) 5 T!e nu1"er of *eo*$e to ta#e care of t!e c$ient ,i$$ "e reduced CF Infor1ation in t!e *atientHs c!art is inad1issi"$e in court as e2idence ,!en: A T!e c$ientHs fa1i$+ refuses to !a2e it used %. The #lient ob=e#ts to its use C T!e !and,riting is not $egi"$e 5 It !as too 1an+ a""re2iations t!at are =unofficia$> CG Nursing audit ai1s to: A *ro2ide researc! data to !os*ita$ *ersonne$

< stud+ c$ientHs i$$ness and treat1ent regi1en c$ose$+ C. #o'pare a#tual nursin" )one to establishe) stan)ar)s 5 *ro2ide infor1ation to !ea$t!Ecare *ro2iders D% A te$e*!one order is gi2en for a c$ient in +our ,ard :!at is +our 1ost a**ro*riate actionA A Co*+ t!e order on to t!e c!art and sign t!e *!+sicianHs na1e as c$ose to !is origina$ signature as *ossi"$e %. Repeat the or)er ba#& to the physi#ian/ #opy onto the or)er sheet an) in)i#ate that it is a telephone or)er C :rite t!e order in t!e c$ientHs c!art and !a2e t!e !ead nurse coEsign it 5 Te$$ t!e *!+sician t!at +ou can not ta#e t!e order "ut +ou ,i$$ ca$$ t!e nurse su*er2isor

11
Situation 4 > Nurse Ro&ue8 a ne,$+ !ired nurse8 is as#ed to ta#e o2er an a"sent nurse in anot!er unit S!e ,i$$ ta#e care of c$ients ,it! 2arious conditions D1 :!ic! of t!e fo$$o,ing c$ient conditions s!ou$d "e )iss Ro&ueHs *riorit+ in t!e *ediatric unitA A T!e "a"+ ,!ose fantane$$e is "u$ging and fir1 ,!i$e as$ee* %. The in*ant who is brou"ht in *or upper respiratory tra#t in*e#tion whose te'perature is sli"htly ele(ate) C A "a"+ ,!o is ,ai$ing after "eing a,a#ened "+ t!e "anging door 5 A "a"+ "o+ ,!ose circu1cision !as +e$$o,is! e0udate D' :!en suctioning t!e endotrac!ea$ tu"e8 t!e nurse s!ou$d: A E0*$ain *rocedure to *atient? insert cat!eter gent$+ a**$+ing suction :it!dra,n using t,isting 1otion %. Insert #atheter until resistan#e is 'et/ then with)raw sli"htly/ applyin" su#tion inter'ittently as #atheter is with)rawn C @+*ero0+genate c$ient insert cat!eter using "ac# and fort! 1otion 5 Insert suction cat!eter four inc!es into t!e tu"e8 suction -% seconds using t,ir$ing 1otion as cat!eter is ,it!dra,n D- Nurse Ro&ue is gi2ing instructions to 5oris8 t!e daug!ter of a co1atose *atient8 to gi2e a s*onge "at! :!i$e 5oris is doing s*one "at!8 ,!at action of 5oris needs correctionA A Ans,ering t!e *!one ,!i$e ,earing g$o2es used for s*onge "at! < Ro$$ing t!e *atient $i#e a $og to do "ac# ru" C. .inin" the rubber 'at with be) sheet as in#ontinen#e pa) *or the patient 5 Turning t!e *atient on t!e $eft side ,it! !ead s$ig!t$+ e$e2ated D3 5ina sustained a fracture of t!e u$na and a cast ,i$$ "e a**$ied :!at nursing action "efore cast a**$ication is 1ost i1*ortant for Nurse Ro&ue to doA A Use "a"+ *o,der to reduce irritation under t!e cast < Assess sensation of eac! ar1 C. E(aluate s&in te'perature in the area 5 C!ec# radia$ *u$ses "i$atera$$+ and co1*are D6 To o"tain s*eci1en for s*utu1 cu$ture and sensiti2it+8 ,!ic! of t!e fo$$o,ing instruction is "estA A. Upon wa&in" up/ #ou"h )eeply an) e<pe#torate into #ontainer < Coug! after *ursed $i* "reat!ing C Sa2e s*utu1 for t,o da+s in co2ered container 5 After res*irator+ treat1ent8 e0*ectorate into a container Situation 6 > Infections are &uite co11on$+ t!e reasons for a c$ientHs !os*ita$i7ation A**ro*riate inter*retation of diagnostic tests and 1easures for infection contro$ are !e$*fu$ in t!e 1anage1ent of *atient care DC 5orot!+ under,ent diagnostic test and t!e resu$t of t!e "$ood e0a1ination are "ac# On re2ie,ing t!e resu$t t!e nurse notices ,!ic! of t!e fo$$o,ing as a"nor1a$ findingA A Neutro*!i$s C%M < :!ite "$ood ce$$s .:<C/ G%%%911

C. Erythro#yte se)i'entation rate CESRD is 69 '':hr 5 Iron D6 1g91%% 1$ DD Surgica$ se*sis is o"ser2ed ,!en: A. insertin" an intra(enous #atheter < dis*osing of s+ringes and need$es in *uncture *roof containers C ,as!ing !ands "efore c!anging ,ound dressing 5 *$acing dirt+ soi$ed $inen in 1oisture resistant "ags

12
DF A c$ient ,it! 2ira$ infection ,i$$ 1ost $i#e$+ 1anifest ,!ic! of t!e fo$$o,ing during t!e i$$ness stage of t!e infectionA A C$ient ,as e0*osed to t!e infection ' da+s ago "ut ,it!out an+ s+1*to1s %. 3ral te'perature shows *e(er C Acute s+1*to1s are no $onger 2isi"$e 5 C$ient =fee$s sic#> "ut can do nor1a$ acti2ities DG :!ic! of t!e fo$$o,ing $a"orator+ test resu$t indicate *resence of an infectious *rocessA A Er+t!roc+te sedi1entation rate .ESR/ 1' 119!r %. 0hite bloo) #ells C0%CD 8/999:''6 C Iron G% g91%%1$ 5 Neutro*!i$s CDM F% A1ong t!e c$ients +ou are assigned to ta#e care of8 ,!o is t!e 1ost susce*ti"$e to infectionA A 5ia"etic c$ient C c$ient ,it! *u$1onar+ e1*!+se1a < Client with burns 5 c$ient ,it! 1+ocardia$ infarction Situation 5 > Bou are a ne,$+ !ired nurse in a tertiar+ !os*ita$ Bou !a2e finis!ed +our orientation *rogra1 recent$+ and +ou are "eginning to assi1i$ate t!e cu$ture of t!e *rofession F1 Using <ennerHs stages of nursing e0*ertise8 +ou are a "eginning nurse *ractitioner Bou ,i$$ ran# +ourse$f as a9an: A co1*etent nurse C *roficient nurse %. no(i#e nurse 5 ad2anced "eginner F' <ennerHs =Proficient> nurse $e2e$ is different fro1 t!e ot!er $e2e$s in nursing e0*ertise in t!e conte0t of !a2ing: A t!e a"i$it+ to organi7e and *$an acti2ities < !a2ing attained an ad2anced $e2e$ of education C. a holisti# un)erstan)in" an) per#eption o* the #lient 5 intuiti2e and ana$+tic a"i$it+ in ne, situations F- As +ou "eco1e socia$i7ed into t!e nursing =cu$ture> +ou "eco1e a *atient ad2ocate Ad2ocac+ is e0*$ained "+ t!e fo$$o,ing E(CEPT: A res*ecting a *ersonHs rig!t to "e autono1ous %. )e'onstratin" loyalty to the institution-s ri"hts C s!ared res*ect8 trust and co$$a"oration in 1eeting !ea$t! needs 5 *rotecting and su**orting anot!er *ersonHs rig!ts F3 )odern da+ nursing !as $ed to t!e $ed de2e$o*1ent of t!e e0*anded ro$e of t!e nurse as seen in t!e function of a: A Clini#al nurse spe#ialist C co11unit+ !ea$t! nurse < Critica$ care nurse 5 staff nurse F6 Bou ;oin a continuing education *rogra1 to !e$* +ou: A Earn credits for $icense rene,a$ < Get in touc! ,it! co$$eagues in nursing C En!ance +our "asic #no,$edge +. Up)ate your &nowle)"e an) s&ills relate) to *iel) o* interest

13
Situation ; > :!en creating +our $esson *$an for cere"ro2ascu$ar disease or STROIE It is i1*ortant to inc$ude t!e ris# factors of stro#e

FC T!e 1ost i1*ortant ris# factor is: A Cigarette s1o#ing C "inge drin#ing < 2ypertension 5 !eredit+ FD Part of +our $esson *$an is to ta$# a"out etio$og+ or cause of stro#e T!e t+*es of stro#e "ased on cause are t!e fo$$o,ing E(CEPT: A E1"o$ic stro#e C. )iabeti# stro&e < @e1orr!agic stro#e 5 t!ro1"otic stro#e FF @e11or!agic stro#e occurs sudden$+ usua$$+ ,!en t!e *erson is acti2e A$$ are causes of !e1orr!age8 E(CEPT: A phlebitis C da1age to "$ood 2esse$ < trau1a 5 aneur+s1 FG T!e nurse e1*!asi7es t!at intra2enous drug a"use carries a !ig! ris# of stro#e :!ic! drug is c$ose$+ $in#ed to t!isA A A1*!eta1ines C s!a"u < Co#aine 5 5e1ero$ G% A *artici*ant in t!e STROIE c$ass as#s ,!at is a ris# factor of stro#e Bour "est res*onse is: A. !?ore re) bloo) #ells thi#&en bloo) an) 'a&e #lots 'ore possible.$ < =Increased R<C count is $in#ed to !ig! c!o$estero$ > C =)ore red "$ood ce$$ increases !e1og$o"in content > 5 =@ig! R<C count increases "$ood *ressure > Situation A > Accurate co1*utation *rior to drug ad1inistration is a "asic s#i$$ a$$ nurses 1ust !a2e G1 Rudo$f is diagnosed ,it! a1oe"iasis and is to recei2ed )etronida7o$e .F$ag+$/ ta"$ets 1 6 g1 dai$+ in - di2ided doses for D consecuti2e da+s :!ic! of t!e fo$$o,ing is t!e correct dose of t!e drug t!at t!e c$ient ,i$$ recei2ed *er ora$ ad1inistrationA A 18%%% 1g tid C 186%% 1g tid < ;99 '" ti) 5 6% 1g tid G' R!ona8 a ' +ear o$d fe1a$e ,as *rescri"ed to recei2e C' 6 1g sus*ension t!ree ti1es a da+ T!e a2ai$a"$e dose is 1'6 1g91$ ,!ic! of t!e fo$$o,ing s!ou$d Nurse Pao$o *re*are for eac! ora$ doseA A 9.; 'l C ' 6 1$ < 1 6 1$ 5 1% 1$ G- T!e *!+sician ordered Potassiu1 C!$oride .ICL/ in 56: 1 $iter to "e infused in '3 !ours for )rs Go1e7 Since Potassiu1 C!$oride is a !ig! ris# drug8 Nurse Ro"ert used an intra2enous *u1* :!ic! of t!e fo$$o,ing s!ou$d Nurse Ro"ert do to safe$+ ad1inister t!is drugA A. Che#& the pu'p settin" e(ery 4 hours < Teac! t!e c$ient !o, t!e infusion *u1* o*erates C @a2e anot!er nurse c!ec# t!e infusion *u1* setting 5 Set t!e a$ar1 of t!e *u1* $oud enoug! to "e !eard G3 <a"+ Li7a8 - 1ont!s o$d8 ,it! a congenita$ !eart defor1it+8 !as an order fro1 !er *!+sician: =gi2e - %% cc of Lano0in toda+ for 1 dose on$+> :!ic! of t!e fo$$o,ing is t!e 1ost a**ro*riate action "+ t!e nurseA A. Clari*y or)er with the atten)in" physi#ian < 5iscuss t!e order ,it! t!e *ediatric !eart s*ecia$ist in t!e unit

14
C Ad1inister Lano0in intra2enous$+ as it is t!e usua$ route of ad1inistration 5 Refer to t!e 1edication ad1inistration record for *re2ious ad1inistration of Lano0in G6 :!en Nurse Nor1a ,as a"out to ad1inister t!e 1edications of c$ient Lennie8 t!e re$ati2e of Lennie to$d t!e nurse t!at t!e+ "u+ !er 1edicines and s!o,ed t!e container of 1edications of t!e c$ient :!ic! of t!e fo$$o,ing is t!e 1ost a**ro*riate action "+ t!e nurseA A @o$d t!e nurse ad1inistration of t!e c$ientHs 1edication and refer to t!e !ead nurse < Put aside t!e 1edications s!e *re*ared and instead ad1inister t!e c$ientHs 1edications

C. Tell the #lient that she will in*or' the physi#ian about this 5 <ring t!e 1edications of t!e c$ient to t!e nurseHs station and *re*are according$+ Situation B > Bou are ta#ing care of )rs Santi$$an a 3F +ear o$d ,o1an ,!o is unconscious after a cere"ro2ascu$ar accident Bou are a,are t!at t!ere are 1an+ *!+sica$ co1*$ications due to i11o"i$it+ GC Bou s!ou$d "e a$ert for t!e fo$$o,ing co1*$ications s!e 1a+ e0*erience E(CEPT: A I'paire) 'obility C !+*ostatic *neu1onia < Contractures and 1usc$e atro*!+ 5 *ressure sores GD Pro*er *ositioning of an i11o"i$i7ed unconsciousness c$ient is i1*ortant for t!e fo$$o,ing reasons E(CEPT: A )aintain s#in integrit+ < Pro1otes o*ti1a$ $ung e0*ansion C Pre2ent in;uries and defor1ities of t!e 1uscu$oEs#e$eta$ s+ste1 +. 8a#ilitates rest an) sleep GF :!en *ositioning +our c$ient8 +ou s!ou$d o"ser2e good "od+ 1ec!anics for +ourse$f and t!e c$ient T!is 1eans t!at t!e nurse: A Uses "ac# 1usc$es %. Assu'es #orre#t bo)y ali"n'ent an) e**i#ient use o* 'us#les to a(oi) in=ury C O"ser2es r!+t!1ic 1o2e1ents ,!en 1o2ing a"out 5 Uses $arge 1usc$es on$+ GG Bou are going to 1o2e )rs Santi$$an8 a 16% $"s unconscious ,o1an So1e *rinci*$s to use ,!en 1o2ing t!e c$ient inc$ude t!e fo$$o,ing E(CEPT: A *re*are to 1o2e c$ient "+ ta#ing dee* "reat! and tig!tening a"do1ina$ and g$utea$ 1usc$es < 1aintain ,ide "ase of su**ort ,it! feet and ,it! #nees f$e0ed C *us! and *u$$ using ar1s and $egs instead of $ifting +. 'o(e #lose to the ob=e#t to be 'o(e) leanin" or ben)in" at the waist 1%% After 1o2ing )rs Santi$$an to t!e desired *osition8 ,!ic! action ,i$$ +ou a2oidA A A2oid friction "et,een "on+ *ro1inences < P$ace *i$$o,s to *osition c$ientHs e0tre1eties C. Apply restraints 5 Raise "ed rai$s

SU%?IT T2IS TEST %33E.ET T3GET2ER 0IT2 T2E ANS0ER S2EET T3 F3UR 0ATC2ERS. %RINGING T2E TEST %33E.ET 3UT 38 T2E R33? 0I.. %E A GR3UN+ 83R CANCE..ATI3N 38 F3UR EGA?INATI3N. NNNEN5NNN 15 NURSING PRACTICE II SET A _________________________________________________________________ NURSING PRACTICE II Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS: C T!is test "oo#$et contains 1%% test &uestions D Read INSTRUCTIONS TO E(A)INEES *rinted on +our ans,er s!eet F S!ade on$+ one .1/ "o0 for eac! &uestion on +our ans,er s!eets T,o or 1ore "o0es s!aded ,i$$ in2a$idate +our ans,er G A4OI5 ERASURES 1% T!is is PRC property. Unaut!ori7ed *ossession8 re*roduction8 and9or sa$e of t!is test is punishable by law. Per RA 898 .

_________________________________________________________________
INSTRUCTIONS: 3 5etac! one .1/ ans,er s!eet fro1 t!e "otto1 of +our E0a1inee I59Ans,er S!eet Set 6 :rite t!e su";ect tit$e !Nursin" Pra#ti#e II$ on t!e "o0 *ro2ided

C S!ade Set <o0 =A> on +our ans,er s!eet if +our test "oo#$et is Set A? Set <o0 =<> if +our test "oo#$et is Set < )ULTIPLE C@OICE 1 Registered nurses can "e identified as a: A Organi7ation C grou* %. Cu$ture +. sub#ulture ' A1ong c!i$dren candidates for organ trans*$ant8 ,!en a$$ se$ected c!i$dren !a2e a**ro*riate tissue 1atc!es for t!e sa1e donated organ8 t!e "asis for t!e decision as to ,!ic! c!i$d gets t!e organ is gi2en to t!e c!i$d ,!o: A ,i$$ recei2e t!e 1ost "enefit fro1 t!e ne, organ < is 1ost $i#e$+ to die ,it!out t!e trans*$ant C is se$ected "+ t!e $otter+ s+ste1 for a2ai$a"$e organs +. is at the top o* the list an) has waite) the lon"est ti'e - T!e nurse uses ,!at e&ui*1ent to c!ec# for f$uid "et,een t!e *arieta$ and 2iscera$ $a+ers of t!e tunica 2agina$is8 t!e outer1ost co2ering of t!e testesA A -% cc s+ringe C F$uid 1eter < transillu'inator 5 )ano1eter 3 :!ic! of t!e fo$$o,ing e0a1*$es "est defines t!e ter1 ro$e re2ersa$A A a $a7+ *erson "eco1es 2er+ *roducti2e in t!e fa1i$+ < t!e good c!i$d ta#es on a "ad c!i$d ro$e C a *erson ,!o !as "een a good *ro2ider &uits !is or !er ;o" +. the #hil) assu'es a #are"i(er role towar) the #are"i(er 6 :!en a nurse "reac!es t!e dut+ of confidentia$it+8 !e or s!e can "e disci*$ined "+ "ot! t!e e1*$o+er and t!e <oard of Nursing In addition to t!is disci*$ine8 !e or s!e can: A. be hel) responsible *or any )a'a"es that result < "e fined "+ t!e federa$ go2ern1ent C "e sentenced for u* to 1 +ear in ;ai$ 5 i11ediate$+ $ose !is or !er nursing $icense C A strateg+ for a c!ange t!at focuses on teac!ing ,or#ers ne, tec!no$og+ is:

16
A nor'ati(e7rea#ti(e C *ro2iding infor1ation < training 5 *o,er coerci2e D T!e nurse #no,s t!at t!e occurrence of s!ou$der d+stocia during $a"or is: A *o$+!+dra1nios C *reter1 "irt! < 1aterna$ age +. 'a#roso'ia F T!e nurse instructs t!e 1ot!er t!at ,!en o2ersti1u$ated t!e infant ,i$$: A s!o, increased a$ertness and e+e contact < res*ond ,it! coordinated8 s+nc!ronous "od+ 1o2e1ent C. loo& away to re)u#e the intensity o* the intera#tion 5 drift off to dee* s$ee* to s!ut out t!e interaction G So1e strategies to 1aintain *rofessiona$ !ea$t! are $isted "e$o, :!ic! is NOT necessari$+ correctA A Net,or#ing ,it! ot!ers in t!e !ea$t! care fie$d < Koin a *rofessiona$ organi7ation C Goa$ setting +. Rea) *i#tion an) non7*i#tion 'aterials 1% T!e nurse is assessing an F 1ont!Eo$d infant for !ead $ag8 *u$$ing t!e infant "+ t!e !ands fro1 a su*ine to a sitting *osition T!e !ead does not sta+ in $ine ,it! t!e "od+ ,!en "eing *u$$ed for,ard :!ic! of t!e fo$$o,ing state1ents "est re*resents t!e significance of t!is findingA A @ead $ag s!ou$d not "e tested unti$ t!e c!i$d is o2er 1 +ear of age %. Si"ni*i#ant hea) la" a*ter the a"e o* A 'onths 'ay in)i#ate brain in=ury an) nee)s *urther in(esti"ations. C T!e nurse !as not conducted t!e test correct$+ and 1ust do it again using *ro*er

tec!ni&ue 5 T!is is a nor1a$ finding8 as t!e infantHs !ead ,i$$ not sta+ in $ine unti$ after F 1ont!s of age 11 :!ic! state1ent is correct regarding t!e use of t!e cer2ica$ ca*A A. It 'ay a**e#t Pap s'ear results. < It does not need to "e fitted "+ t!e *!+sician C It does not re&uire t!e use of s*er1icide 5 It 1ust "e re1o2ed ,it!in '3 !ours 1' T!e 1a;or co1*onents of t!e co11unication *rocess are: A 2er"a$8 ,ritten and non2er"a$ < s*ea#er8 $istener and re*$+ C facia$ e0*ression8 tone of 2oice and gestures +. 'essa"e/ sen)er/ #hannel/ re#ei(er an) *ee)ba#& 1- T!e e0tent of "urns in c!i$dren are nor1a$$+ assessed and e0*ressed in ter1s of: A t!e a1ount of "od+ surface t!at is un"urned %. per#enta"es o* total bo)y sur*a#e area CT%SAD C !o, dee* t!e dee*est "urns are 5 t!e se2erit+ of t!e "urns on a 1 to 6 "urn sca$e 13 T!e sc!oo$ nurse notices a c!i$d ,!o is ,earing o$d8 dirt+8 *oorEfitting c$ot!es? is a$,a+s !ungr+? !as no $unc! 1one+? and is a$,a+s tired :!en t!e nurse as#s t!e "o+ !is tiredness8 !e ta$#s of *$a+ing outside unti$ 1idnig!t T!e nurse ,i$$ sus*ect t!at t!is c!i$d is: A "eing raised "+ a *arent of $o, inte$$igence &uotient .IO/ < an or*!an C. a (i#ti' o* #hil) ne"le#t 5 t!e 2icti1 of *o2ert+

17
16 :!ic! of t!e fo$$o,ing indicates t!e t+*e.s/ of acute rena$ fai$ureA A Four t+*es: !e1orr!agic ,it! and ,it!out c$otting8 and non!e1orr!agic ,it! and ,it!out c$ottings < One t+*e: acute C. Three typesH prerenal/ intrarenal an) postrenal 5 T,o t+*es: acute and su"acute 1C A 1eans of faci$itating *rofessiona$ staff de2e$o*1ent is "+ "ui$ding u*on s#i$$s8 a"i$ities8 and of e0*erience of eac! *ractitioner is ca$$ed: A the no(i#e to e<pert 'o)el C career en!ance1ent < situationa$ $eaders!i* 1ode$ 5 c$inica$ $adder 1D :!ic! of t!e fo$$o,ing &uestions "+ t!e nurse ,ou$d "e "est fit t!e *!i$oso*!+ of t!e nursing 1utua$ *artici*ation 1ode$ of care .N)P)C/A A. !2a(e you brushe) your #hil)-s teeth to)ay1$ < =@o, does +our c!i$d $oo# to +ou toda+A> C =:!ere !a2e +ou "een a$$ 1orningA> 5 =5o +ou t!in# +our c!i$dHs co$or is ,orse>A 1F T!ere are nu1erous definitions of t!e ,ord =!ea$t!> :!ic! definition "e$o, is fro1 F$orence Nig!tinga$eA A A state or a *rocess of "eing and "eco1ing an integrated and ,!o$e *erson < T!e state of "eing free fro1 i$$ness or in;ur+ C. %ein" well an) usin" e(ery power the in)i(i)ual possesses to the *ullest e<tent 5 A state of co1*$ete *!+sica$8 socia$8 and 1enta$ ,e$$E"eing and not 1ere$+ t!e a"sence of disease or infir1it+ 1G Infor1a$ co11unication ta#es *$ace ,!en indi2idua$s ta$# and is "est descri"ed "+ sa+ing t!e *artici*ants: A are in2o$2ed in a *ree0isting infor1a$ re$ations!i* < ta$# ,it! s$ang ,ords

C. ha(e no parti#ular a"en)a or proto#ol 5 are re$a0ed '% Tertiar+ care "+ t!e !o1e !ea$t! nurse is directed to,ard c!i$dren ,it!: A proble's in 'obility C 1inor *ro"$e1s < s!ortEter1 needs 5 c$inica$$+ a**arent disease '1 T!e endo1etriu1 t!ic#ens during ,!ic! *!ase of t!e 1enstrua$ c+c$eA A. Secretor+ *!ase C. Proli*erati(e phase < )enstrua$ *!ase 5 Isc!e1ic *!ase '' A 1easure1ent too$ to articu$ate t!e nursing ,or#$oad for a s*ecific *atient or grou*s of *atients o2er a s*ecific *eriod of ti1e is ca$$ed: A staffing *attern C "enc!1ar#ing %. s#i$$ 1i0 +. patient #lassi*i#ation '- T!e 1ot!er of a G 1ont!Eo$d infant is concerned t!at t!e !ead circu1ference of !er "a"+ is greater t!an t!e c!est circu1ference T!e <EST res*onse "+ t!e nurse is: A =T!ese circu1ference nor1a$$+ are t!e sa1e8 "ut in so1e "a"ies t!is ;ust differs > < =Per!a*s +our "a"+ ,as s1a$$ for gestationa$ age or *re1ature > C. !This is nor'al until the a"e o* year/ when the #hest will be "reater.$

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5 =Let 1e as# +ou a fe, &uestions8 and *er!a*s ,e can figure out t!e cause of t!is difference > '3 :!ic! of t!e fo$$o,ing a**roac!es ,ou$d ,or# "est ,!en t!e nurse is co11unicating ,it! an infantA A Use an adu$t 2oice ;ust as +ou ,ou$d for an+one < Co11unicate t!roug! t!e caregi2ers C. Allow the #hil) ti'e to war' up to the nurse. 5 Res*ond on$+ after t!e c!i$d cries for a ,!i$e '6 E2idenceE"ased care started in 1edicine as a ,a+ to: A *ro1ote tec!no$ogica$ ad2ances in 1edicine < incor*orate co$$a"oration ,it!in a$$ !ea$t! care disci*$ines C. inte"rate in)i(i)ual e<perien#e with #lini#al resear#h 5 teac! 1edica$ students t!e art and science of 1edicine 'C T!e nurse assessing ne,"orn "a"ies and infants during t!eir !os*ita$ sta+ after "irt! ,i$$ notice ,!ic! of t!e fo$$o,ing s+1*to1s as a *ri1ar+ 1anifestation of @irsc!s*rungHs diseaseA A A fine ras! o2er t!e trun# %. 8ailure to pass 'e#oniu' )urin" the *irst 45 to 58 hours a*ter birth C T!e s#in turns +e$$o, and t!en "ro,n o2er t!e first 3F !ours of $ife 5 @ig!Egrade fe2er 'D A c$ient is D 1ont!s *regnant and !as ;ust "een diagnosed as !a2ing a *artia$ *$acenta *re2ia S!e is sta"$e and !as 1ini1a$ s*otting and is "eing sent !o1e :!ic! of t!ese instructions to t!e c$ient 1a+ indicate a need for furt!er teac!ingA A )aintain "ed rest ,it! "at!roo1 *ri2i$eges %. A(oi) inter#ourse *or three )ays. C Ca$$ if contractions occur 5 Sta+ on $eft side as 1uc! as *ossi"$e ,!en $+ing do,n 'F :!ic! of t!e fo$$o,ing grou*s of *eo*$e in t!e ,or$d dis*ro*ortionate$+ re*resents t!e !o1e$ess *o*u$ationA A @is*anics C African A1ericans < Asians 5 Caucasians 'G T!e nurse notes t!at t!e infant is ,earing a *$asticEcoated dia*er If a to*ica$ 1edication ,ere to "e *rescri"ed and it ,ere to go on t!e sto1ac!s or "uttoc#s8 t!e nurse ,ou$d teac! t!e caregi2ers to: A. a(oi) #o(erin" the area o* the topi#al 'e)i#ation with the )iaper < a2oid t!e use of c$ot!ing on to* of t!e dia*er

C *ut t!e dia*er on as usua$ 5 a**$+ an ice*ac# for 6 1inutes to t!e outside of t!e dia*er -% T!e nurse assessing a c!i$d or ado$escent ,it! a diagnosis of d+sr!+t1ic disorder ,ou$d find ,!ic! of t!e fo$$o,ing s+1*to1sA A La"i$e 1ood and !+*eracti2e t!+roid ,it! an increase in circu$ating t!+roid !or1ones and associated s+1*to1s < Se2ere s!a#ing of t!e !ands ,!en tr+ing to !o$d a g$ass of ,ater or ot!er o";ect C A de*ression t!at is dee*er8 1ore acute8 and 1ore $i#e$+ to $ead to suicide t!an 1a;or de*ressi2e disorder +. A )epresse) or irritable 'oo) *or 'ost o* the )ay/ on 'ost )ays/ *or 4 or 'ore years an) low ener"y or *ati"ue.

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-1 Bou ,ere t!e nurse assigned to ,or# ,it! a c!i$d ,!o !as !ad ,!o$e "rain radiation Bou !a2e assessed t!e c!i$d to "e s$ee*ing u* to '% !ours a da+ and is !a2ing so1e nausea8 1a$aise8 fe2er and d+s*!asia <ased on t!is assess1ent8 +ou are to ,or# ,it! t!e *atients in ,!ic! of t!e fo$$o,ing areas A Acce*ting a reoccurrence of t!e tu1or %. +ealin" with the si)e e**e#ts o* ra)iation therapy C Caring for t!e d+ing c!i$d 5 Acce*ting t!e i11inent deat! of t!eir c!i$d -' T!e nurse is *$anning inter2entions for a c!i$d ,!o !as inf$a11ator+ "o,e$ disease .I<5/ ,it! a nursing diagnosis of =Nutrition: Less t!an "od+ re&uire1ents > :!ic! of t!e fo$$o,ing inter2entions ,i$$ "e 1ost !e$*fu$ in reso$2ing t!is nursing *ro"$e1A A T,o $arge 1ea$s a da+ instead of se2era$ 1ini1ea$s and snac#s < S*ecia$ I<5 diet .diet t!at !as "een *ro2en effecti2e for treating I<5/ C Sa$tEfree diet !ig! in *otassiu18 2ita1ins and 1inera$s +. +iet as tolerate) with la#tose hy)roly@e) 'il& instea) o* 'il& pro)u#ts/ an) o'ission o* hi"hly seasone) *oo)s/ an) re)u#tion o* *iber -- E1otiona$ inte$$igence consists of a nu1"er of co1*etencies So1e of t!ese are $isted "e$o, :!ic! is NOT a c!aracteristic of e1otiona$ inte$$igenceA A Sel*7estee' C E1*at!+ < Se$fEa,areness 5 Se$fEregu$ation -3 5ata co$$ection for dri2ing and restraining forces8 inc$uding costs8 desira"i$it+ and feasi"i$it+8 is a: A *eo*$e issue C *o$itica$ issue < stru#tural issue 5 tec!no$og+ issue -6 One of four factors descri"ing t!e e0*erience of se0ua$$+ a"used c!i$dren and t!e effect it !as on t!eir gro,t! and de2e$o*1ent is stig1ati7ation t!at occurs ,!en: A a c!i$d "$a1es !i1 or !erse$f for t!e se0ua$ a"use and "egins to ,it!dra, and iso$ate < ne,s*a*ers and t!e 1edia donHt #ee* se0ua$ a"use *ri2ate and accidenta$$+ or on *ur*ose re2ea$ t!e na1e of t!e 2icti1 C t!e c!i$d !as "een "$a1ed "+ t!e a"user for !is or !er se0ua$ "e!a2iors8 sa+ing t!at t!e c!i$d as#ed to "e touc!ed or did not 1a#e t!e a"user to sto* +. the #hil)-s a"ony is share) by other 'e'bers o* the *a'ily or *rien)s when the se<ual abuse be#o'es publi# &nowle)"e -C T!e *ainfu$ *!eno1enon #no,n as ="ac# $a"or> occurs in a c$ient ,!ose fetus in ,!at *ositionA A <ro, *osition C <reec! *osition < Rig!t Occi*itoEAnterior Position +. .e*t 3##ipito7Posterior Position -D FOCUS 1et!odo$og+ stands for: A. 8o#us/ 3r"ani@e/ Clari*y/ Un)erstan) an) Solution < Focus8 O**ortunit+8 Continuous8 Uti$i7e8 Su"stantiate

C Focus8 Organi7e8 C$arif+8 Understand8 Su"stantiate 5 Focus8 O**ortunit+8 Continuous .*rocess/8 Understand8 So$ution -F :!i$e co11unit+ !ea$t! nurses focus on t!e indi2idua$ or t!e fa1i$+8 ,!ic! of t!e fo$$o,ing do t!e+ a$so !a2e as t!eir fina$ o";ecti2eA A T!e ,e$$E"eing of t!e c!ronica$$+ i$$ < T!e financia$ ,e$$E"eing of t!e fa1i$+ C T!e ,e$$E"eing of t!e e0tended fa1i$+

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+. The well7bein" o* the #o''unity -G :!ic! of t!e fo$$o,ing is t!e "est e0a1*$e of t!e et!ica$ *rinci*$e of fide$it+A A 5oing ,!ate2er t!e c$ient or t!e c$ientHs *!+sician as#s of +ou %. Eeepin" a pro'ise to return to the #lient-s roo' at a "i(en ti'e C <eing a good friend to t!e c$ient "+ s!aring secrets 5 Sa2ing t!e c$ient ti1e and 1one+ "+ not ,asting su**$ies 3% :!ic! of t!e fo$$o,ing factors is 1ost i1*ortant in deter1ining t!e success of re$ations!i*s used in de$i2ering nursing careA A T+*e of i$$ness of t!e c$ient < Transference and counter transference C. E**e#ti(e #o''uni#ation 5 Persona$it+ of t!e *artici*ants 31 :!ic! of t!e fo$$o,ing state1ents "est descri"es t!e ter1 g$o2e t+*e "urnA A T!e *arent ,as ,earing !ea2+ g$o2es or stoc#ings on !is or !er !ands ,!i$e i11ersing t!e c!i$d in !ot sca$ding ,ater < T!e *arents !a2e di**ed t!e c!i$d into !ot $i&uid ,!i$e !e or s!e ,as as$ee* C T!e c!i$d ,as ,earing a g$o2e ,!en i11ersed in !ot $i&uid +. The burn has the loo& o* a "lo(e i''erse) in hot s#al)in" water. 3' T!e sc!oo$ nurse #ee*s a $ist of enro$$ed students ,!o !a2e 1edica$ or re$igious o";ections to i11uni7ations and t!ose ,!o are $i#e$+ to !a2e decreased i11unit+ T!e nurse $i#e$+ #ee*s t!is $ist to: A *ro2ide statistics for t!e 5e*art1ent of @ea$t! < reassure t!e fa1i$+ t!at t!e nurse ,i$$ res*ect t!e fa1i$+Hs ,is!es at a$$ ti1es C 1eet nationa$ go2ern1ent re&uire1ents +. *a#ilitate e<#lusion in #ase o* an outbrea& o* a hi"hly #o''uni#able )isease in the s#hool. 3- Presc!oo$ers are a"$e to see t!ings fro1 ,!ic! of t!e fo$$o,ing *ers*ecti2esA A T!eir *eers < T!eir o,n and t!eir caregi2ersH C T!eir o,n and t!eir 1ot!erHs +. 3nly their own 33 In conf$ict 1anage1ent8 t!e ,inE,in a**roac! occurs ,!en: A t!ere are t,o conf$icts and t!e *arties agree to eac! one < eac! *art+ gi2es in on 6%M of t!e disagree1ents 1a#ing u* t!e conf$ict C. both parties in(ol(e) are #o''itte) to sol(in" the #on*li#t 5 t!e conf$ict is sett$ed out of court so t!e $ega$ s+ste1 and t!e *arties ,in 36 According to t!e socia$Einteractiona$ *ers*ecti2e of c!i$d a"use and neg$ect8 four factors *$ace t!e fa1i$+ 1e1"ers at ris# for a"use t!ese ris# factors are t!e fa1i$+ 1e1"ers at ris# for a"use T!ese ris# factors are t!e fa1i$+ itse$f8 t!e caregi2er8 t!e c!i$d8 and A the presen#e o* a *a'ily #risis C t!e nationa$ e1*!asis on se0 < genetics 5 c!ronic *o2ert+ 3C :!en a *erson is discussing t!e strong inf$uences t!at c!i$drearing 1et!ods !a2e on t!e de2e$o*1ent of t!e c!i$d8 t!is *erson is 1ost *ro"a"$+ co1ing fro1 ,!ic! of t!e fo$$o,ing 2ie,*oints or t!eoriesA A Natura$istic C Neoc$assic

< Nature +. Nurture

21
3D In ,or#ing ,it! t!e caregi2ers of a c$ient ,it! an acute or c!ronic i$$ness8 t!e nurse ,ou$d: A. Tea#h #are )aily an) let the #are"i(ers )o a return )e'onstration =ust be*ore )is#har"e < 5ifficu$t+ s,a$$o,ing8 di1inis!ed or a"sent gag ref$e08 and res*irator+ distress C 5ifficu$t+ s$ee*ing8 !+*er2igi$ant8 and an arc!ing of t!e "ac# 5 Parado0ica$ irrita"i$it+8 diarr!ea8 and 2o1iting 3F :!ic! of t!e fo$$o,ing signs and s+1*to1s ,ou$d +ou 1ost $i#e$+ find ,!en assessing and infant ,it! Arno$dEC!iari 1a$for1ationA A :ea#ness of t!e $eg 1usc$es8 $oss of sensation in t!e $egs8 and rest$essness < +i**i#ulty swallowin"/ )i'inishe) or absent "a" re*le</ an) respiratory )istress C 5ifficu$t+ s$ee*ing8 !+*er2igi$ant8 and an arc!ing of t!e "ac# 5 Parado0ica$ irrita"i$it+8 diarr!ea8 and 2o1iting 3G A *arent ca$$s +ou and frantica$$+ re*orts t!at !er c!i$d !as gotten into !er fa1ous ferrous su$fate *i$$s and ingested a nu1"er of t!ese *i$$s @er c!i$d is no, 2o1iting8 !as "$ood+ diarr!ea8 and is co1*$aining of a"do1ina$ *ain Bou ,i$$ te$$ t!e 1ot!er to: A ca$$ e1ergenc+ 1edica$ ser2ices .E)S/ and get t!e c!i$d to t!e e1ergenc+ roo1 < re$a0 "ecause t!ese s+1*to1s ,i$$ *ass and t!e c!i$d ,i$$ "e fine C ad1inister s+ru* of i*ecac +. #all the poison #ontrol #enter 6% A c$ient sa+s s!e !eard fro1 a friend t!at +ou sto* !a2ing *eriods once +ou are on t!e =*i$$> T!e 1ost a**ro*riate res*onse ,ou$d "e: A =T!e *i$$ *re2ents t!e uterus fro1 1a#ing suc! endo1etria$ $ining8 t!at is ,!+ *eriods 1a+ often "e scant or s#i**ed occasiona$$+ > < =If +our friend !as 1issed !er *eriod8 s!e s!ou$d sto* ta#ing t!e *i$$s and get a *regnanc+ test as soon as *ossi"$e > C. !The pill shoul) #ause a nor'al 'enstrual perio) e(ery 'onth. It soun)s li&e your *rien) has not been ta&in" the pills properly.$ 5 =)issed *eriod can "e 2er+ dangerous and 1a+ $ead to t!e for1ation of *recancerous ce$$s > 61 Bou are t!e nurse assigned to ,or# ,it! a c!i$d ,it! acute g$o1eru$one*!ritis <+ fo$$o,ing t!e *rescri"ed treat1ent regi1en8 t!e c!i$d e0*eriences a re1ission Bou are no, c!ec#ing to 1a#e sure t!e c!i$d does not !a2e a re$a*se :!ic! finding ,ou$d 1ost $ead +ou to t!e conc$usion t!at a re$a*se is !a**eningA A E$e2ated te1*erature8 coug!8 sore t!roat8 c!anging co1*$ete "$ood count .C<C/ ,it! diiferentia$ %. A urine )ipsti#& 'easure'ent o* 4I proteinuria or 'ore *or 6 )ays/ or the #hil) *oun) to ha(e 675I proteinutria plus e)e'a. C T!e urine di*stic# s!o,ing g$ucose in t!e urine for - da+s8 e0tre1e t!irst8 increase in urine out*ut8 and a 1oon face 5 A te1*erature of -D F degrees .1%% degrees F/8 f$an# *ain8 "urning fre&uenc+8 urgenc+ on 2oiding8 and c$oud+ urine 6' T!e nurse is ,or#ing ,it! an ado$escent ,!o co1*$ains of "eing $one$+ and !a2ing a $ac# of fu$fi$$1ent in !er $ife T!is ado$escent s!ies a,a+ fro1 inti1ate re$ations!i*s at ti1es +et at ot!er ti1es s!e a**ears *ro1iscuous T!e nurse ,i$$ $i#e$+ ,or# ,it! t!is ado$escent in ,!ic! of t!e fo$$o,ing areasA A Iso$ation C Lac# of fu$fi$$1ent %. Lone$iness +. I)entity 6- T!e use of inter*ersona$ decision 1a#ing8 *s+c!o1otor s#i$$s8 and a**$ication of #no,$edge e0*ected in t!e ro$e of a $icensed !ea$t! care *rofessiona$ in t!e conte0t of *u"$ic !ea$t! ,e$fare and safet+ is an e0a1*$e of: A de$egation C res*onsi"i$it+

22
< su*er2ision +. #o'peten#e 63 A c!i$d suffers a !ead in;ur+ in a tu1"$ing accident in g+1 c$ass T!e nurseHs "est course of action is to: A get t!e c!i$d u* ,a$#ing and 1a#e sure !e or s!e sta+s a,a#e < $ea2e t!e c!i$d and go get !e$* C $ea2e t!e c!i$d in t!e care of an o$der c!i$d and go get !e$* +. stay with the #hil)/ &eep assessin"/ an) ha(e so'eone #all the #are"i(ers 66 T!e A1erican Acade1+ of Pediatrics suggests t!at caregi2ers do ,!ic! of t!e fo$$o,ing t!ings in regard to *!+sica$ acti2ities for *resc!oo$ersA A Pus! t!e c!i$d to *ractice s*orts acti2ities ,!i$e t!e+ are 1ore f$e0i"$e %. En#oura"e a (ariety o* physi#al a#ti(ities in a non#o'petiti(e en(iron'ent C @a2e t!e c!i$d engage in co1*etiti2e s*orts to see ,!ere t!e+ e0ce$ 5 Iee* *!+sica$ acti2ities to a 1ini1u1 unti$ t!e c!i$d is in grade sc!oo$ 6C :!ic! of t!e fo$$o,ing arrange1ents is genera$$+ considered to "e "est for t!e *arents of !os*ita$i7ed infant or +oung c!i$dA A Roo1ingEin < Se*arate caregi2er s$ee*ing roo1 on t!e unit C 5a+ 2isits and s$ee*ing at !o1e 5 Sta+ing at a near"+ !ote$ or 1ote$ 6D :!en one *erson a$$o,s t!e conf$ict to "e reso$2ed at !is or !er o,n e0*ense8 t!is is referred to in conf$ict 1anage1ent as: A $osing C. the win7lose approa#h < ,inning ,!i$e $osing 5 t!e $oseE,in a**roac! 6F :!ic! of t!e fo$$o,ing state1ents "est descri"es ac&uaintance ra*eA A Se0ua$ intercourse ,!en one *erson engaging in t!e acti2it+ is unsure a"out ,anting to do so < :!en t,o *eo*$e donHt $o2e eac! ot!er and engage in se0ua$ acti2ities C. 0hen so'eone on a )ate tri#&s the other person into ha(in" se<ual inter#ourse 5 Se0ua$ intercourse co11itted ,it! force or t!e t!reat of force ,it!out a *ersonHs consent 6G T!e sc!oo$ nurse is teac!ing a !ea$t! education and !+giene course to a grou* of !ig! sc!oo$ 1a$es8 ,!ic! inc$udes a nu1"er of +oung 1en ,!o are on co1*etiti2e s*orts tea1s :!ic! of t!e fo$$o,ing !ea$t! *ractices ,ou$d t!e nurse 1ost stress in *re2enting t!e trans1ission of !u1an i11unodeficienc+ 2irus .@I4/ 2irus in case an+ tea1 1e1"er !as @I4 or ac&uired i11unodeficienc+ s+ndro1e .AI5S/A A No s!aring of underar1 deodorant or s!o,er soa* %. No sharin" o* ra@ors or toothbrushes C )a#ing certain to,e$s !a2e "een ,as!ed in "oi$ing ,ater 5 A2oiding *!+sica$ contact suc! as s*orts !ugs or s,ats C% At 1D ,ee#sH gestation8 a t+*e 1 dia"etic undergoes an u$trasound e0a1ination :!at infor1ation a"out t!e fetus at t!is ti1e in *regnanc+ ,ou$d "e t!e resu$ts of t!is e0a1ination *ro2ideA A P$acenta$ 1aturit+ C Gestationa$ age < Esti'ate) *etal wei"ht 5 Feta$ $ung 1aturit+ C1 :!ic! of t!e fo$$o,ing "est descri"es a difference in co11unicating ,it! sc!oo$ age c!i$dren 2ersus todd$ersA A Todd$ers re&uire 1ore e1*at!+ and 1ore touc!ing and !o$ding

23
< For todd$ers8 *re*aration for *rocedures is ;ust "efore t!e *rocedure and 1uc! ear$ier for sc!oo$Eaged c!i$dren C Caregi2ers need $ess infor1ation ,!en care in2o$2es a sc!oo$ aged c!i$d +. The nu'ber o* wor)s is 'ore when #o''uni#atin" with a to))ler than it is with

a s#hool a"e) #hil)ren C' Genetic testing s!ou$d "e *erfor1ed on a c!i$d on$+ if A t!e *arents "ot! ,ant it *erfor1ed %. it is in the best interests o* the #hil) C it iGs necessar+ for t!e c!i$d to sur2i2e 5 no one o";ects C- Infant !ead contro$ is ;udged "+ t!e: A. ability to hol) the hea) without support < *resence or a"sence of !ead $ag C rigidit+ of t!e nec# and !ead 5 a1ount of nec# ,rin#$ing C3 :!ic! of t!e fo$$o,ing ro$es <EST e0e1*$ifies t!e e0*anded ro$e of t!e nurseA A Circu$ating nurse in surger+ < )edication nurse C O"stetrica$ nurse +. Pe)iatri# nurse pra#titioner C6 T!e tone and *itc! of t!e 2oice8 2o$u1e8 infection8 s*eed8 grunts and ot!er 2oca$i7ations are referred to "+ ,!ic! of t!e fo$$o,ing ter1sA A Para(erbal #lues C T!ird e$e1ent < Anci$$ar+ s*eec! 5 En!ance1ents CC T!e *$anEdoEstud+Eact c+c$e "egins ,it!: A. four stages C. three ,uestions < fi2e agendas 5 t,o conce*ts CD 5uring +our s!ift8 +ou noted one of +our *regnant c$ients considered as =,aiting case> 1anifest 1orning sic#ness and ,!ic! $ater *rogressed :!ic! assess1ent finding 1a+ indicate *ossi"$e de2e$o*ing co1*$icationA A )aterna$ *u$se G% C F@T 166 %. Trace g$ucose in t!e urine +. I &etones in the urine CF T!e nurse is ,or#ing ,it! a c!i$d ,!o is going to !a2e a "one 1arro, as*iration T!e *!+sician orders TAC .tetracaine8 adrena$ine and cocaine/ :!ic! of t!e fo$$o,ing is t!e route of ad1inistrationA A. appli#ation to the s&in/ #o(ere) with a )ressin" prior to the pro#e)ure < su"cutaneous C I4 using a 2er+ s$o, dri* o2er a**ro0i1ate$+ 3 !ours *rior to *rocedure 5 Nasa$ in!a$ation CG According to 5eRosa and Ioc!uraHs .'%%C/ artic$e entit$ed =I1*$e1ent Cu$tura$$+ Co1*etent @ea$t! Care in +our ,or#*$ace8> cu$tures !a2e different *atterns of 2er"a$ and non2er"a$ co11unication :!ic! difference does NOT necessari$+ "e$ongA A Persona$ "e!a2ior C. Sub=e#t 'atter < E+e contact 5 Con2ersationa$ st+$e D% T!e nurse instructs t!e caregi2ers of a ne,"orn to notc! t!e dia*ers or fo$d t!e1 in suc! a ,a+ as to e0*ose t!e cord T!e 1a;or *ur*ose of e0*osing t!e cord is to: A re1ind caregi2ers to do cord care < #ee* t!e dia*er fro1 ru""ing t!e cord

24
C. pro(i)e air #ir#ulation *or the #or) 5 a$$o, 2isua$i7ations at a$$ ti1es D1 T!e $e2e$ of !ea$t! of an indi2idua$8 fa1i$+8 grou*8 *o*u$ation8 or co11unit+ is ca$$ed: A !ea$t! assets C &ua$it+ of $ife < health status 5 !ea$t! needs D' T!e nurse is teac!ing a grou* of e0*ectant 1ot!ers a"out t!e *re2ention of dia*er der1atitis T!e nurse e0*$ains t!at one of t!e *re2enti2e 1easures is t!e use of: A absorbent )isposable )iapers C *$astic *anties o2er dia*ers

< "a"+ *o,der or cornstarc! 5 c$ot! dia*er D- T!e Code of Nurses A de$ineates a$$ o"$igations and res*onsi"i$ities of t!e nurse %. is a bin)in" oath/ whi#h tells nurses how to 'a&e ethi#al )e#isions C assists t!e nurse in for1u$ating a *ersona$ "e$ief s+ste1 5 su**orts t!e conce*t of res*ect for a$$ *ersons D3 T!e o"$igation to correct$+ *erfor1 oneHs assigned duties is: A 5e$egation C. responsibility < Assign1ent 5 accounta"i$it+ D6 5uring a routine *ost*artu1 assess1ent fo$$o,ing a nor1a$ 2agina$ de$i2er+8 t!e nurse notes t!e fundus to "e s$ig!t$+ "ogg+ :!ic! action s!ou$d t!e nurse ta#e to decrease t!e ris# of uterine in2ersion during uterine 1assageA A. ?assa"e only when #ra'pin" be"ins. < P$ace one !and on t!e a"do1en a"o2e t!e s+1*!+sis *u"is C As# t!e c$ient to a1"u$ate to t!e "at!roo1 to e1*t+ !er "$adder 5 Position t!e c$ient in a s$ig!t Trende$en"urg *osition SITUATI3NA. Situation > Nurse Lisa 1anages !er o,n Re*roducti2e and C!i$drenHs Nursing C$inic in Sorsogon and necessari$+ s!e attends to !ea$t! conditions of 1ot!ers and c!i$dren T!e fo$$o,ing conditions *ertain to t!e GRO:ING FETUS DC O"stetrica$ c$ient )aric!u as#s !o, 1uc! $onger Nurse Lisa ,i$$ refer to t!e "a"+ inside !er as an e1"r+o :!at ,ou$d "e +our "est e0*$anationA A @er "a"+ ,i$$ "e a fetus as soon as t!e *$acenta for1s %. 8ro' the ti'e o* i'plantation until ; to 8 wee&s/ the baby is an e'bryo C After t!e '%t! ,ee# of *regnanc+8 t!e "a"+ is ca$$ed a 7+gote 5 T!is ter1 is used during t!e ti1e "efore ferti$i7ation DD )aric!u is ,orried t!at !er "a"+ ,i$$ "e "orn ,it! a congenita$ !eart disease :!at assess1ent of a fetus at "irt! is i1*ortant to !e$* detect congenita$ !eart defectA A 5eter1ining t!at t!e co$or of t!e u1"i$ica$ cord if not green %. Assessin" whether the u'bili#al #or) has two arteries an) one (ein. C Assessing ,!et!er t!e :!artonHs ;e$$+ of t!e cord !as a *@ !ig!er t!an D ' 5 )easuring t!e $engt! of t!e cord to "e certain t!at it is $onger t!an - feet DF Additiona$$+8 Nurse Lisa ,ou$d gat!er 1ore infor1ation a"out )aric!uHs ,orr+ a"out ,!at 1a+ t!reaten t!e !ea$t! of !er "a"+ :!at ,ou$d Nurse Lisa !o*e to findA A @as )aric!u "een o2er$+ an0ious a"out so1et!ing < @as )Aric!u suffered fro1 an+ co11unica"$e9contagious disease at t!e ti1e of !er ear$+ stage of *regnanc+

25
C @as )Aric!u engaged in se0ua$ acti2it+ during t!e feta$ de2e$o*1ent state of !er c!i$d +. 2as ?Ari#hu en"a"e) in any )etri'ental a#ti(ities )urin" the *etal )e(elop'ent sta"e e.". s'o&in"/ )rin&in"/ ta&in" )ru"s/ a ba) *all/ or atte'pts to ter'inate pre"nan#y. DG )aric!u is sc!edu$ed to !a2e an u$trasound e0a1ination :!at instruction ,ou$d +ou gi2e !er "efore !er e0a1inationA A Bou can !a2e 1edicine for *ain for an+ contractions caused "+ t!e test %. +rin& at least 6 "lasses o* *lui) be*ore the pro#e)ure. C T!e intra2enous f$uid infused to di$ate +our uterus does not !urt t!e fetus 5 4oid i11ediate$+ "efore t!e *rocedure to reduce +our "$adder si7e F% )aric!u is sc!edu$ed to !a2e an a1niocentesis to test for feta$ 1aturit+ :!at instruction ,ou$d +ou gi2e !er "efore t!is *rocedureA A T!e (Era+ used to re2ea$ +our fetusH *osition !as no $ong ter1 effects < T!e intra2enous f$uid infused to di$ate +our uterus does not !urt t!e fetus C No 1ore a1niotic f$uid for1s after,ard8 ,!ic! is ,!+ on$+ a s1a$$ a1ount is re1o2ed

+. Joi) i''e)iately be*ore the pro#e)ure to re)u#e your bla))er si@e. Situation 4 > @ea$t! instructions are essentia$$+ gi2en to *regnant 1ot!ers F1 A *u"$ic !ea$t! nurse ,ou$d instruct a *regnant ,o1an to notif+ t!e *!+sician i11ediate$+ if ,!ic! of t!e fo$$o,ing s+1*to1s occur during *regnanc+A A Presence of dar# co$or in t!e nec# < Increased 2agina$ disc!arge C. Swellin" o* the *a#e 5 <reast tenderness F' A ,o1an ,!o is G ,ee#s *regnant co1es to t!e @ea$t! Center ,it! 1oderate "rig!t red 2agina$ "$eeding On *!+sica$ e0a1ination8 t!e *!+sician finds t!e c$ientHs cer2i0 ' c1 di$ated :!ic! ter1 "est descri"es t!e c$ientHs conditionA A. )issed a"ortion C. Ine(itable abortion < Inco1*$ete a"ortion 5 T!reatened a"ortion F- In a "ig go2ern1ent !os*ita$8 Nurse Pura is ta#ing care of a ,o1an ,it! a diagnosis of a"ru*tion *$acenta :!at co1*$ication of t!is condition is of 1ost concern to Nurse PuraA A Urinar+ tract infection < Pu$1onar+ e1"o$is1 C @+*oca$ce1ia +. +isse'inate) intra(as#ular #oa"ulation F3 :!ic! of t!e fo$$o,ing findings on a ne,$+ de$i2ered ,o1anHs c!art ,ou$d indicate s!e is at ris# for de2e$o*ing *ost*artu1 !e1orr!ageA A PostEter1 de$i2er+ C. Gran) 'ultiparity < E*idura$ anest!esia 5 Pre1ature ru*ture of 1e1"rane F6 )rs @acienda Gracia8 -6 +ear o$d *ost*artu1 c$ient is at ris# of t!ro1"o*!$e"itis :!ic! of t!e fo$$o,ing nursing inter2entions decreases !er c!ance of de2e$o*ing *ost*artu1 t!ro1"o*!$e"itisA A "reastfeeding t!e ne,"orn %. early a'bulation C ad1inistration of anticoagu$ant *ost*artu1 5 i11o"i$i7ation and e$e2ation of t!e $o,er e0tre1ities

26
Situation 6 > :it! t!e increasing docu1ented cases of CANCER t!e "est a$ternati2e to treat1ent sti$$ re1ains to "e PRE4ENTION T!e fo$$o,ing conditions a**$+ FC :!ic! a1ong t!e fo$$o,ing is t!e *ri1ar+ focus of *re2ention of cancerA A. Eli'ination o* #on)itions #ausin" #an#er < 5iagnosis and treat1ent C Treat1ent at ear$+ stage 5 Ear$+ detection FD In t!e *re2ention and contro$ of cancer8 ,!ic! of t!e fo$$o,ing acti2ities is t!e 1ost i1*ortant function of t!e co11unit+ !ea$t! nurseA A. Con)u#t #o''unity asse'blies. < Referra$ to cancer s*ecia$ist t!ose c$ients ,it! s+1*to1s of cancer C Use t!e nine ,arning signs of cancer as *ara1eters in our *rocess of detection8 contro$ and treat1ent 1oda$ities 5 Teac! ,o1an a"out *ro*er9correct nutrition FF :!o a1ong t!e fo$$o,ing are reci*ients of t!e secondar+ $e2e$ of care for cancer casesA A. Those un)er early #ase )ete#tion < T!ose under *ost case treat1ent C T!ose sc!edu$ed for surger+ 5 T!ose undergoing treat1ent FG :!o a1ong t!e fo$$o,ing are reci*ients of t!e tertiar+ $e2e$ of care for cancer casesA A T!ose under ear$+ treat1ent C T!ose under ear$+ detection < Those un)er supporti(e #are 5 T!ose sc!edu$ed for surger+

G% In Co11unit+ @ea$t! Nursing8 des*ite t!e a2ai$a"i$it+ and use of 1an+ e&ui*1ent and de2ices to faci$itate t!e ;o" of t!e co11unit+ !ea$t! nurse8 t!e "est too$ an+ nurse s!ou$d "e ,e$ "e *re*ared to a**$+ is a scientific a**roac! T!is a**roac! ensures &ua$it+ of care e2en at t!e co11unit+ setting T!is is nursing *ar$ance is not!ing $ess t!an t!e: A nursing diagnosis C nursing researc! %. nursing *rotoco$ +. nursin" pro#ess Situation 5 > 5engue !e11or!agic fe2er is a co11on !ea$t! concern in P!i$i**ine societ+ It does not on$+ *ose a t!reat to !ea$t! "ut 1ore so to t!e $i2es of "ot! +oung and o$d8 and ,e$$ as ric! and 1argina$i7ed sectors of t!e societ+ G1 An i1*ortant ro$e of t!e co11unit+ !ea$t! nurse in t!e *re2ention and contro$ of 5engue @fe2er inc$udes: A ad2ising t!e e$i1ination of 2ectors "+ #ee*ing ,ater containers co2ered < conducting strong !ea$t! education dri2es9ca1*aign directed to,ards *ro*er gar"age dis*osa$ C. e<plainin" to the in)i(i)uals/ *a'ilies/ "roups an) #o''unity the nature o* the )isease an) its #ausation 5 *racticing residua$ s*ra+ing ,it! insecticides G' Co11unit+ !ea$t! nurses s!ou$d "e a$ert in o"ser2ing a 5engue sus*ect T!e fo$$o,ing is NOT an indicator for !os*ita$i7ation of @Efe2er sus*ectsA A )ar#ed anore0ia8 a"do1ina$ *ain and 2o1iting < Increasing !e1atocrit count C. 8e(er *or 'ore than 4 )ays 5 Persistent !eadac!e G- T!e co11unit+ !ea$t! nursesH *ri1ar+ concern in t!e i11ediate contro$ of !e1orr!age a1ong *atients ,it! dengue is: A ad2ising $o, fi"er and nonEfat diet < *ro2iding ,ar1t! t!roug! $ig!t ,eig!t co2ers

27
C. obser(in" #losely the patient *or (ital si"ns lea)in" to sho#& 5 #ee*ing t!e *atient at rest G3 :!ic! of t!ese signs 1a+ NOT "e REGAR5E5 as a tru$+ *ositi2e signs indicati2e of 5engue @Efe2erA A Pro$onged "$eeding ti1e %. Appearan#e o* at least ; pete#hiae C Steadi$+ increasing !e1atocrit count 5 Fa$$ in t!e *$ate$et count G6 :!ic! of t!e fo$$o,ing is t!e 1ost i1*ortant treat1ent of *atients ,it! 5engue @EFe2erA A Gi2e as*irin for fe2er %. Repla#e'ent o* bo)y *lui)s C A2oid unnecessar+ 1o2e1ent of *atient 5 Ice ca* o2er t!e a"do1en in case of 1e$ena Situation ; > T,o c!i$dren ,ere "roug!t to +ou One ,it! c!est indra,ing and t!e ot!er !ad diarr!ea T!e fo$$o,ing &uestions a**$+: GC Using Integrated )anage1ent and C!i$d!ood I$$ness .I)CI/ a**roac!8 !o, ,ou$d +ou c$assif+ t!e 1st c!i$dA A <ronc!o*neu1onia C. Se(ere pneu'onia < No *neu1onia : coug! or co$d 5 Pneu1onia GD T!e 1st c!i$d ,!o is 1- 1ont!s !as fast "reat!ing using I)CI *ara1eters !e !as: A. 59 breaths per 'inute or 'ore < 6% "reat!s *er 1inute C -% "reat!s *er 1inute or 1ore 5 C% "reat!s *er 1inute GF Nina8 t!e 'nd c!i$d !as diarr!ea for 6 da+s T!ere is no "$ood in t!e stoo$ S!e is irrita"$e8 and

!er e+es are sun#en T!e nurse offered f$uids and and t!e c!i$d drin#s eager$+ @o, ,ou$d +ou c$assif+ NinaHs i$$nessA A So'e )ehy)ration C Se2ere de!+dration < 5+senter+ 5 No de!+dration GG NinaHs treat1ent s!ou$d inc$ude t!e fo$$o,ing E(CEPT: A reassess t!e c!i$d and c$assif+ !i1 for de!+dration < for infants under C 1ont!s o$d ,!o are not "reastfed8 gi2e 1%%E'%% 1$ c$ean ,ater as ,e$$ during t!is *eriod C Gi2e in t!e !ea$t! center t!e reco11ended a1ount of ORS for 3 !ours +. +o not "i(e any other *oo)s to the #hil) *or ho'e treat'ent 1%% :!i$e on treat1ent8 Nina 1F 1ont!s o$d ,eig!ed 1F #gs and !er te1*erature registered at -D degrees C @er 1ot!er sa+s s!e de2e$o*ed coug! - da+s ago Nina !as no genera$ danger signs S!e !as 36 "reat!s91inute8 no c!est inEdra,ing8 no stridor @o, ,ou$d +ou c$assif+ NinaHs 1anifestation A. No *neu1onia C. Pneu'onia < Se2ere *neu1onia 5 <ronc!o*neu1onia

SU%?IT T2IS TEST %33E.ET T3GET2ER 0IT2 T2E ANS0ER S2EET T3 F3UR 0ATC2ERS. %RINGING T2E TEST %33E.ET 3UT 38 T2E R33? 0I.. %E A GR3UN+ 83R CANCE..ATI3N 38 F3UR EGA?INATI3N. NNNEN5NNN 28 NURSING PRACTICE III SET A ________________________________________________________________________ NURSING PRACTICE III Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS: 11 T!is test "oo#$et contains 1%% test &uestions 1' Read INSTRUCTIONS TO E(A)INEES *rinted on +our ans,er s!eet 1- S!ade on$+ one .1/ "o0 for eac! &uestion on +our ans,er s!eets T,o or 1ore "o0es s!aded ,i$$ in2a$idate +our ans,er 13 A4OI5 ERASURES 16 T!is is PRC property. Unaut!ori7ed *ossession8 re*roduction8 and9or sa$e of t!is test is punishable by law. Per RA 898 .

________________________________________________________________________
INSTRUCTIONS: D 5etac! one .1/ ans,er s!eet fro1 t!e "otto1 of +our E0a1inee I59Ans,er S!eet Set F :rite t!e su";ect tit$e !Nursin" Pra#ti#e III$ on t!e "o0 *ro2ided G S!ade Set <o0 =A> on +our ans,er s!eet if +our test "oo#$et is Set A? Set <o0 =<> if +our test "oo#$et is Set <

)ULTIPLE C@OICE
6 T!ere is an order of Centra$ 4enus *ressure .C4P/ reading As a nurse t!at t!is is a 1easure of o"ser2ing signs of: A !+*o0ia C !+*ot!er1ia <. hypo(ole'ia 5 !+*o0e1ia C Pu$1onar+ ede1a is a *otentia$ danger t!at ,e nurses s!ou$d 1onitor in *ost *neu1onecto1+ T!is is usua$$+ due to: A e0tre1e te1*erature < $i"era$ f$uid inta#e C rapi) in*usion o* IJ *lui)s 5 f$uid retention due to *ro$onged "ed rest Situation 4ET!e PRC regu$ates t!e *ractice of 3' *rofessions in t!e P!i$i**ines C :!at is t!e "asic re&uire1ent of t!e state for a nurse to *ractice !er *rofessionA A :i$$ingness to *ractice t!e *rofession

< A <SN degree C. A nursin" li#ense 5 An NCLE( and CGFNS *asser D T!e code of Good Go2ernance for t!e *rofessions in t!e P!i$i**ines s!a$$ "e ada*ted "+: A a$$ registered *rofessiona$s C a$$ *rofessiona$s %. all 8ilipino pro*essionals 5 a$$ registered nurses F T!e standardi7ed guide$ines and *rocedures for t!e i1*$e1entation of Continuing Professiona$ Education .CPE/ for a$$ *rofessiona$ Reso$ution Nu1"er '%%3E1DG *ro2ides t!at t!e tota$ CPE credit units for registered *rofessiona$s ,it! "acca$aureate degree s!ou$d "e: A '% credit units *er +ear C. A9 #re)it units *or 6 years < -% credit units for - +ears 5 1% credit units re&uired

29
G T!e "oard of Nursing is 2ested ,it! *o,er to issue8 sus*end or re2o#e for cause t!e: A certificate of Good )ora$ C!aracter C. #erti*i#ate o* Re"istration < certificate of Practice 5 certificate of E1*$o+1ent 1% RA D1G- sti*u$ates t!e re1o2a$ e0a1ination of t!e nurse $icensure e0a1ination s!a$$ "e ta#en: A :it!in - +ears after t!e $ast fai$ed e0a1ination < An+ti1e t!e e0a1inee ,ants to ta#e t!e e0a1ination C. 0ithin 4 years a*ter the last *aile) e<a'ination 5 :it!in t!e sa1e +ear after t!e fi$ed e0a1ination Situation 6 E Pain is a$,a+s associated to surger+ 11 As a surgica$ nurse8 ,!ic! of t!e fo$$o,ing nursing inter2ention ,i$$ a$$a+ an0iet+ and *ain a1ongA surgica$ *atientsA A. Asses the #lient *or #on#erns espe#ially those that #an potentially #ause pain < 4erif+ t!at t!e o*erated *er1it is signed C 5iscourage t!e c$ient fro1 discussing t!e detai$s of t!e surgica$ *rocedure 5 Ensure safet+ of c$ient ,!i$e in surger+ 1' R!i7oto1+ is a condition surgica$ *rocedure to 1anage t!ose t!at can *otentia$$+ cause *ain :!at is t!e crucia$ in deter1ining a good candidate for r!i7oto1+A A Pain ,!ic! is resistant to nonE*!ar1aco$ogic for C 1ont! < Pain ,!ic! is resistant to *!ar1aco$ogic *rotoco$ for 1' 1ont!s C. .o#al pain with no ra)iatin" pain or si"ns o* ner(ous #o'passion 5 5ee* *ain ,it! o"2ious signs of *eri*!era$ ner2e da1age 1- :!ic! of t!e fo$$o,ing ,ou$d "e t!e nurseHs a**ro*riate res*onse to a cr+ing fe1a$e c$ient sc!edu$ed for e1ergenc+ surger+ ,!o is 2er"a$i7ing fear of *ain "ut afraid to go to s$ee*A A Let !er cr+ and te$$ significant ot!er to stand "+ < S&uee7e !er !and and assure !er t!at t!ere ,i$$ " no *ain at a$$ "ecause s!e ,i$$ "e gi2en anest!esia C. Stan) by her si)e an) ,uietly as& her to )es#ribe her *eelin"s. 5 C!ec# !er na1e tag and re&uest anest!esio$ogist to sedate c$ient 13 :!ic! of t!e fo$$o,ing c$ients state1ent indicates t!at !e understands t!e nurseHs instruction a"out *osto*erati2e ,ound *ainA A =I s!a$$ ca$$ t!e nurse ,!en 1+ ,ound itc!es and s1e$$s> %. !I shall e<pe#t sli"ht pain an) )is#o'*ort *ro' the sur"i#al in#ision$. C =I s!ou$d ca$$ 1+ doctor if 1+ ,ound !as no drainage and intact> 5 =I s!ou$d not touc! 1+ surgica$ ,ound> 16 :!at do +ou t!in# is an i1*ortant res*onsi"i$it+ re$ated to *ain t!at is su";ecti2e in natureA A 5i2ert attention of c$ient in *ain < Lea2e t!e *atient a$one ,!i$e in *ain C. %elie(e what the patient says about the pain 5 Assu1e res*onsi"i$it+ to e$i1inate *ain as descri"ed "+ t!e c$ient Situation 5ENurseHs attitudes to,ard t!e *ain inf$uence t!e ,a+ t!e+ *ercei2e and interact ,it! c$ients in *ain

1C Nurses s!ou$d "e a,are t!at o$der adu$ts are at ris# of underrated *ain Nursing assess1ent and 1anage1ent of *in s!ou$d address t!e fo$$o,ing "e$iefs E(CEPT:

30
A O$der *atients se$do1 tend to re*ort *ain t!an t!e +ounger ones < Pain is a sign of ,ea#ness C. 3l)er patients )o not belie(e in anal"esi#s/ they are tolerant 5 Co1*$aining of *ain ,i$$ $ead to "eing $a"e$ed a P"adH *atient 1D Nurses s!ou$d understand t!at ,!en a c$ient res*onds fa2ora"$+ to a *$ace"o8 it is #no,n as t!e P*$ace"o effectH P$ace"os do not indicate ,!et!er or not a c$ient !as: A Conscience C 5isease %. Real pain 5 5rug to$erance 1F Bou are t!e nurse in t!e *ain c$inic ,!ere +ou !a2e c$ient ,!o !as difficu$t+ s*ecif+ing t!e $ocation of *ain @o, can +ou assist suc! c$ientA A T!e *ain is 2ague < <+ c!artingEit !urts a$$ o2er C Identif+ t!e a"sence and *resence of *ain +. As the #lient to point to the pain*ul are by =ust one *in"er 1G :!at s+1*to18 1ore distressing t!an *ain8 s!ou$d t!e nurse 1onitor ,!en gi2ing o*ioids es*ecia$$+ a1ong e$der$+ c$ients ,!o are in *ainA A Forgetfu$ness C 5ro,siness < Consti*ation 5 A$$ergic reactions $i#e *ruritis '% P!+sica$ de*endence occurs in an+one ,!o ta#es o*ioods o2er a *eriod of ti1e :!at do +ou te$$ a 1ot!er of a Pde*endentH ,!en as#ed for ad2iceA A Start anot!er drug and s$o,$+ $essen t!e o*ioid dosage < Indu$ge in recreationa$ outdoor acti2ities C Iso$ate o*ioid de*endent to a restfu$ resort +. Instru#t slow taperin" o* the )ru" )osa"e an) alle(iate physi#al with)rawal sy'pto's Situation ;7 As a *erio*erati2e nurse8 +ou are a,are of t!e correct *rocessing 1et!ods for *re*aring instru1ents and ot!er de2ices for *atient use to *re2ent infection '1 Ite1s t!at enter steri$e tissue or 2ascu$ar s+ste1 are categori7ed as critica$ ite1s and s!ou$d "e: A C$ean C. Sterili@e) < 5econta1inated 5 5isinfected '' As an OR nurse8 ,!at are +our fore1ost considerations for se$ecting c!e1ica$ agents for disinfectionA A. ?aterial #o'patibility an) e**i#ien#y < Odor and a2ai$a"i$it+ C Cost and duration of disinfection *rocess 5 5uration of disinfection and efficienc+ '- <efore +ou use a disinfected instru1ent it is essentia$ t!at +ou: A Rinse ,it! ta* ,ater fo$$o,ed "+ a$co!o$ < :ra* t!e instru1ent ,it! steri$e ,ater C 5r+ t!e instru1ent t!oroug!$+ +. Rinse with sterile water '3 Bou !a2e a critica$ !eat $a"i$e instru1ent to steri$i7e and are considering touse !ig! $e2e$ disinfectant :!at s!ou$d +ou doA A Co2er t!e soa#ing 2esse$ to contain t!e 2a*or < 5ou"$e t!e a1ount of !ig! $e2e$ disinfectant C Test t!e *otenc+ of t!e !ig! $e2e$ disinfectant +. Prolon" the e<posure ti'e a##or)in" to 'anu*a#turer-s )ire#tion

31
'6 As a nurse8 +ou #no, t!at intact s#in acts as an effecti2e "arrier to 1ost 1icroorganis1s T!erefore8 ite1s t!at co1e in contact ,it! t!e intact s#in s!ou$d "e:

A. +isin*e#te) C C$ean < Steri$e 5 A$co!o$i7ed Situation A7T!e OR is di2ided into t!ree 7ones to contro$ traffic f$o, and conta1ination 'C :!at OR attires are ,orn in t!e restricted areaA A Scru" suit8 OR s!oes8 !ead ca* %. 2ea) #ap/ s#rub suit/ 'as&/ 3R shoes C )as#8 OR s!oes8 scru" suit 5 Ca*8 1as#8 g$o2es8 s!oes -- Nursing inter2ention for a *atient on $o, dose I4 insu$in t!era*+ inc$udes t!e fo$$o,ing8 E(CEPT: A. Ele(ation o* seru' &etones to 'onitor &etosis < 4ita$ signs inc$uding <P C Esti1ate seru1 *otassiu1 5 E$e2ation of "$ood g$ucose $e2e$s -3 T!e doctor ordered to incor*orate 1%%%>u> insu$in to t!e re1aining on going I4 T!e strengt! is 6%% 91$ @o, 1uc! s!ou$d +ou incor*orate into t!e I4 so$utionA A 1% 1$ C % 6 1$ %. 4 'l 5 6 1$ -6 )u$ti*$e 2ia$EdoseEinsu$in ,!en in use s!ou$d "e A. &ept at roo' te'perature C #e*t in narcotic ca"inet < #e*t in t!e refrigerator 5 store in t!e free7er Situation 8ECo$$a"orati2e *$anning is essentia$ if nursing and !ea$t! care are to "e 1ade a2ai$a"$e to a$$ *eo*$e -C Perio*erati2e e0a1*$es of co$$a"oration are t!e fo$$o,ing E(CEPT: A Co11unicate ,it! ot!er 1e1"ers of t!e !ea$t! *rofession to i1*ro2e t!e integrit+ < Co11unicate ,it! !ea$t! officia$s t!e incidence of @e*atitis < a1ong OR *ersonne$ C. Collaboration with other 3R personnel re"ar)in" the pra#ti#es o* sur"eons #olle#tin" e<orbitant pro*essional *ees 5 Co$$a"orate ,it! 5O@ regarding dis*osa$ or s*eci1ens -D T!e nurses co$$a"orate ,it! ot!er 1e1"ers of t!e !ea$t! *rofession to i1*ro2e t!e integrit+ of t!e !os*ita$ ,or#ing en2iron1ent t!e fo$$o,ing ,a+s E(CEPT A Koining "aranga+ !ea$t! c$u" *ro;ects %. Koinin" the ?ayo Uno .abor Union C Koining $a"or da+ ra$$+ to increase ,ages of !ea$t!care ,or#ers and i1*ro2e di$a*idated !ea$t! centers 5 Affi$iating ,it! T!e @ea$t!care A$$iance -F An e0a1*$e of co$$a"orating effort on *u"$ic ser2ice *articu$ar$+ during su11er is: A <oto 1o8 I*atro$ 1o C C$ean and Green < O*eration Linis +. 3peration Tuli

32
-G :!en does a nurse re;ect t!e interde*endence of *ro2iders and *atients in ac!ie2ing access to !ea$t! careA A. !3ur hospital )oes not honor (isitin" )o#tors$ < :!en t!e nurse re*$ies to t!e c$ientHs re$ati2e =Bou !a2e t!e "est doctor in to,n> C :!en t!e nurse co11unicates to t!e attending *!+sician t!e desire of t!e *atient to "e seen "+ a uro$ogist 5 =T!e doctor is not on dut+ toda+> 3% Indi2idua$ *atients and societ+ as a ,!o$e "enefit fro1 nursing *artici*ation in decisions 1ade a"out !ea$t! care T!is is e0e1*$ified in: A. Supportin" politi#al #an)i)ates that a)(an#e nursin" #are issues < <ringing t!e NCLE( in P!i$i**ines C Su**orting t!e *ro$iferation of co$$eges of nursing in t!e countr+

5 Fo$$o,ing t!e decision of CGFNS to reta#e Test III and I4 to 2a$idate t!e 2isa screen for t!e U S Situation 97*ain 1anage1ent is not $i1ited to *!ar1aco$ogica$ 1eans: 31 Rona$d one of +our c$ients ,!o is "eing ,or#ed out for AI5S te$$s +ou t!at !e !as "een using acu*uncture to !e$* ,it! !is *ain Bou &uestioned !is treat1ent "ecause: A. A#upun#ture uses nee)les to sti'ulate #ertain points on the bo)y to treat pain < Acu*uncture uses 2ariet+ of !er"s and oi$s fro1 ,i$d *$ants C Acu*uncture uses 1ani*u$ation of t!e s#e$eta$ 1usc$es to re$ie2e stress and *ain 5 Acu*uncture uses *ressure fro1 t!e fingers and !ands to sti1u$ate "od+ res*onses 3' Bour +ounger "rot!er ca1e !o1e ,it! rig!t "$ac# e+e @e as#ed +ou for an e+e oint1ent to re$ie2e t!e *ain and s,e$$ing Bou s!ou$d offer: A. i#e pa#& o(er the ri"ht eye < !ot co1*ress o2er t!e rig!t e+e C tetrac+c$ine o*!t!a$1ic oint1ent 5 ice co$d drin#s 36 )enstrua$ *ain and disco1fort account for a"sences in sc!oo$s and offices A non*!ar1aco$ogica$ re1ed+ for 1enstrua$ *ain is: A regu$ar "o,e$ 1o2e1ent %. &nee7#hest e<er#ise be*ore 'enstruation an) hot water ba" appli#ation o(er lower ab)o'en )urin" onset C ,ar1 s!o,er during onset of 1enstrua$ *eriod 5 diet restriction on fatt+ foods and $i"era$ f$uid inta#e Situation 9 One $earns "+ doing es*ecia$$+ ,!en +ou *ractice t!e "est 1et!ods 3C :!ic! action "+ a ne, nurse signifies a need for furt!er teac!ing in infection contro$A A T!e nurse *$aces t!e side rai$s t!e ti1e to an unconscious *atient < T!e nurse e$e2ates t!e !ead of t!e "ed to c!ec# t!e <P C. The nurse uses her bare han)s to #han"e the )ressin" 5 T!e nurse a**$ies o0+gen cat!eter to t!e 1out! 3D Bou are on P) s!ift and a"out 6 *atients are of disc!arge Bou noted t!at t!e order$+ ,as $oo#ing t!roug! t!e ite1s of one of t!e *atients :!ic! action s!ou$d +ou *ursueA A. Call the attention o* the or)erly in pri(ate < Ignore t!e situation "ecause +ou are "us+ C Re*ort t!is "e!a2ior to t!e nurse in c!arge 5 )onitor t!e situation and note ,!et!er an+ ot!er ite1s are re*orted 1issing 3F :!at a**ro*riate action s!ou$d +ou do ,!en +ou o2er!ear t!e nursing attendant s*ea#ing !ars!$+ to an e$der$+ *atientA

33
A. Try to e<plore the intera#tion with the nursin" atten)ant #on#erne) < C!ange t!e attendantHs assign1ent C Initiate a grou* discussion ,it! a$$ ot!er nursing attendants 5 5iscuss t!e 1atter ,it! t!e *atientHs fa1i$+ 3G Bou !a2e "een in t!e surgica$ ,ard for a$1ost a +ear and !a2e cared for a nu1"er of *atients ,it! C4P :!ic! o"ser2ation fro1 a co$$eague ,ou$d indicate a need for furt!er teac!ingA A T!e co$$eague turns t!e sto*Ecoc# to t!e off *osition fro1 t!e I4 f$uid to t!e *atient %. The nurse #ollea"ue note) the le(el at the top o* the 'enis#us C. The #ollea"ue instru#ts the #lients to per*or' the (alsal(a 'aneu(er )urin" the CJP rea)in" +. The nurse #ollea"ue #hartin" 'e)i#ation a)'inistration that she has not yet "i(en 6% Bou sa, one co$$eague c!arting 1edication ad1inistration t!at s!e !as not +et ad1inistered After ta$#ing to !er8 +ou a$so re*ort t!e incident to t!e c!arge nurse T!e c!arge nurse s!ou$d: A. Re,uire the sta** to sub'it an in#i)ent report

< Ter1inate t!e nurse C C!arge t!e erring nurse ,it! dis!onest+ 5 Re*ot to t!e <oard of Nursing Situation Bou are assigned at t!e PACU At G:-% A)8 *ostEo* c$ients started to "e 1 in fro1 t!e OR 61 :!ic! nursing diagnosis !as *riorit+ a1ong c$ient in t!e PACUA A Acute *ain re$ated to disco1fort off ,ound and i11o"i$it+ < <od+ i1age distur"ance "ecause of ,ound dressing and drains C. Ine**e#ti(e airway #learan#e relate) to "eneral anesthesia. 5 Ino,$edge deficit re$ated to $ac# of infor1ation "ecause *atients are a$$ sedated 6' :!ic! of t!e fo$$o,ing c$ients at t!e PACU ,i$$ de1onstrate t!e effecti2eness of 1 teac!ingA A. The #lient )e'onstrate) )eep breathin"/ #ou"hin"/ splinterin" an) le" e<er#ises. < T!e c$ient 1anifests nor1a$ te1*erature C T!e c$ient s$ee*s ,e$$ 5 T!e c$ient !as good "a$ance I and O 6- :!ic! of t!e fo$$o,ing re1ar# indicates t!at t!e c$ientHs re$ati2e understood t!e disc!arge instruction for ,ound careA A =If t!e ,ound is *ainfu$8 I ,i$$ sa+ it is nor1a$> < =It is a$rig!t to use ad!esi2e ta*e o2er t!e ,ound to #ee* it intact> C =It is o# for !is *et to re1ain at !is "edside to #ee* !i1 co1*an+> +. !I will report any re)ness or swellin" o* the woun)$ 63 Bou 1ust transfer out a *ostEo* c$ient to !er roo1 :!at ,ou$d +our instruction to t!e fa1i$+ inc$ude to *re2ent accidentsA A Re*ort ,!en t!e I4 infusion is a$1ost finis!ed < Test t!e ca$$ s+ste1 if functioning C Iee* t!e roo1 $ig!ts on for '3 !ours +. ?a&e sure the si)e rails are up 66 One of +our *ostEo* *atients !as a te1*erature of -D GQC and ,as s!i2ering Bou co2ered !i1 ,it! a "$an#et and $ater too# !is te1*erature again and it is no, -F GQC T!e nursing student as#ed +ou to e0*$ain t!e a"sence of s!i2ering e2en if t!e te1*erature ,as !ig!er A T!e *atient is no $onger fe"ri$e t!us !e is no $onger c!i$$ing

34
< S!i2ering nor1a$$+ disa**ears as te1*erature "eco1es !ig!er C. The bo)y has rea#he) its new set point thus the absen#e o* shi(erin" 5 T!e *atients is fee$ing "etter Situation 4 Patients ,it! c!est tu"es can "e 2er+ c!a$$enging to ne, nurses 6C T!e c!est tu"e drainage of Tirso !as continuous "u""$ing in t!e ,ater sea$ drainage After an !our +ou noticed t!at t!e "u""$ing sto*s :!ic! of t!e fo$$o,ing condition is t!e *ossi"$e cause of t!e 1a$functioning sea$ed drainageA A A suction "eing too !ig! C A tu"e "eing too s1a$$ < An air lea& 5 A tension *neu1ot!ora0 6D :!i$e +ou ,ere 1a#ing +our endorse1ent8 +ou found out t!e c!est tu"e of a c$ient ,as disconnected :!at ,ou$d "e +our a**ro*riate actionA A Assist t!e c$ient "ac# to !is "ed and *$ace !i1 on t!e affected side < Co2er t!e end of t!e c!est tu"e ,!i$e steri$i7e gau7e C. Re#onne#t the tube to the #hest tube syste' 5 Put t!e end of t!e c!est tu"e into a cu* of steri$e nor1a$ sa$ine 6F 5r Re+es as#ed +ou to assist !i1 ,it! t!e re1o2a$? of TirsoHs c!est tu"e Bou ,ou$d instruct t!e c$ient to: A Continuous$+ "reat!e nor1a$$+ during t!e nor1a$ of t!e c!est tu"e %. Ta&e a )eep breath/ e<hale/ an) bear )own C E0!a$e u*on actua$ re1o2a$ of t!e tu"e

5 @o$d "reat! unti$ t!e c!est tu"e is *u$$ed out 6G C!est tu"e dia1eter is 1easured or e0*ressed in: A *ren#h C 1i$$i$iters < gauge 5 inc!es C% :!en trans*orting c$ients ,it! c!est tu"e8 t!e s+ste1 s!ou$d "e: A disconnected < c$osed C. pla#e) lower than the patient-s #hest 5 *$aced "et,een t!e $egs of t!e c$ient to *re2ent "rea#age Situation 6 T!e *reo*erati2e nurse co$$a"orates ,it! t!e c$ient significant ot!ers8 and !ea$t!care *ro2iders C1 To contro$ en2iron1enta$ !a7ards in t!e OR8 t!e nurse co$$a"orates ,it! t!e fo$$o,ing de*art1ents E(CEPT: A "io1edica$ di2ision C infection contro$ co11ittee < #haplain#y ser(i#es 5 *at!o$og+ de*art1ent C- :aste dis*osa$ *oses a "ig *ro"$e1 for t!e !os*ita$ <io$ogica$ ,astes .i e a1*utated $i1"s/ dis*osa$ s!ou$d "e coordinated ,it! fo$$o,ing agencies E(CEPT: A Cre1atoriu1 C ))5A < +32 5 5ILG C3 Tess8 t!e PACU nurse8 disco2ered t!at )a$ou8 ,!o ,eig!ts 11% $"s *rior to surger+8 is in se2ere *ain - !rs after c!o$ec+stecto1+ U*on c!ec#ing t!e c!art8 )a$ou found out t!at s!e !as an order of 5e1ero$ 1%% 1g I ) *rn for *ain Tess s!ou$d 2erif+ t!e order ,it!: A Nurse su*er2isor C. Sur"eon < Anest!esio$ogist 5 Intern on dut+

35
C6 Rosie8 6D8 ,!o is dia"etic is for de"ride1ent if incision ,ound :!en t!e circu$ating nurse c!ec#ed t!e *resent I4 f$uid8 s!e found out t!at t!ere is no insu$in incor*orated as ordered :!at s!ou$d t!e circu$ating nurse doA A. +ouble #he#& the )o#tor-s or)er an) #all the atten)in" ?+ < Co11unicate ,it! t!e ,ard nurse to 2erif+ if insu$in ,as incor*orated or not C Co11unicate ,it! t!e c$ient to 2erif+ if insu$in ,as incor*orated 5 Incor*orate insu$in as ordered Situation 13 Tec!no$og+ and *atientHs education !as dra1atica$$+ i1*ro2ed t!e 1anage1ent of t!e dia"etic c$ient CC T!e current insu$in *u1*s a2ai$a"$e in t!e 1ar#et !a2e t!e fo$$o,ing ca*a"i$it+8 E(CEPT: A Pre2ent une0*ected sa2ing in "$ood g$ucose 1easure1ents %. +ete#t si"ns an) sy'pto's o* hypo"ly#ae'ia an) hyper#al#e'ia. C 5e$i2er a *reE1ea$ "o$us dose of insu$in "efore eac! 1ea$ 5 5e$i2er a continuous "asa$ rate of insu$in at 6 % units to ' % units *er !our CD 5isc!arge *$an of dia"etic c$ients inc$ude in;ectionEsiteErotation Bou s!ou$d e1*!asi7e t!at t!e s*ace "et,een sites s!ou$d "e: A C c1 < 6 c1 C. 4.; #' 5 3 c1 CF It is critica$ a$so t!at a dia"etic c$ient s!ou$d "e educated in t!e *ossi"$e sites if regu$ar insu$in in;ection T!e fastest a"sor*tion rate !a**ens at t!e tissue areas of: A G$utea$ area < 5e$toid area C Anterior area +. Ab)o'inal area CG Se$fE1onitoring of "$ood g$ucose .S)<G/ is reco11ended for *atientHs use Bou ,i$$ reco11end t!is tec!no$og+ in t!e fo$$o,ing dia"etic *atients8 E(CEPT:

A. Client with proli*erati(e retinopathy < Unsta"$e dia"etes C @+*og$+ce1ia ,it!out ,arning 5 A"do1ina$ rena$ g$ucose t!res!o$d D% It is necessar+ for a dia"etic c$ient to e0ercise regu$ar$+ :!at is t!e effect of regu$ar e0ercise to a dia"etic c$ientA A It "urns e0cess g$ucose < It i1*ro2es insu$in uti$i7ation and $o,ers "$ood g$ucose C. It lowers "lu#ose/ i'pro(es insulin utili@ationL )e#rease total tri"ly#eri)e le(els 5 It ,i$$ 1a#e +ou fit and energi7ed Situation ;E RNHs s!ou$d a$,a+s "e conscious t!at t!e contents in c!arting are ad1issi"$e in court as e2idence D1 If t!ere is an+ de2iation fro1 nor1a$ *ractice or *rocedure e g stre*to1+cin ,as gi2en "+ I4 not I)8 t!is s!ou$d docu1ented in t!e: A Progress notes %. In#i)ent report C NurseHs not 5 PatientHs c!art D' T!e docu1entation of a$$ nursing acti2ities *erfor1ed is $ega$$+ and *rofessiona$$+ 2ita$

36
:!ic! of t!e fo$$o,ing s!ou$d NOT "e inc$uded in t!e *atientHs c!artA A Presence of *rost!etoid de2ices suc! as dentutes8 artificia$ $i1"s !earing aid8 etc < <ase$ine *!+sica$8 e1otiona$8 and *s+c!osocia$ data C. Ar"u'ents between nurses an) resi)ents re"ar)in" treat'ents 5 O"ser2ed unto,ard signs and s+1*to1s and inter2entions inc$uding conta1inant inter2ening factors D- 5uring +our 1orning rounds8 )r Ti*o$8 C% +ear o$d ,ido,er tried to sit u* an instead of !o$ding to t!e side rai$ !e$d t!e I4 stand causing t!e I4 "ott$e to fa$$ and "rea# Bou ,rote an incident re*ort to s!o,: A. +o#u'ent the in#i)ent < <e a *art of t!e *atientHs c!art C Present confidentia$ re*ort 5 E2idence of t!e &ua$it+ of care D3 Erasures8 a$terations8 and additions in 1edica$ records and t!e nurseHs notes can "e a2oided T!e fo$$o,ing are so1e ti*s on !o, to do corrections E(CEPT: A Cross out "$an# s*aces < Cross out ,rong ,ord or *!rase ,it! one or t,o $ines 1a#ing t!e crossed out ,ord discerni"$e C. Insert a))itions or #orre#tions 5 State t!e reason for an+ de2iation fro1 nor1a$ *rocedure9*ractice D6 Iat!+ is one of +our *atientHs @er unc$e8 ,!o is a doctor8 ,ants to read !er c!art Bour a**ro*riate action ,ou$d "e: A. Instru#t Eathy-s un#le to present a written authori@ation si"ne) by the patient < Refer to t!e !os*ita$ director C Instruct Iat!+Hs unc$e to *resent a ,ritten re&uest to t!e )edica$ Records Section of t!e !os*ita$ 5 Refer to t!e attending *!+sician Situation AE 5uring t!e 1ont! of Ku$+8 +ou noticed t!at t!ere is an incidence of u**er res*irator+ 5isorders DC One of +our cases is ,it! acute *!ar+ngitis Bour nursing 1anage1ent inc$udes t!e fo$$o,ing E(CEPT:

A Suggest a soft or $i&uid diet during acute stage %. En#oura"e liberal a'ount o* #ol) *ruit =ui#es C Encourage "ed rest during stage 5 A**$+ ice co$$ar for s+1*at!etic re$ief of se2ere sore t!roat DD For nurse to asses an u**er res*irator+ tract infection8 +ou s!ou$d *a$*ate t!e fo$$o,ing: A T!e ears8 e+es8 nose8 and t!roat %. A)enoi)s tonsils an) nose C Nose and t!roat on$+ 5 T!e trac!ea$ and nasa$ 1ucosa inc$uding t!e fronta$ sinuses DF A1ong t!e *atients ,it! u**er air,a+ infection8 air,a+ c$earance can "e faci$itated "+ t!e fo$$o,ing E(CEPT: A Regu$ar$+ ad1inistering *rescri"ed 2asoconstricti2e 1edication %. +e#reasin" syste'ati# hy)ration C Positiona$ drainage 5 @u1idif+ing ins*ired roo1 air DG A friend as#ed +ou so1e nursing 1easures of unco1*$icated co11on co$ds Bou ,i$$ inc$ude t!e fo$$o,ing 1easures E(CEPT:

37
A Instruct c$ient a"out s+1*to1s of secondar+ infections %. A)'inister pres#ribe) antibioti#s C Teac! t!at t!e causati2e 2irus is contagious e2en "efore s+1*to1s a**ear 5 Suggest ade&uate of f$uids and rest F% T!e fo$$o,ing are +our nursing suggestions for a *atient ,it! acute or c!ronic sinusitis E(CEPT: A. .o#al heat appli#ation to pro'ote )raina"e < Consu$t an ENT surgeon C Increase !u1idit+ 5 Ad2ice ade&uate f$uid inta#e Situation BE A s*eci1en is a *iece of tissue or "od+ f$uid ta#en fro1 t!e disease "od+ organ or tissue to aid t!e !ea$t! care tea1 in diagnosis and effecti2e treat1ent F1 Car1en is sus*ected to !a2e a $eft CA S!e is sc!edu$ed in +our roo1 on 6 for fro7en section @o, ,i$$ +ou *re*are t!e s*eci1en for $a"orator+A A Refrigerate and send it a$ong ,it! t!e da+Hs s*eci1ens %. Sen) to patholo"y i''e)iately without soa&in" solution C Soa# it in NSS 5 Soa# it in for1a$in F' @o, ,i$$ +ou $a"e$ t!is s*eci1enA :!at infor1ation ,as essentia$ in t!e $a"e$A A Na1e of t!e c$ient8 age8 se08 !os*ita$ nu1"er < Na1e of t!e c$ient8 age8 se0 C Na1e8 age8 site8 t+*e of s*eci1en8 !os*ita$ nu1"er8 doctor +. Na'e/ )o#tor/ type o* spe#i'en/ hospital nu'ber F- Foreign "od+ t!e e0tracted fro1 t!e "od+ $i#e *ins8 need$es8 seeds or "u$$ets are a$so considered as a s*eci1en Bou assisted in t!e 1u$ti*$e gunEs!ot ,ound e0*$oration 5uring t!e surger+ t!e s*eci1en to: A. The )epart'ent o* patholo"y < T!e nationa$ "ureau of in2estigation C T!e OR !ead nurse 5 C$ientHs fa1i$+ F3 A *ost di$ation and curettage .5 and C/ c$ient is for disc!arge Fo$$o,Eu* of $a" resu$t s!ou$d "e *art of t!e disc!arge *$an Bou ,i$$ instruct t!e c$ient to fo$$o, u* resu$t at t!e: A )edica$ record < La"orator+ C. +o#tor-s #lini# 5 NurseHs station

F6 Bou are t!e circu$ating nurse in OR ' Bou !a2e 3 t!+roidecto1+ cases for t!e da+ @o, do +ou *re2ent s,itc!ing of s*eci1ensA A. Sen) spe#i'ens to laboratory ri"ht away a*ter the operation with the proper labels < Co$$ect a$$ s*eci1ens and send to $a"orator+ at t!e end of t!e da+ C La"e$ s*eci1en at once 5 Pre*are 3 s*eci1en 2ia$s first t!ing in t!e 1orning Situation 8E )r Santos8 6%8 is to undergo c+stosco*+ due to 1u$ti*$e *ro"$e1s $i#e scant$+ urination8 !e1aturia and d+suria FC Bou are t!e nurse in c!arge in )r Santos :!en as#ed ,!at are t!e organs to "e e0a1ined during c+stosco*+8 +ou ,i$$ enu1erate as fo$$o,s: A Uret!ra8 #idne+8 "$adder8 uret!ra

38
%. Urethra/ bla))er wall/ tri"one/ ureteral openin" C <$adder ,a$$8 uterine ,a$$8 and uret!ra$ o*ening 5 Uret!ra$ o*ening8 uretera$ o*ening "$adder FD In t!e OR8 +ou ,i$$ *osition )r Santos ,!o is c+stosco*+ in: A Su*ine %. .ithoto'y C Se1iEfo,$er 5 Trende$en"urg FF After c+stosco*+8 )r Santos as#ed +ou to e0*$ain ,!+ t!ere is no incision of an+ #ind :!at do +ou te$$ !i1A A =C+stosco*+ is direct 2isua$i7ation and e0a1ination "+ uro$ogist> < =C+stosco*+ is done "+ 0Era+ 2isua$i7ation of t!e urinar+ tract> C =C+stosco*+ is done "+ using $asers on t!e urinar+ tract> +. !Cystos#opy is an en)os#opi# pro#e)ure o* the urinary tra#t$. FG :it!in '3E3F !ours *ost c+stosco*+8 it is nor1a$ to o"ser2e one t!e fo$$o,ing: A. Pin&7tin"e) urine < 5istended "$adder C Signs of infection 5 Pro$onged !e1aturia G% Leg cra1*s are NOT unco11on *ost c+stosco*+ Nursing inter2ention inc$udes: A <ed rest %. 0ar' 'oist soa& C Ear$+ a1"u$ation 5 @ot sit7 "at! Situation 9E 5uring t!e surgica$ *rocedure8 conta1ination s!ou$d "e confined and contained ,it!in t!e i11ediate 2icinit+ of t!e surgica$ fie$d to *re2ent t!e s*read of *at!ogenic 1icroorganis1s G1 T!e fo$$o,ing tec!ni&ues i$$ustrates t!e conce*t =confine and contain> E(CEPT: A Conta1inated ite1s $i#e s*onges are !and$ed using $o2es < A$$ "$ood tissue8 and "od+ f$uid s*eci1ens s!ou$d "e *$aced in $ea#E*roof containers C. Sur"eons #on)u#t their patient-s roun)s in s#rub suit 5 Pro1*t c$eanu* of accidenta$ s*i$$s of conta1inated de"ris e g "$ood8 "od+ f$uids G' T!e OR is a restricted area ,!ere OR attire is ,orn Te1*erature and !u1idit+ are set for *atient and *ersonne$ safet+ and reduce "acteria$ conta1ination 5uring t!e surger+8 1o2e1ent of *ersonne$ inc$uding t!e circu$ating nurse is: A. Eept to 'ini'u' < E$i1inated ,!en *ossi"$e C Restricted 5 )onitored

G- Steri$e is t!e condition of a$1ost a$$ ite1s8 de2ices or su**$ies used in t!e OR for an+ surgica$ *rocedure S!e$fE$ife of a *ac#aged steri$e ite1 is e2ent re$ated and de*ends on t!e fo$$o,ing8 E(CEPT: A. Type o* sterili@er use) to sterili@e ite's < A1ount of !and$ing C T!e &ua$it+ of *ac#aging 1ateria$ used 5 Storage conditions G3 Precaution reco11ends t!at t!e use of standard *ersona$ *rotecti2e e&ui*1ent .PPE/ to *re2ent cross conta1ination :!ic! is NOT considered a *iece of PPEA A. Co(er "own

39
< E+e,ear C G$o2es 5 Face s!ie$ds G6 Traffic *atterns in t!e OR suite s!ou$d A Pre2ent unaut!ori7ed *ersonne$ fro1 entering t!e OR %. Pre(ent trans'ission o* patho"eni# 'i#roor"anis's C Assure t!at t!e *ersonne$ ,a$# in t!e sa1e direction 5 A$$o,s *ersonne$ to 1o2e free$+ "et,een restricted and unrestricted areas Situation 49E No#ia is so *o,erfu$ to =connect *eo*$e> fro1 t!e continent to continent8 a$$ t!roug! co11unication 2ia t!e ce$$*!one Ot!er ,a+s of co11unicating to re$a+ infor1ation or instructions e0ist e2en in t!e !ea$t!care setting GC An anest!esio$ogist is *re*aring to do a s*ina$ anest!esia to a ''% $"8 -% +ear o$d at!$ete s!e re&uest t!e circu$ating nurse to *re*are a *in# s*ina$ set ,it! anot!er "$ue set as stand "+ :!at gauge s*ina$ sets ,i$$ 1a#e a2ai$a"$e in t!e OR suiteA A. Gau"e A an) 44 < Gauge 1F and 1C C Gauge 1C and '% 5 Gauge 6 and '' GD )edica$ gases are used a $oGt in t!e OR So1e gases are used to o*erate e&ui*1ent and so1e are used to ad1inister genera$ anest!esia t!roug! in!a$ation :!at is t!e identif+ing co$or of t!e tan# ,!ic! contains P$aug!ing gasHA A Be$$o, < Green C <$ac# +. %lue GF On t!e traffic $ig!t8 +e$$o, 1eans =*roceed ,it! caution> In t!e fie$d of !ea$t!care8 ,!ere do +ou discard +our used tissue *a*ersA A. Fellow bin < Orange "in C Green "in 5 <$ac# "in GG An instru1ent tra+ ,it! "$ac# stri*ed autoc$a2e9stea1 c!e1ica$ indicator ta*e co11unicates t!at t!e instru1ent tra+ A Is c$ean < Is read+ for use in surger+ C Is steri$e +. 2as un)er"one the sterili@ation pro#ess 1%% In !ea$t! care ,!en $ad a*ron is re&uired in an+ *rocedure $i#e ort!osurger+8 t!ere is danger of e0*osure to: A :ater and "$ood s*$as!es < Pseudo1onas C. Ra)iation

5 <one frag1ents

SU%?IT T2IS TEST %33E.ET T3GET2ER 0IT2 T2E ANS0ER S2EET T3 F3UR 0ATC2ERS. %RINGING T2E TEST %33E.ET 3UT 38 T2E R33? 0I.. %E A GR3UN+ 83R CANCE..ATI3N 38 F3UR EGA?INATI3N. 40 NNNEN5NNN NURSING PRACTICE IJ SET A ________________________________________________________________________ NURSING PRACTICE I4 Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS: 1C T!is test "oo#$et contains 1%% test &uestions 1D Read INSTRUCTIONS TO E(A)INEES *rinted on +our ans,er s!eet 1F S!ade on$+ one .1/ "o0 for eac! &uestion on +our ans,er s!eets T,o or 1ore "o0es s!aded ,i$$ in2a$idate +our ans,er 1G A4OI5 ERASURES '% T!is is PRC property. Unaut!ori7ed *ossession8 re*roduction8 and9or sa$e of t!is test is punishable by law. Per RA 898 .

________________________________________________________________________
INSTRUCTIONS: 1% 5etac! one .1/ ans,er s!eet fro1 t!e "otto1 of +our E0a1inee I59Ans,er S!eet Set 11 :rite t!e su";ect tit$e !Nursin" Pra#ti#e IJ$ on t!e "o0 *ro2ided 1' S!ade Set <o0 =A> on +our ans,er s!eet if +our test "oo#$et is Set A? Set <o0 =<> if +our test "oo#$et is Set <

)ULTIPLE C@OICE
1%1 Bou are t!e nurse in an Adu$t Care Unit Bou o2er%!ear one of +our coEstaff nurse assigned to A$ing Kosie ,!o is DF +ears o$d sa+8 t!at if s!e refuses to ta#e !er 1edications8 s!e ,i$$ not "e gi2en !er fa2orite dessert Bou re*ort +our coEstaffHs "e!a2ior as: A <atter+ C Neg$igence < Assault 5 )a$*ractice 1%' Ka#e is in t!e Post Anest!esia Care Unit fo$$,ing a co$orecta$ resection @e !as an I4 of 5e0trose 6M Lactated Ringers So$ution U*on assess1ent +ou o"ser2e t!at !e is e0!i"iting sudden onset of crac#$es in t!e $ungs8 1oist res*iration and tac!+*nea :!ic! of t!e fo$$o,ing ,i$$ +ou do FIRSTA A Notif+ anest!esio$ogist C P$ace on Fo,$erHs *osition < Increase O' f$o, rate +. Re)u#e IJ rate 1%- As a !ead nurse of t!e unit8 ,!ic! of t!e fo$$o,ing sources s!ou$d +ou ta#e into consideration ,!en 1a#ing effecti2e assign1ents for t!e ne0t s!iftA A seniorit+ *references < recent *erfor1ance e2a$uation C *ersona$it+ traits +. #lient #lassi*i#ation )ata 1%3 Four c$ients in;ured in an auto1o"i$e accident enter t!e e1ergenc+ de*art1ent .E5/ at t!e sa1e ti1e and are i11ediate$+ seen "+ a triage nurse As t!e triage nurse8 +ou ,ou$d assign t!e @IG@EST *riorit+ to t!e c$ient ,it! t!e: A se2ere !ead in;ur+ and no "$ood *ressure %. 'a<illo*a#ial in=ury an) "urlin" respirations C second tri1ester *regnanc+ ,it! *re1ature $a"or 5 $u1"ar s*ina$ cord in;ur+ and $o,er e0tre1it+ *ara$+sis

41
1%6 :!en a nurse 2o$unteers to ,or# in a !os*ita$ setting and s!e co11its a 1ista#e8 ,!o is $ega$$+ res*onsi"$eA A. (olunteer nurse/ hospital an) the nurse in #har"e

< t!e *rofessiona$ organi7ation ,!ic! t!e 2o$unteer nurse re*resents C !os*ita$ 5 2o$unteer nurse "ecause t!ere is no e1*$o+er e1*$o+ee re$ations!i* 1%C 5anie$ ,it! 1u$ti*$e 1+e$o1a co1*$ains of dee* "one *ain As !is nurse8 ,!ic! of t!e fo$$o,ing ,i$$ +ou do FIRSTA A. Assess bone pain < Ad1inister *rescri"ed ana$gesic C Teac! *ain re$ief strategies 5 Su**ort *osition ,it! *i$$o, 1%D Bou are re2ie,ing t!e $a"orator+ resu$ts of C$are ,!o !as r!eu1atoid art!ritis :!ic! $a"orator+ resu$t s!ou$d +ou e0*ect to findA A Increased *$ate$et count < A$tered "$ood urea nitrogen .<UN/ and creatinine $e2e$s C E$ectro$+te i1"a$ance +. Ele(ate) erythro#yte se)i'entation rate CESRD 1%F )rs Paras is recei2ing tota$ *arentera$ nutrition .TPN/ If +ou ,i$$ e2a$uate !er nutritiona$ status8 ,!ic! of t!e fo$$o,ing indicators ,i$$ te$$ +ou t!at TPN ,as effecti2eA A $a"orator+ ,or# u* < ade&uate !+dration C. wei"ht "ain 5 di1inis! e*isode of nausea and 2o1iting 1%G :!i$e Ka+2ee8 a "urn *atient is "eing transferred fro1 t!e "urn unit to t!e o*erating roo18 t!e I4 "ott$e fe$$ on Ka+2eeHs !ead @e sustained a $aceration on !is fore!ead T!e nurse ,as *ro2en gui$t+ of neg$igence :!ic! of t!e fo$$o,ing did t!e nurse fai$ to doA A @o$d t!e I4 "ott$e < C!ec# t!e I4 stand C. Pla#e the IJ stan) on the *oot part o* the stret#her 5 Restrain Ka+2ee 11% :!i$e )rs Enri&ue7 is recei2ing c!e1ot!era*+ ,!ic! of t!e fo$$o,ing ,i$$ +ou inc$ude in t!e *$an of care to address !er nutritiona$ needsA A. a)'inister Co'pa@ine be*ore 'eals < enric! diet ,it! red 1eats C ser2e !ot sou* and food 5 increase t!e a1ount of s*ice in t!e diet 111 Nurses ,or#ing in t!e -6 "ed Fe1a$e )edica$ Unit ,ere noted to i1*$e1ent ne, and inno2ati2e c$ient care acti2ities $ong "efore ot!er units in t!e !os*ita$ :!ic! of t!e fo$$o,ing $eaders!i* c!aracteristics e0!i"ited "+ t!e nurse 1anager "est descri"es t!is strengt!A A Co11unication s#i$$s C. Jision an) passion < Ino,$edge and s#i$$s 5 Inter*ersona$ a"i$ities 11' O$ga is recei2ing 56: 1 $iter regu$ated at -% dro*s91in to "e consu1ed in F !rs It ,as started at Fa1 At 1%a18 !er re$ati2e infor1ed +ou t!at t!e "ott$e is e1*t+ :!ic! of t!e fo$$o,ing ,i$$ +ou do firstA A refer to nurse 1anager < assess O$ga and c!ec# $e2e$ of f$uid $eft in t!e "ott$e

42
C. )is#ontinue IJ an) assess 3l"a 5 re*$ace I4 f$uid ,it! *rescri"ed fo$$o,Eu* 11- A researc! stud+ found out t!at C%M of *atients co1*$ains ,ere due to de$a+ed res*onses of nurses in t!e e1ergenc+ de*art1ent :!ic! of t!e fo$$o,ing 1easure1ent of data ,as used in t!is stud+A A )easures of 2aria"i$it+ C Fre&uenc+ distri"ution < )easures of centra$ tendenc+ +. In*erential statisti#s 113 5uring a 1ea$8 a c$ient ,it! !e*atitis < dis$odges !er I4 $ine and "$eeds on t!e surface

of t!e o2erEt!eE"ed ta"$e It ,ou$d "e 1ost a**ro*riate for t!e nurse to instruct a !ouse#ee*er to c$ean t!e ta"$e ,it!: A A$co!o$ C a11onia %. Acetone +. blea#h 116 Nino is "eing treated ,it! radiation t!era*+ :!at s!ou$d "e inc$uded in t!e *$an of care to 1ini1i7e s#in da1age fro1 t!e radiation t!era*+A A Co2er t!e areas ,it! t!ic# c$ot!ing 1ateria$s < A**$+ a !eating *ad to t!e site C :as! s#in ,it! ,ater after t!e t!era*+ +. A(oi) applyin" #rea's an) pow)ers to the area 11C Bou are assigned to t!e fo$$o,ing *atients :!ic! of t!e fo$$o,ing *atients is 1ost at ris# for 1eta"o$ic a$#a$osisA A. Gra#e/ 69 year ol) post sur"i#al patient who has #ontinuous naso"astri# su#tion < Rac!e$ a 66 +ear o$d ,!o !as ;ust e0*erienced a stro#e C @e$en8 D% +ear o$d ,it! a$tered $e2e$ of consciousness ,!o is una"$e to access ,ater free$+ 5 )ar+ Kane a ' +ear o$d infant recei2ing isotonic sodiu1 c!$oride I4 so$ution 11D Studies !a2e s!o,n t!at t!e !ig!est incidence of @odg#inHs disease is co11on a1ong +oung adu$ts Kuana8 '% +ears o$d a**roac!es +ou and te$$s +ou =I a1 ,orried a"out t!e 1ass on 1+ nec#> :!at s!ou$d +ou do as a nurseA A Te$$ !er t!ere is not!ing to ,orr+ if it does not "ot!er !er < Pa$*ate KuanaHs nec# and e0*$ain t!e *ossi"$e cause C Te$$ !er @odg#inHs disease is co11on a1ong +oung adu$ts $i#e !er +. Tell her to see a )o#tor 11F As a nurse8 +ou accidenta$$+ ad1inister 3% 1g of Pro*ano$o$ .Indera$/ to a c$ient instead of 1% 1g A$t!oug! t!e c$ient e0!i"its no ad2erse reactions to t!e $arger dose8 +ou s!ou$d: A. #o'plete an in#i)ent report < ca$$ t!e !os*ita$ attorne+ C infor1 t!e c$ientHs fa1i$+ 5 do not!ing "ecause t!e c$ientHs condition is sta"$e 11G Bou are t!e nurse 1anager of t!e )edica$ Unit :!ic! of t!e fo$$o,ing is a *riorit+ for +ou to consider ,!en *$anning for t!e care of a grou* of c$ients uti$i7ing e2idenceE"ased *racticeA A. Client-s #are is planne) base) on the nurse-s #lini#al e<pertise an) latest resear#h *in)in"s < Standardi7ed care *$ans are used on a$$ of t!e nurseHs c$ients C Standards of care are de2e$o*ed "+ t!e !os*ita$ nursing ser2ice and s!ou$d "e fo$$o,ed

43
5 C$ientHs needs are assessed and indi2idua$i7ed care *$an are de2e$o*ed for eac! c$ient 1'% <ecause of increase incidents of 1edication error due to ,rong transcri*tion of *!+sician 1edication orders "+ t!e nurse8 a tertiar+ !os*ita$ uti$i7ed a co1*uteri7ed 1edication order s+ste1 :!ic! of t!e fo$$o,ing *rocedures 1a+ "e done t!roug! t!e said s+ste1A A. Corre#t errors in the physi#ian 'e)i#ation or)er < E$i1inate drug interaction C Pro2ide a $ist of drugs ,it! t!eir generic na1e 5 5ocu1ent drug ad1inistration SITUATI3NA. Situation > P Cru78 C6 +ears o$d8 ,as ad1itted in t!e Te$e1etr+ "ecause of signs and

s+1*to1s of acute 1+ocardia$ infarction Bou are e0*ected to recogni7e e$ectrocardiogra*!ic readings on t!e cardiac 1onitor 1'1 :!ic! of t!e fo$$o,ing a**ear a"nor1a$ on an EIG ,!en isc!e1ia and in;ur+ occur in t!e 1+ocardiu1A A ORS inter2a$ C P ,a2e < ST se"'ent 5 PR inter2a$ 1'' Fro1 an ECG reading8 a ORS co1*$e0 re*resents: A Jenti#ular )epolari@ation C End of 2entricu$ar de*o$ari7ation < 4entricu$ar re*o$ari7ation 5 Atria$ de*o$ari7ation 1'- :!ic! of t!e fo$$o,ing re*resents 2entricu$ar re*o$ari7ationA A T wa(e C ORS co1*$e0 < ST seg1ent 5 PR inter2a$ 1'3 It is i1*ortant t!at t!e nurse 1easures inter2a$s of ORS co1*$e0 :!ic! of t!e fo$$o,ing re*resent t!e nor1a$ inter2a$ of ORS co1*$e0A A greater t!an '% sec C. . 9 se# < '% sec 5 1' sec to '% sec 1'6 Later in t!e acute *!ase of )+ocardia$ Infarction8 ,!ic! of t!e fo$$o,ing t+*ica$$+ a**ears as t!e first sign of tissue deat!A A ST seg1ent su**ression C Pro$onged PR inter2a$ < S!ort T ,a2e +. Patholo"i# M wa(e Situation 4 > To "e a"$e to !e$* our c$ients ,it! t!eir *s+c!o$ogica$ concerns8 ,e !a2e to e0*$ore !o, t!e+ 2ie, t!e1se$2es and t!eir "od+ i1age 1'C :!en assessing *atientHs "od+ i1age8 ,!ic! of t!e fo$$o,ing ,ou$d "e 1ost i1*ortant to as#A A. 0hat are your hobbies1 < :!at #ind of ,or# did +ou do *rior to t!is i$$nessA C Are +our $i2ing acco11odation a$$ on one $e2e$A 5 :!at #ind of food do +ou $i#eA 1'D T!e 1ost a**ro*riate nursing inter2ention to faci$itate c$ientHs acce*tance of a c!ange in "od+ i1age ,ou$d "e to: A encourage de*endence %. establish a therapeuti# relationship

44
C ;o#e ,it! t!e c$ient 5 esta"$is! a socia$ re$ations!i* 1'F :!ic! of t!e fo$$o,ing res*onses ,ou$d indicate t!at t!e c$ient is "eginning to acce*t c!ange in !is9!er "od+ i1ageA A. 8eelin" o* the )ressin" o(er the in#isional site < Stating !e9s!e is too tired to !a2e 2isitors C 5iscussing !is !er sta1* co$$ection ,it! t!e nurse 5 S!o,ing no interest in t!e dressing c!ange 1'G It is i1*ortant for +ou to re1e1"er8 t!at a sudden c!ange in "od+ i1age ,ou$d occur fro1: A :eig!t gain < Side effects of 1edication on s#in C Radiation treat1ent of t!e "reast +. Sur"i#al re'o(al o* an eyeball 1-% <efore +ou can !e$* Lorna acce*t a c!ange in "od+ i1age +ou 1ust FIRST: A "e in agree1ent ,it! t!e *!i$oso*!+ of t!era*+ for t!e c$ient %. be#o'e aware o* her own attitu)e towar) 'utilation an) )is*i"ure'ent C "e a,are of t!e attitudes and fee$ings of t!e c$ient and !er fa1i$+ 5 acce*t t!e fact t!at a *erson can $i2e ,it! a "od+ *art 1issing

Situation 6 > Radiation t!era*+ is anot!er 1oda$it+ of cancer 1anage1ent :it! e1*!asis on 1u$tidisci*$inar+ 1anage1ent +ou !a2e i1*ortant res*onsi"i$ities as nurse 1-1 A$"ert is recei2ing e0terna$ radiation t!era*+ and !e co1*$ains of fatigue and 1a$aise :!ic! of t!e fo$$o,ing nursing inter2entions ,ou$d "e 1ost !e$*fu$ for A$"ertA A Te$$ !i1 t!at so1eti1es t!ese fee$ings can "e *s+c!ogenic < Refer !i1 to t!e *!+sician C Reassure !i1 t!at t!ese fee$ings are nor1a$ +. 2elp hi' plan his a#ti(ities 1-' I11ediate$+ fo$$o,ing t!e radiation te$et!era*+8 A$"ert is A considered radioacti2e for '3 !rs < gi2en a co1*$ete "at! C *$aced on iso$ation for C !ours +. *ree *ro' ra)iation 1-- A$"ert is ad1itted ,it! a radiation induced t!ro1"oc+to*enia As a nurse +ou s!ou$d o"ser2e t!e fo$$o,ing s+1*to1s: A. pete#hiae/ e##hy'osis/ epista<is < ,ea#ness8 eas+ fatiga"i$it+8 *a$$or C !eadac!e8 di77iness8 "$urred 2ision 5 se2ere sore t!roat8 "actere1ia8 !e*ato1ega$+ 1-3 :!at nursing diagnosis s!ou$d "e of !ig!est *riorit+A A Ino,$edge deficit regarding t!ro1"oc+to*enia *recautions < Acti2it+ into$erance C. I'paire) tissue inte"rity 5 Ineffecti2e tissue *erfusion8 *eri*!era$8 cere"ra$8 cardio2ascu$ar8 gastrointestina$8 rena$ 1-6 :!at inter2ention s!ou$d +ou inc$ude in +our care *$anA

45
A. Inspe#t his s&in *or pete#hiae/ bruisin"/ GI blee)in" re"ularly < P$ace A$"ert on strict iso$ation *recaution C Pro2ide rest in "et,een acti2ities 5 Ad1inister anti*+retics if !is te1*erature e0ceeds -FC Situation 5 > Andrea is ad1itted to t!e ER fo$$o,ing an assau$t ,!ere s!e ,as !it in t!e face and !ead S!e ,as "roug!t to t!e ER "+ a *o$ice ,o1an E1ergenc+ 1easures ,ere started 1-C As AndreaHs nurse8 ,!at ,i$$ "e +our *riorit+ inter2entions A Insert an intra2enous cat!eter < Insert an ora$ or naso*!ar+ngea$ air,a+ C. 3btain arterial bloo) "ases 5 Gi2e 1%%M o0+gen "+ 1as# 1-D AndreaHs arteria$ "$ood gases ref$ect res*irator+ acidosis T!is is 1ost $i#e$+ re$ated to: A Partia$$+ o"structed air,a+ %. Ine**e#ti(e breathin" pattern C @ead in;ur+ 5 Pain 1-F Andrea $oses consciousness Bou s!ou$d *re*are for ,!ic! of t!e fo$$o,ing FIRSTA A P$ace1ent of a nasogastric tu"e < P$ace1ent of a second I4 $ine C. En)otra#heal intubation or sur"i#al airway pla#e'ent 5 CT scan of t!e !ead 1-G AndreaHs *!+sician gi2es an order of )annito$ % '6 g9#g I4 "o$us for increased ICP T!is is gi2en to: A. pro'ote #erebral7tissue *lui) 'o(e'ent < *ro1ote rena$ *erfusion

C correct acidE"ase i1"a$ances 5 en!ance rena$ e0cretion of drugs 13% As AndreaHs nurse +our goa$ is to *re2ent increased intracrania$ *ressure .ICP/ :!ic! of t!e fo$$o,ing inde*endent nursing inter2entions nursing inter2entions is NOT suited for !erA A. +o oropharyn"eal su#tion e(ery ; 'inutes to pre(ent pul'onary aspiration < Iee* !ead of "ed -%E36 degrees e$e2ated C )aintain AndreaHs !ead in straig!t a$ign1ent and *re2ent !i* f$e0ion 5 Pre2ent consti*ation and increases in intraEa"do1ina$ *ressure Situation ; > S*ecific surgica$ inter2entions 1a+ "e done ,!en $ung cancer is detected ear$+ Bou !a2e =i1*ortant *eriEo*erati2e> res*onsi"i$ities in caring for *atients ,it! $ung cancer 131 @orace under,ent $o"ecto1+ :!ic! of t!e fo$$o,ing is t!e *ur*ose of @oraceHs c$osed c!est drainage *ost $o"ecto1+A A Faci$itation of coug!ing %. Pro'otion o* woun) healin" C E0*ansion of t!e re1aining $ung 5 Pre2ention of 1ediastina$ s!ift 13' :!ic! of t!e fo$$o,ing o"ser2ations indicates t!at t!e c$osed c!est drainage s+ste1 is functioning *ro*er$+A A A"sence of "u""$ing in t!e suctionEcontro$ "ott$e %. The *lu#tuatin" 'o(e'ent o* *lui) in the lon" tube o* the water7seal bottle )urin" inspiration C Inter1ittent "u""$ing t!roug! t!e $ong tu"e of t!e suction contro$ "ott$e

46
5 Less t!an '6 1$ drainage in t!e drainage "ott$e 13- Fo$$o,ing $o"ecto1+8 +ou can "est !e$* @orace to reduce *ain during dee* "reat!ing and coug!ing e0ercises "+: A *$acing !i1 on !is o*erati2e side during e0ercises %. splintin" his #hest with both han)s )urin" the e<er#ises C ad1inistering t!e *rescri"ed ana$gesic i11ediate$+ *rior to e0ercises 5 *ro2iding rest for si0 !ours "efore e0ercises 133 Peter under,ent *neu1onecto1+ 5uring t!e i11ediate *osto*erati2e *eriod8 dee* trac!ea$ suction s!ou$d "e done ,it! e0tre1e caution "ecause: A Peter ,i$$ not "e a"$e to to$erate coug!ing < T!e trac!eo"rac!ia$ trees are dr+ C T!e re1aining nor1a$ $ung needs 1ini1a$ sti1u$ation +. The bron#hial suture line 'ay be trau'ati@e) 136 On ,!ic! of t!e fo$$o,ing *ositions s!ou$d +ou *$ace Peter ,!o ;ust under,ent *neu1onecto1+A A Prone *osition < On !is a"do1en or on t!e side o**osite t!e surger+ C. 3n his ba#& or on the si)e o* sur"ery 5 An+ *osition is acce*ta"$e Situation A > As a nurse +ou s!ou$d "e a"$e to address *ro"$e1s and disco1forts e0*erienced "+ t!e acute$+ i$$ o$der *ersons 13C Pain in t!e o$der *ersons re&uire carefu$ assess1ent "ecause t!e+: A Are e0*ected to e0*erience c!ronic *ain %. E<perien#e) re)u#e sensory per#eption C @a2e increased sensor+ *erce*tion 5 @a2e a decreased *ain t!res!o$d 13D Ad1inistration of ana$gesic to t!e o$der *ersons re&uires carefu$ *atient assess1ent "ecause o$der *eo*$e: A !a2e increased !e*atic8 rena$ and gastrointestina$ functions

< 1o"i$i7e drug 1ore ra*id$+ C !a2e increased sensor+ *erce*tion +. are 'ore sensiti(e to )ru"s 13F T!e o$der *erson is at !ig!er ris# for incontinence "ecause of: A increased g$o1eru$ar fi$tration C diuretic use < )e#rease) bla))er #apa#ity 5 di$ated uret!ra 13G T!e 1ost de*enda"$e cause of infection in t!e o$der *erson is A. #han"e in 'ental status < fe2er C decreased "reat! sounds ,it! crac#$es 5 *ain 16% Bour *riorities ,!en caring for t!e o$der *erson ,!o sustained trau1atic in;uries inc$ude: A circu$ation8 air,a+8 "reat!ing < air,a+8 "reat!ing disa"i$it+ .neuro$ogic/ C. airways/ breathin"/ #ir#ulation 5 disa"i$it+ .neuro$ogic/8 air,a+8 "reat!ing

47
Situation B > )ang Fe$i08 a DG +ear o$d 1an ,!o is "roug!t to t!e Surgica$ Unit fro1 PACU after a transuret!ra$ resection Bou are assigned to recei2e !i1 Bou noted t!at !e !as a -E,a+ ind,e$$ing urinar+ cat!eter for continuous fast dri* "$adder irrigation ,!ic! is connected to a straig!t drainage 161 I11ediate$+ after surger+8 ,!at ,ou$d +ou e0*ect !is urine to "eA A Lig!t +e$$o, C <rig!t red < A1"er +. Pin&ish to re) 16' T!e *ur*ose of t!e continuous "$adder irrigation is to: A a$$o, continuous 1onitoring of t!e f$uid out*ut status %. pro(i)e #ontinuous *lushin" o* #lots an) )ebris *ro' the bla))er C a$$o, for *ro*er e0c!ange of e$ectro$+tes and f$uid 5 ensure accurate 1onitoring of inta#e and out*ut 16- )ang Fe$i0 infor1s +ou t!at !e fee$s so1 disco1fort on t!e !+*ogastric area and !e !as to 2oid :!at ,i$$ "e +our 1ost a**ro*riate actionA A Re1o2e !is cat!eter t!en a$$o, !i1 to 2oid on !is o,n < Irrigate !is cat!eter C te$$ !i1 to =Go a!ead and 2oid Bou !a2e an ind,e$$ing cat!eter > +. assess #olor an) rate o* out*low/ i* there is a #han"e re*er to urolo"ist *or possible irri"ation. 163 Bou decided to c!ec# on )ang Fe$i0Hs I4 f$uid infusion Bou noted a c!ange in f$o, rate8 *a$$or and co$dness around t!e insertion site :!at is +our assess1ent findingA A P!$e"itis %. In*iltration to sub#utaneous tissue C P+rogenic reaction 5 Air e1"o$is1 166 Ino,ing t!at *ro*er docu1entation of assess1ent findings and inter2entions are i1*ortant res*onsi"i$ities of t!e nurse during first *ost o*erati2e da+8 ,!ic! of t!e fo$$o,ing is t!e LEAST re$e2ant to docu1ent in t!e case of )ang Fe$i0A A C!est *ain and 2ita$ signs < Intra2enous infusion rate C A1ount8 co$or8 and consistenc+ of "$adder irrigation drainage +. A#ti(ities o* )aily li(in" starte) Situation 8 > )an+ !os*ita$s for1 "ioet!ica$ re2ie, co11ittees to ensure "etter &ua$it+ of $ife of *atients Bou are in2ited "+ t!e nursing ser2ice de*art1ent to *artici*ate in t!eir "ioet!ica$ re2ie, co11ittee Bou are e0*ected to #no, t!e

*ur*ose and a**$+ "ioet!ica$ *rinci*$es 16C :!ic! of t!e fo$$o,ing is t!e *ur*ose of t!e et!ica$ re2ie, co11itteeA A. Pro'ote i'ple'entation o* "eneral stan)ar)s < En!ance !ea$t! care *ro2iderHs $ia"i$it+ C Increase indi2idua$s res*onsi"i$it+ for decision 1a#ing 5 5ecrease *u"$ic scrutin+ of !ea$t! care *ro2iderHs action 16D 5aria ,!o is ad1itted to t!e !os*ita$ ,it! autoi11une t!ro1"oc+to*enia and a *$ate$et count of '%8%%%9RL de2e$o*s e*ista0is and 1e$ena Treat1ent ,it! corticosteroids and i11unog$o"u$in !as not "een successfu$ @er *!+sician reco11ended s*$enecto1+ 5aria states =I donHt need surger+ T!is ,i$$ go a,a+ on its o,n > In considering +our res*onse to 5aria8 +ou 1ust de*end on t!e et!ica$ *rinci*$e of: A <eneficence C. Autono'y

48
< Kustice 5 Ad2ocac+ 16F Lora+da is ter1ina$$+ i$$ and is e0*eriencing se2ere *ain S!e as "one and $i2er 1etastasis S!e !as "een on 1or*!ine for se2era$ 1ont!s no, Lora+da is a,are t!at t!e+ are !a2ing financia$ *ro"$e1s S!e decides to sign a 5NR for1 :!at et!ica$ *rinci*$e did Lora+da and !er fa1i$+ uti$i7e as "asis for t!eir decision to sign a 5NR A Kustice C <eneficence < Autono'y 5 Ad2ocac+ 16G Tricia8 a staff nurse ,or#ing in a cancer unit8 is considered a ro$e 1ode$ not on$+ "+ !er co$$eagues "ut a$so "+ !er *atients S!e goes out of !er ,a+ to !e$* ot!er S!e is 2er+ acti2e in t!eir *rofessiona$ organi7ation and s!e *ractices ,!at s!e teac!es :!at et!ica$ *rinci*$es is s!e *racticingA A %ene*i#en#e C Ad2ocac+ < Autono1+ 5 Kustice 1C% Bou are co11uting to ,or# riding t!e LRT An o$der *erson co$$a*sed and no"od+ see1 to notice !er T!e securit+ guard tried to 1a#e !er sit do,n "ut s!e re1ained unconscious Bou sa, ,!at !a**ened and +ou decided to !e$* :it! !e$*8 +ou "roug!t t!e *atient to t!e nearest !os*ita$ Bou $earned $ater t!at ,o1an ,as dia"etic S!e ,as on !er ,a+ to t!e dia"etes c$inic to !a2e !er fasting "$ood sugar tested S!e de2e$o*ed !+*og$+ce1ia Bou ,ere a"$e to sa2e a $ife Bou fe$t good :!at *rinci*$e ,as a**$iedA A Ad2ocac+ C Kustice < %ene*i#en#e 5 Autono1+ Situation 9 > Ensuring safet+ "efore8 during and after a diagnostic *rocedure is an i1*ortant res*onsi"i$it+ of t!e nurse 1C1 To !e$* Fernan "etter to$erate t!e "ronc!osco*+8 +ou s!ou$d instruct !i1 to *ractice ,!ic! of t!e fo$$o,ing *rior to t!e *rocedureA A c$enc!ing !is fist e2er+ ' 1inutes %. breathin" in an) out throu"h the nose with his 'outh open C tensing t!e s!ou$der 1usc$es ,!i$e $+ing on !is "ac# 5 !o$ding !is "reat! *eriodica$$+ for -% seconds 1C' Fo$$o,ing a "ronc!osco*+8 ,!ic! of t!e fo$$o,ing co1*$ains to Fernan s!ou$d "e noted as a *ossi"$e co1*$ication: A nausea and 2o1iting %. shortness o* breath an) laryn"eal stri)or C "$ood tinged s*utu1 and coug!ing 5 sore t!roat and !oarseness 1C- I11ediate$+ after "ronc!osco*+8 +ou instructed Fernan to: A e0ercise t!e nec# 1usc$es %. breathe )eeply C retrain fro1 coug!ing and ta$#ing 5 c$ear !is t!roat

1C3 T!oracentesis 1a+ "e *erfor1ed for c+to$ogic stud+ of *$eura$ f$uid As a nurse +our 1ost i1*ortant function during t!e *rocedure is to: A #ee* t!e steri$e e&ui*1ent fro1 conta1ination < assist t!e *!+sician C o*en and c$ose t!e t!reeE,a+ sto*coc# +. obser(e the patient-s (ital si"ns 1C6 Rig!t after t!oracentesis8 ,!ic! of t!e fo$$o,ing is 1ost a**ro*riate inter2entionA

49
A instruct t!e *atient not to coug! or dee* "reat!e for t,o !ours %. obser(e *or sy'pto's o* ti"htness o* #hest *or blee)in" C *$ace an ice *ac# to t!e *uncture site 5 re1o2e t!e dressing to c!ec# for "$eeding Situation 9 > As a nurse +ou are e0*ected to "e co1*etent in uti$i7ing t!e nursing *rocess in t!e care of +our c$ients 1CC Gett+ is recei2ing c!e1ot!era*+ for cancer Bou re2ie, Gett+Hs $a"orator+ re*ort and note t!at !e !as ane1ia To ,!ic! nursing diagnosis s!ou$d +ou gi2e t!e !ig!est *riorit+A A Acti2it+ into$erance < I1*aired ora$ 1ucous 1e1"rane C. I'paire) tissue per*usion/ #erebral/ #ar)io(as#ular/ "astrointestinal 5 I1*aired tissue integrit+ 1CD An i11ediate o";ecti2e for nursing care of an o2er,eig!t 1i$d$+ !+*ertensi2e c$ient ,it! uretera$ co$ic and !e1aturia is to decrease: A @+*ertension C !e1aturia < Pain 5 ,eig!t 1CF A difficu$t *ro"$e1 to dea$ ,it! ,!en caring for a *atient ,it! a *artia$Et!ic#ness "urns sustained - da+s ago is: A a$teration in "od+ i1age C fre&uent dressing c!ange < 1aintenance of steri$it+ +. se(ere pain 1CG :!ic! outco1e criterion ,ou$d "e 1ost a**ro*riate for a c$ient ,it! a nursing diagnosis of ineffecti2e air,a+ c$earanceA A Continued use of o0+gen ,!en necessar+ %. %reath soun)s #lear on aus#ultation C Res*irator+ rate of '391in 5 Presence of congestion 1D% :!ic! assess1ent ,ou$d "e 1ost su**orti2e of t!e nursing diagnosis8 i1*aired s#in integrit+ re$ated to *uru$ent ,ound drainage A @eart rate of FF "eats91in C. 3ral te'perature o* 68.8 )e" C < 5r+ and intact ,ound dressing 5 :ound !ea$ing "+ first intention Situation > Nurses !a2e i1*ortant res*onsi"i$ities ,!en caring for !os*ita$i7ed acute$+ i$$ *atients 1D1 5o1ingo8 F% +ears o$d dia"etic and !+*ertensi2e is ad1itted in t!e *ri2ate ,ard for degenerati2e neuro$ogica$ c!anges @is *!+sician ,as considering de1entia Side rai$s ,ere *$aced to ensure t!at !e ,i$$ not fa$$ fro1 "ed At ':%% A)8 t!e ca$$ $ig!t at !is roo1 ,as on Bou ca1e in and sa, 5o1ingo s$u1*ed on t!e f$oor 1oaning @is daug!ter to$d +ou t!at !e got out of "ed to go to t!e toi$et @e c$i1"ed o2er t!e side rai$ "ut !is foot got caug!t in t!e "eddings @e !as an o*en ,ound on !is fore!ead :!ic! a1ong t!e fo$$o,ing ,i$$ +ou do FIRSTA A Transfer !i1 to "ed < A**$+ restraints C. Ensure airway/ breathin"/ #ir#ulation 5 Ca$$ !is *!+sician

50
1D' Ai1ee !as c!est *ain and decides to ta#e nitrog$+cerine en route to t!e !os*ita$ <ased

on t!e ECG o"tained on ad1ission at t!e ER and c$inica$ findings8 t!e *!+sician ga2e a diagnosis of 1+ocardia$ infarction .)I/ and *rescri"ed I4 1or*!ine to re$ie2e continuing *ain A *ri1ar+ goa$ of nursing care for Ai1ee is to recogni7e $ifeEt!reatening co1*$ications of )I As Ai1eeHs nurse8 +ou !a2e to antici*ate occurrence of co1*$ications Ta#e note t!at t!e 1a;or cause of deat! after an )I is: A. Car)ia# arrhyth'ias C Cardiogenic s!oc# < @eart fai$ure 5 Pu$1onar+ e1"o$is1 1D- T!e cardiac 1onitor indicates t!at CedricHs !eart rate !as increased to 16% "eats *er 1inute S!ort$+ after t!is increase8 +ou notice Cedric is in 2entricu$ar tac!+cardia after re*orting t!is to t!e *!+sician8 +ou antici*ate t!at t!e *!+sician ,i$$ order A intracardiac e*ine*!rine < insertion of a *ace1a#er C. bolus o* .i)o#aine 5 1anua$ cardio*u$1onar+ resuscitation 1D3 @er1ie ,it! a $eftEsided !eart fai$ure co1*$ains of increasing s!ortness of "reat! and is agitated and coug!ing u* of *in#Etinged foa1+ s*utu1 Bou s!ou$d recogni7e t!is as signs and s+1*to1s of: A cardiogenic s!oc# C. a#ute pul'onary e)e'a < rig!tEsided !eart fai$ure 5 *neu1onia 1D6 Bou are caring for Lu$u !as acute *u$1onar+ ede1a To i11ediate *ro1ote o0+genation and re$ief of d+s*nea8 +ou s!ou$d first: A *erfor1 c!est *!+siot!era*+ < !a2e !er ta#e dee* "reat!s and coug! C. pla#e .ulu on hi"h *owler-s position 5 ad1inister o0+gen Situation 4 > Acute res*irator+ distress is $ife t!reatening Bour *resence and critica$ decision 1a#ing as a nurse are i1*ortant 1DC Fran# is ad1itted to t!e Intensi2e Care Unit ,it! a diagnosis of acute res*irator+ distress s+ndro1e :!en assessing Fran# +ou ,ou$d e0*ect to find: A faci$itate Fran#Hs 2er"a$ co11unication < 1aintain steri$it+ of t!e 2enti$ation s+ste1 C assess !is res*onse to t!e e&ui*1ent 5 *re*are !i1 for e1ergenc+ surger+ E. +yspnea/ 8larin" o* the Nares 1DD Fran#Hs res*irator+ status necessitates endotrac!ea$ intu"ation and *ositi2e *ressure 2enti$ation Bour 1ost i11ediate nursing inter2ention for Fran# at t!is ti1e ,ou$d "e to: A faci$itate Fran#Hs 2er"a$ co11unication < 1aintain steri$it+ of t!e 2enti$ation s+ste1 C assess !is res*onse to t!e e&ui*1ent +. prepare hi' *or e'er"en#y sur"ery 1DF Tiger ,it! a *u$1onar+ e1"o$us is intu"ated and *$aced on 1ec!anica$ 2enti$ation :!en suctioning t!e endotrac!ea$ tu"e8 +ou s!ou$d: A a**$+ suction ,!i$e inserting t!e cat!eter < use s!ort and ;a""ing 1o2e1ents of t!e cat!eter to $oosen secretions C. hypero<y"enate with 99N o<y"en be*ore an) a*ter su#tionin" 5 suction t,o to t!ree ti1ed in &uic# succession to re1o2e a$$ secretions

51
1DG As a nurse8 +ou s!ou$d o"ser2e <ernard8 ,!o !as a restricti2e air,a+ disease8 for ear$+ indications of res*irator+ acidosis8 ,!ic! inc$ude: A $ig!tE!eadedness C "rad+cardia < "rad+*nea +. restlessness 1F% T!e *!+sician orders $o, concentration o0+gen to "e gi2en continuous$+ for Iennet! ,!o !as a c!ronic o"structi2e *u$1onar+ disease to *re2ent:

A an e0cessi2e dr+ing of t!e res*irator+ 1ucosa %. )epression o* the respiratory #enter C ru*ture of e1*!+se1atous "u$$ae 5 a decrease in red "$ood ce$$ for1ation Situation 6 > As a nurse +ou !a2e to "e *re*ared to care for *atients recei2ing "$ood transfusion T!e *!+sician !as ordered - units of ,!o$e "$ood to "e transfused to 5iego fo$$o,ing fo$$o,ing a re*air of a dissecting aneur+s1 of t!e aorta 1F1 Bou are *re*aring a unit of ,!o$e "$ood for transfusion Fro1 t!e ti1e +ou o"tain it fro1 t!e "$ood "an# !o, $ong s!ou$d +ou infuse itA A 5 hours C ' !ours < 1 !our 5 C !ours 1F' :!at s!ou$d +ou do FIRST "efore +ou ad1inister "$ood transfusionA A C!ec# I4 site and use a**ro*riate <T set and need$e %. Jeri*y physi#ian-s or)er C 4erif+ c$ient identit+ and "$ood *roduct "$ood *roduct8 seria$ nu1"er8 "$ood t+*e8 cross 1atc!ing resu$ts8 e0*iration date ,it! anot!er nurse 5 4erif+ c$ient identit+ and "$ood *roduct8 seria$ nu1"er8 "$ood t+*e8 cross 1atc!ing resu$ts8 e0*iration date 1F- As 5iegoHs nurse ,!at ,i$$ +ou do after t!e transfusion !as "een startedA A 5iscontinue t!e *ri1ar+ I4 of 5e0trose 6M ,ater %. Stay with +ie"o *or ; 'inutes to note *or any possible %T rea#tion C C!ec# !is 2ita$ signs e2er+ 16 1inutes 5 Add t!e tota$ a1ount of t!e "$ood to "e transfused to t!e inta#e and out*ut 1F3 5iego is undergoing "$ood transfusion of t!e first unit T!e ear$iest signs of transfusion reactions are: A o$iguria and ;aundice < urticaria and ,!ee7ing C !+*ertension and f$us!ing +. hea)a#he/ #hills/ *e(er 1F6 In case 5iego ,i$$ e0*erience an acute !e1o$+tic reaction8 ,!at ,i$$ "e +our *riorit+ inter2entionA A I11ediate$+ sto* t!e "$ood transfusion8 infuse de0trose 6M in ,ater and ca$$ t!e *!+sician < S$o, t!e "$ood transfusion and 1onitor t!e *atient c$ose$+ C I11ediate$+ sto* t!e "$ood transfusion8 notif+ t!e "$ood "an# and ad1inister anti!ista1ines +. I''e)iately stop the bloo) trans*usion/ in*use nor'al saline solution/ #all the physi#ian/ noti*y the bloo) ban&

52
Situation 5 > <ased on studies of nurses ,or#ing in s*ecia$ units $i#e t!e intensi2e care unit and coronar+ care unit8 it is i1*ortant for nurses to gat!er as 1uc! infor1ation to "e a"$e to address t!eir needs for nursing care 1FC Critica$$+ i$$ *atients fre&uent$+ co1*$ain a"out ,!ic! of t!e fo$$o,ing ,!en !os*ita$i7edA A @os*ita$ food C. .a#& o* pri(a#y < Lac# of "$an#ets 5 Inade&uate nursing staff 1FD :!o of t!e fo$$o,ing is at greatest ris# of de2e$o*ing sensor+ *ro"$e1A A Fe1a$e *atient C Trans*$ant *atient < Ado$oscent +. Unresponsi(e patient 1FF :!ic! of t!e fo$$o,ing factors 1a+ in!i"it $earning in critica$$+ i$$ *atientsA A gender %. 'e)i#ation

C educationa$ $e2e$ 5 *re2ious #no,$edge of i$$ness 1FG :!ic! of t!e fo$$o,ing state1ents does not a**$+ to critica$$+ i$$ *atientsA A )a;orit+ need e0tensi2e re!a"i$itation %. All ha(e been hospitali@e) pre(iously C Are *!+sica$$+ unsta"$e 5 )ost !a2e c!ronic i$$ness 1G% Fa1i$ies of critica$$+ i$$ *atients desire ,!ic! of t!e fo$$o,ing needs to "e 1et first "+ t!e nurseA A Pro2ision of co1forta"$e s*ace %. E'otional support C U*dated infor1ation on c$ientHs status 5 S*iritua$ counse$ing Situation ; > Pain is t!e 1ost co11on reasons ,!+ *eo*$e consu$t t!eir *!+sicians It is no, regarded as t!e 6t! 2ita$ sign T!is strateg+ is used to gi2e e1*!asis on !o, *ain s!ou$d "e 1anaged Bou !a2e co$$a"oration as ,e$$ as inde*endent nursing inter2entions for *ain 1G1 T!e :@O Ana$gesic $adder *ro2ides t!e !ea$t! *rofessiona$ ,it!: A *!ar1aco$ogic and non*!ar1aco$ogic *ain 1anage1ent c!oices %. "eneral pain 'ana"e'ent #hoi#es base) on le(el o* pain C non*!ar1aco$ogic inter2entions "ased on $e2e$ of *ain 5 s*ecific *ain 1anage1ent c!oices "ased on se2erit+ of *ain 1G' As a nurse caring for *atients in *ain8 +ou s!ou$d e2a$uate for o*ioid side effects ,!ic! inc$ude t!e fo$$o,ing E(CEPT: A physi#al )epen)en#e C Res*irator+ de*ression < *ruritus 5 consti*ation 1G- :!ic! of t!e fo$$o,ing state1ents a"out cancer *ain is NOT TRUE: A undertreat1ent of *ain is often due to a c$inicianHs fai$ure to e2a$uate t!e se2erit+ of t!e c$ientHs *ro"$e1 %. a)=u(ant 'e)i#ation su#h as steroi)s/ anti#on(ulsants/ non7steroi)al antiin*la''atory )ru"s enhan#e pain per#eption C o*ioids are drug of c!oice for se2ere *ain

53
5 *ain associated ,it! cancer and t!e ter1ina$ *!ase of t!e disease occurs in 1a;orit+ of *atients 1G3 Kac# !as "een on 1or*!ine on a regu$ar "asis for se2era$ ,ee#s @e is no, co1*$aining t!at t!e usua$ dose !e !as "een recei2ing is no $onger re$ie2ing !is *ain as effecti2e$+ Assu1ing t!at not!ing !as c!anged in !is condition8 +ou ,ou$d sus*ect t!at Kac# is: A "eco1ing *s+c!o$ogica$$+ de*endent < needing to !a2e 1or*!ine discontinued C. )e(elopin" toleran#e to 'orphine 5 e0aggerating !is $e2e$ of *ain 1G6 T!e guide$ines for c!oosing a**ro*riate non*!ar1aco$ogic inter2entions for *ain inc$ude a$$ of t!e fo$$o,ing E(CEPT: A *ain *ro"$e1 identification %. type o* opioi) bein" use) C s#i$$ of !ea$t! *rofessiona$ 5 effecti2eness for *atient Situation A > T!e nurseHs accurate assess1ent is 2er+ crucia$ in *re2enting co1*$ication during t!e se2ere *ost "urn *eriod 1GC 5ino sustained circu1ferentia$ t!er1a$ "urns of t!e $eft u**er e0tre1it+ and c!est Bou noted t!at *u$se cou$d not "e a**reciated in !is in;ured e0tre1it+ :!ic! of t!e fo$$o,ing ,i$$

+ou do FIRSTA A E$e2ate t!e in;ured e0tre1it+ to increase "$ood f$o, to t!e !eart < Re1o2e t!e dead tissues ,!ic! i1*ede circu$ation C Tr+ to ta#e t!e *u$se in t!e unin;ured e0tre1it+ +. Noti*y the physi#ian i''e)iately as this re,uires e'er"en#y inter(ention 1GD :!i$e un$oading containers ,it! c!e1ica$s fro1 a truc#8 )ar# accidenta$$+ s*i$$ed t!e ,!o$e can of corrosi2e c!e1ica$s a$$ o2er !is "od+ :!ic! of t!e fo$$o,ing ,ou$d +ou consider as t!e *riorit+ inter2ention in t!e e1ergenc+ 1anage1ent of )ar#A A )aintain a *atent air,a+ < :as! t!e c!e1ica$ off ,it! coo$ ,ater C Assess for associated in;uries +. Re'o(e all #lothin" #ontainin" the #he'i#al 1GF Bou are assigned in t!e <urn Unit and +ou are going to e2a$uate t!e status of Ra+1ond ,!o sustained a "urn in;ur+ 1' !ours ago and !as a urinar+ out*ut of '%% 1$ since t!e in;ur+ :!ic! of t!e fo$$o,ing ,i$$ +ou do FIRSTA A Increase t!e rate of t!e I4 f$uid < Ad1inister t!e *rescri"ed Furose1ide .Lasi0/ C. Che#& #atheter *or &in&s 5 Increase t!e ora$ inta#e to -%9!r 1GG Iat!+8 ,!o !as *artia$Et!ic#ness "urns on t!e face8 in&uiries a"out s#in care after disc!arge :!ic! of t!e fo$$o,ing s!ou$d +ou inc$ude in +our disc!arge teac!ingA A Continue to eat !ig! ca$oric !ig! food for t!e ne0t 1ont! < :ear a *ressure gar1ent dai$+ for one +ear C. A(oi) sunli"ht *or the ne<t three 'onths 5 A2oid facia$ 1a#eu* for at $east a +ear '%% Bou are caring for Lenard ,!o sustained se2ere "urn in;ur+ and !e is in t!e e1ergent *!ase of "urn in;ur+ As !is nurse8 +ou gat!ered t!e fo$$o,ing: @e1og$o"in 1- 6 g91%% 1$8 @e1atocrit 6%M8 seru1 Na 1-% 1E&9L @o, ,i$$ +ou e0*$ain t!e $a"orator+ resu$tsA A T!ese are due to !e1odi$ution fro1 ra*id I4 f$uid re*$ace1ent < A$$ t!e $a"orator+ tests are ,it!in nor1a$ rage C T!e+ are s$ig!t$+ a"nor1a$ "ut ,i$$ nor1a$i7e once I4 f$uids !a2e "een started

54
+. These are )ue to a loss o* seru' an) interstitial *lui) throu"h the burn woun).

SU%?IT T2IS TEST %33E.ET T3GET2ER 0IT2 T2E ANS0ER S2EET T3 F3UR 0ATC2ERS. %RINGING T2E TEST %33E.ET 3UT 38 T2E R33? 0I.. %E A GR3UN+ 83R CANCE..ATI3N 38 F3UR EGA?INATI3N.
NNNEN5NNN

NURSING PRACTICE J SET A ________________________________________________________________________ NURSING PRACTICE 4 Foundation of PROFESSIONAL Nursing Practice
GENERAL INSTRUCTIONS: '1 T!is test "oo#$et contains 1%% test &uestions '' Read INSTRUCTIONS TO E(A)INEES *rinted on +our ans,er s!eet '- S!ade on$+ one .1/ "o0 for eac! &uestion on +our ans,er s!eets T,o or 1ore "o0es s!aded ,i$$ in2a$idate +our ans,er '3 A4OI5 ERASURES '6 T!is is PRC property. Unaut!ori7ed *ossession8 re*roduction8 and9or sa$e of t!is test is punishable by law. Per RA 898 .

________________________________________________________________________
INSTRUCTIONS: 1- 5etac! one .1/ ans,er s!eet fro1 t!e "otto1 of +our E0a1inee I59Ans,er S!eet Set

13 :rite t!e su";ect tit$e !Nursin" Pra#ti#e J$ on t!e "o0 *ro2ided 16 S!ade Set <o0 =A> on +our ans,er s!eet if +our test "oo#$et is Set A? Set <o0 =<> if +our test "oo#$et is Set <

)ULTIPLE C@OICE SITUATI3NA.

Situation > T!e fo$$o,ing &uestions refer to nurseHs efforts to do co$$a"oration and tea1,or# Se$ect t!e "est ans,er 1 T!e 1ost i1*ortant ro$e of t!e nurse as a 1e1"er of t!e tea1 is to: A carr+ out 1edica$ orders < 1eet t!e needs for t!e *!+sica$ ,e$$ "eing of *atients C. #oor)inate the psy#holo"i#al #are an) 'ana"e'ent o* #lients 5 #ee* a '3 !our ,atc! for t!e *atients ' A "io$ogica$91edica$ a**roac! to *atient care uti$i7es ,!ic! of t!e fo$$o,ingA A )i$$ion t!era*+ C <e!a2iora$ t!era*+ %. So'ati# therapy 5 Ps+c!ot!era*+ - :!ic! of t!ese nursing actions "e$ong to t!e secondar+ $e2e$ of *re2enti2e inter2entionA

55
A Pro2iding 1enta$ !ea$t! consu$tation to !ea$t! care *ro2iders %. Pro(i)in" e'er"en#y psy#hiatri# ser(i#es C <eing *o$itica$$+ acti2e in re$ation to 1enta$ !ea$t! issues 5 Pro2iding 1enta$ !ea$t! education to 1e1"ers of t!e co11unit+ 3 :!en t!e nurse identifies a c$ient ,!o !as atte1*t to co11it suicide t!e nurse s!ou$d: A ca$$ a *riest < counse$ t!e c$ient C. re*er the #lient to the psy#hiatrist 5 refer t!e 1atter to t!e *o$ice 6 T!e co11unit+ !ea$t! nurse ,as in2ited "+ t!e *rinci*a$ of an e$e1entar+ sc!oo$ and ,as as#ed to gi2e a ta$# to *arents An a**ro*riate to*ic ,ou$d "e: A t!e $ega$ as*ects of drug a"use %. )is#iplinin" #hil)ren at ho'e an) s#hool C 1arita$ crises 5 t!e *ro"$e1s of out of sc!oo$ +out! Situation 4 > T!e nurse 2isited t!e Re+es fa1i$+ to c!ec# on t!eir t,o gro,ing c!i$dren8 aged D and 3 +ears U*on !er 2isit s!e o"ser2ed t!at co11on areas of argu1ents "et,een )r and )rs Re+es are a"out conf$icting ,a+s of "ringing u* t!eir c!i$dren )rs Re+es is $a0 and to$erant ,!i$e )r Re+es often insists strict ,a+s to a *oint of *rotecti2eness fro1 ,!at !e *ercei2es as unsafe i e co11unit+ and neig!"ors t!at cannot "e trusted C )r Re+es re1ar#ed =I a1 ,ar+ a"out *eo*$e 2isitingE ,it! a$$ t!e 1edia ne,s a"out c!i$d #idna**ing and ro""eries =T!e nurseHs <EST res*onse ,ou$d "e: A =:ou$d +ou rat!er ,is! t!at I donHt co1e and 2isit +ou 1a+ regard 1e as a strangerA> < =I get t!at > T!e nurse di2erts t!e attention to ta$# a"out nonEt!reatening to*ics C. !It 'ust be )istressin" to thin& an) *eel the way you )o.$ 5 =I ac#no,$edge ,!at +ou are sa+ing )+ concern is t!e !ea$t! care of +our fa1i$+ and infor1ation are strict$+ confidentia$ > D )rs Re+es e0*ressed t!at !er socia$i7ing ,it! neig!"ors is $i1ited "ecause !er !us"and t!in#s s!e is getting o2er$+ friend$+ ,it! a gu+ ne0t door :!ic! of t!e fo$$o,ing ,ou$d t!e nurse e1*!asi7e as "asicA A. Eeepin" trust in the relationship < A2oid re$ating ,it! neig!"ors to 1ini1i7e conf$ict C <e asserti2e to e0*ress to e0*ress !er indi2idua$it+ 5 Ignore t!e !us"and and ;ust "e su**orti2e

F For t!e nurse to "e effecti2e in de2e$o*ing ra**ort ,it! t!e fa1i$+ it is essentia$ t!at s!e #ee*s !er a**oint1ent on ti1e and stic# to a care *$an S!e is a**$+ing t!e *rinci*$e of: A res*onsi"i$it+ and accounta"i$it+ < consistenc+ and *redicta"i$it+ C. honesty an) inte"rity 5 e1*at!+ and co1*assion G :!ic! of t!ese s+1*to1s if de1onstrated "+ )r Re+es ,ou$d necessitate referra$ to a doctorA A @+*er2igi$ance C !+*ersensiti2e < Sus*icious affect +. loss o* reality #onta#t 1% T!e *aranoid c$ient uti$i7es ,!ic! of t!e fo$$o,ing defense 1ec!anis1sA A Su"$i1ation C Rationa$i7ation < Pro=e#tion 5 Reaction for1ation

56
Situation 6 > )r Sison !as "een diagnosed as !a2ing ear$+ c!ronic g$auco1a @e !as "een ad1itted to t!e !os*ita$ for treat1ent 11 T!e nurse identified a nursing *ro"$e1 of distur"ed sensor+ *erce*tion: 2isua$ i1*air1ent c!aracteri7ed "+: A sudden $oss of e+esig!t < $oss of nig!t 2ision C. loss o* peripheral (ision 5 $oss of centra$ 2ision 1' In order to understand t!e rationa$e for drug t!era*+8 it is i1*ortant for t!e nurse to #no, t!at g$auco1a is usua$$+ caused "+: A o*acit+ in t!e $ens < gradua$ di1inution of t!e retina C da1age to t!e *roteins in t!e $ens +. in#rease pro)u#tion o* a,ueous *lui) 1- 5ia1o0 is a drug used in t!e treat1ent of g$auco1a :!ic! of t!ese is t!e effect of t!is drugA A Constricts t!e *u*i$ < Acts as os1otic diuretic C. Re)u#es the pro)u#tion o* a,ueous hu'or 5 Faci$itates outf$o, of a&ueous !u1or 13 Pu"$ic !ea$t! nurses s!ou$d identif+ ,!ic! of t!ese *atients as a ris# grou* for de2e$o*1ent of g$auco1a8 !ence t!e need for annua$ e+e e0a1inations: A Patient ,it! Par#insonHs disease < Cancer *atients C. +iabeti# an) hypertensi(e patients 5 Patient ,it! COP5 16 T!e a**ro*riate 1et!od of insti$$ing e+e dro*s is: Insti$$ing into an o*ened e+e8 ,it! t!e !ead !e$d "ac# and ,it! t!e e+e $oo#ing: A Upwar) C aggressi2eness < do,n,ard 5 sus*iciousness Situation 5 > SE(UAL 5ISOR5ER 1C A !os*ita$i7ed 1a$e ado$escent f$irts ,it! and is se0ua$$+ *ro2ocati2e to,ard a fe1a$e nurse T!e nurse can res*ond )OST t!era*eutica$$+ "+ doing ,!ic! of t!e fo$$o,ingA A Te$$ing !i1 s!e is 1arried and too o$d for !i1 < Introducing !i1 to fe1a$e c$ients !is o,n age C Encouraging !i1 to ,atc! T4 in !is roo1 +. I"norin" his *lirtatious an) pro(o#ati(e beha(iors 1D T!e *re1or"id *ersona$it+ of a *erson ,it! a nonE*s+c!otic 1a$ada*ti2e res*onse to an0iet+ 1a+ 1ost accurate$+ "e descri"ed as:

A un*redicta"$e8 i1*u$si2e and aggressi2e < rigid8 insecure and confor1ing C de*endent8 *essi1istic and 1ood+ +. an<ious/ insensiti(e an) sel*7absorbe) 1F An ora$Ede*endent *ersona$it+ is c!aracteri7ed "+ ,!ic! of t!e fo$$o,ingA A @e$*$essness C Aggressi2eness < @o*e$essness +. Suspi#iousness

57
1G T!e *edo*!i$eHs c!oice of a se0 o";ect is *ri1ari$+ "ased on: A. )i**i#ulty relatin" with a)ults < fee$ings of tenderness to,ard c!i$dren C fears of incestuous i1*u$ses 5 *referred for a *assi2e se0ua$ ro$e '% A +oung adu$t 1a$e una"$e to sta+ *ut in one ;o" and !as no co11it1ent in !is re$ations!i* is !a2ing difficu$t+ ac!ie2ing a sense of: A Autono1+ C industr+ < Trust +. inti'a#y Situation ; > Anita is e0*eriencing ra*eEtrau1a s+ndro1e in an acute *!ase S!e !ad "een in2ited to a fraternit+ *art+ S!e !ad too 1uc! drin# and s!e !as fee$ings of anger8 !u1i$iation8 !e$*$essness8 nausea8 2o1iting8 nig!t1are and 1usc$e tension '1 :!en t!e nurse a**roac!ed Anita8 initia$$+ s!e ,as ;ust cr+ing8 fe$t s!e ,as in a nig!t1are and s!e ,as at a $oss T!e a**ro*riate nursing diagnosis is A Situationa$ $o, se$fEestee1 < Se0ua$ 2io$ence C. Ine**e#ti(e #opin" 5 Se0ua$ d+sfunction '' Anita e0*ressed to t!e nurse t!at s!e douc!ed8 s!o,ered for an !our and sti$$ did not fee$ c$ean Anita is e0*eriencing: A "uilt C denia$ < anger 5 frustration '- :!ic! of t!ese co11unicate unconditiona$ acce*tance of Anita and !r situationA A. !Fou are here an) I a' rea)y to listen.$ < :!+ did +ou date a gu+ +ou !ard$+ #ne,A> C Te$$ 1e ,!en +ou are read+ and IH$$ co1e "ac# to +ou > 5 I ,ou$d "e "est of !e$* if +ou sto* cr+ing > '3 Anita is e0*eriencing: A 1aturationa$ crisis C. So#ial #risis < de2e$o*1enta$ crisis 5 frustration '6 :!ic! of t!ese "e!a2iors of Anita signa$ !er readiness to *roceed to t!e ,or#ing *!ase of t!e nurseE*atient re$ations!i*A A. She states she truste) the nurse < S!e ,ants to ta$# to a $a,+er C S!e in&uires a"out *ersona$ infor1ation a"out t!e nurse 5 S!e ,ants to "e to$d ,!at !er rig!ts are Situation A > T!e *s+c!iatric 1enta$ !ea$t! nurse ad!eres to standards t!at ensure &ua$it+ i1*ro2e1ent T!e fo$$o,ing situations and "e!a2iors are 1eans to ac!ie2e t!is goa$ 'C T!is is a *rocess ,!erein t!e c$ientHs c!art is re2ie,ed to co1*are criteria for &ua$it+ care ,it! actua$ *ractice: A. Psy#hiatri# Au)it < Nursing Care Process C Interaction Process Ana$+sis 5 A$gorit!1s

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'D In order to assess =Re$ia"i$it+> as a "e!a2iora$ c!aracteristic8 t!e nurse ,ou$d as# !erse$f ,!ic! of t!e fo$$o,ing &uestions regarding !er recording: A 5id t!e !istor+ of t!e *resent *ro"$e1 corre$ate ,it! t!e re2ie, of gro,t! and de2e$o*1entA < @o, $ong did it ta#e to co1*$ete t!e nursing data "aseA C Is t!e nursing data "ase co1*$eteA +. Are the nursin" history an) psy#hoso#ial assess'ent a##urate1 'F A$$ of t!ese are t!e ad2antages of *eer re2ie, E(CEPT: A 5e1ands accounta"i$it+ for nursing actions < @as t!e *ossi"i$it+ of en!ancing intra *rofessiona$ res*ect C. It re,uires the )e(elop'ent o* stan)ar)s *or ,uality #are 5 Pro2ide an e2a$uation of t!e nurseHs a"i$ities 'G T!e nursing tea1 $eader ,ants to in2o$2e a$$ t!e nurses in *artici*ating in t!eir o,n *ersona$ and *rofessiona$ gro,t! t!roug! a "rainstor1ing session One of t!e 1ost i1*ortant ground ru$es is: A Fo$$o, t!e *ro"$e1 so$2ing a**roac! %. +o not pass =u)"'ent on the i)eas presente) C Ideas 1ust "e feasi"$e 5 Suggestions 1ust "e cost effecti2e -% =5id t!e nurse *erfor1 in t!e "est *ossi"$e 1anner ,it!out ,asteA> ai1s to descri"e t!e nurseHs: A t!oroug!ness C. e**i#ien#y < re$ia"i$it+ 5 ana$+tic sense Situation B > A nurse ,as interested to stud+ t!e researc! &uestion: =:!at are t!e differences and si1i$arities "et,een aggressi2e and nonEaggressi2e cogniti2e$+ i1*aired8 e$der$+8 institutiona$i7ed *eo*$eA> -1 In2estigation of cogniti2e$+ i1*aired indi2idua$ *resented so1e et!ica$ di$e11as :!ic! of t!e fo$$o,ing *rotoco$ ,ou$d "e considered unet!ica$A A Recording interaction ,it! t!e e$der$+ ,it! t!eir *er1ission %. Jerbal per'ission *ro' the sub=e#t is unne#essary C 5ata coded and recorded so$e$+ "+ t!e in2estigation 5 A ,ritten consent fro1 t!e institution and a significant ot!er -' A se1iEstructured inter2ie, ,as conducted T!is 1eans t!at: A Inter2ie, is conducted *recise$+ in t!e sa1e 1anner < Inter2ie,er is not !e$d to an+ s*ecific &uestion C Su";ect is a$$o,ed to e0*ress ,it!out an+ suggestion fro1 inter2ie,er +. Inter(iewer is *ree to probe beyon) a nu'ber o* spe#i*i# 'a=or ,uestions -- T!e t+*e of stud+ conducted is: A +es#ripti(e C e0*eri1enta$ < OuasiEe0*eri1enta$ 5 case stud+ -3 T!e re2ie, of $iterature inc$uded reference to retros*ecti2e studies Suc! studies !a2e t!e ad2antages E(CEPT: A 5ata are ine0*ensi2e to o"tain %. Possibility o* 'e'ory bias an) )istortion o* *a#t C T!ere is 1uc! 1ateria$ a2ai$a"$e 5 It is eas+ to get data

59
-6 T!e a2erage age of t!e res*ondents ,as FC t!is re*resents: A. the su' a"es )i(i)e) by total nu'ber o* parti#ipants < t!e +oungest *artici*ant is FC +ears o$d C t!e o$dest *artici*ant is FC +ears o$d 5 1ost of t!e nu1"er *artici*ant is FC +ears o$d

Situation 8 > )r 5a2id is "roug!t to t!e !os*ita$ due to *ain radiating to t!e !i* and $eg @e is diagnosed ,it! a !erniated $u1"ar dis# @ is sc!edu$ed for 1+e$ogra1 -C After t!e *rocedure8 t!e nurse 1ust inc$ude ,!ic! of t! fo$$o,ing nursing action in !is careA A Assess for 1o2e1ent and sensation of t!e $o,er e0tre1it+ < P$ace t!e c$ient in 1ost co1forta"$e *osition C L+ing su*ine ,it! !ee$s f$e0ed +. %e) rest with be) ele(ate) at 5; )e"rees -D )r 5a2id is sc!edu$ed for $u1"ar $a1inecto1+ Post o*erati2e$+ t!e nurse s!ou$d: A Logro$$ t!e c$ient ,it! t!e !e$* of anot!er nurse < Infor1 t!e c$ient t!at !e s!ou$d "e in su*ine *osition C. Assess the sensory loss in his le"s 5 Instruct t!e *atient to 1o2e fro1 side to side -F Tri1et!o"en7a1ine @+droc!$oride .Tigan/ ,as ad1inistered *osto*erati2e$+ T!e action of t!is drug is effecti2e ,!en it: A Controls nausea C contro$s 1usc$e s*as1 < Contro$s *ain 5 contro$s ede1a -G )r 5a2id is to a1"u$ate for t!e first ti1e fo$$o,ing surger+ :!at nursing action s!ou$d "e <EST ,!en t!e c$ient "egins to faintA A Get anot!er nurse for !e$* < )aneu2er t!e c$ient to a sitting *osition C Get "ac# to !is "ed and *$ace in side $+ing *osition +. Assist the #lient to *or' a wi)e base o* support an) lean a"ainst the nurse 3% )r 5a2id !as to ,ear "ac# "race :!ic! *osition is reco11ended ,!en t!e "race is a**$iedA A Sitting *osition C $+ing on !is side in "ed < Standing *osition +. supine position in be) Situation 9 > T!roug! t!e nurseE*atient re$ations!i*8 t!e nurse inter2enes uti$i7ing effecti2e co11unication tec!ni&ues T!e fo$$o,ing are 2aried situations in a *s+c!iatr+ ,ard 31 T!e *atient 2er"a$i7es8 Masama and pakiramdam ko. Hindi ako nakatulog kagabi.A t!era*eutic res*onse of t!e nurse ,ou$d "e: A. Baka ini-istorbo ka na naman ng mga boses. B. Sinabi mo sana sa nars nabigyan ka ng sedati e mo. !. "ela# lang$ Hu%ag ka masyadong mag-iisip ng mga problema mo. D. Maari mo bang sabihin sa akin and mga naiisip at nararamdaman mo? 3' So$edad is ter1ina$$+ i$$ of cancer Loo#ing sad8 s!e e0*resses8 &ala na yata akong pagasang mabu'ay pa( A res*onse ,!ic! fosters !o*e is: A. !Mukhang napakabigat ang dinaramdam ninyo. Andito po ako at puwede tayong mag-usap.

60
B. =Hu%ag po ninyong isipin ang sakit ninyo. Bale %ala yon. Andito naman ako para makausap ninyo. !. )akasan ang loob ninyo. )a'at naman po tayo ay doon ang patutungu'an. *. +agaling din po kayo. Hu%ag po kayong mag-aalala. 3- Ca1i$ia 2er"a$i7es8 =,inag-uusapan nila ako. Aya% nila ako. A t!era*eutic res*onse is: A. =Nalulungkot ba ang pakiramdam mo- < Hayaan mo sila. Ang ma'alaga ay ang palagay mo sa sarili mo. C. Sino ang ni a! na tinutukoy mo?" 5 Hu%ag mong isipin yan. Hindi tama yan. 33 5uring socia$i7ation8 Nicanor ,as *ro2o#ed8 "eca1e furious and started s!outing =&alang 'iya kayo$ Ako ang bida dito$ T!e nurseHs action is: A. Ta&e hi' away *or' the "roup until he 'ana"es to ha(e #ontrol o* hi'sel*.

< I11ediate$+ restrain !i1 and *ut !i1 on iso$ation to *rotect ot!er *atients C Pre2ent !i1 fro1 "eco1ing 1ore furious "+ gi2ing an e0tra PRN dose of sedati2e 5 Res*ond ,it!8 =Ni.anor( pare-pare'o lang kayo ng mga ibang pasyente dito. 36 Nicanor "eco1es 2er"a$$+ assau$ti2e to t!e nurse @e sa+s8 =/ka%( nurse( %ala kanga lam$ Marunong pa ako sa iyo e. Ano ba ang ipinagmamalaki mo$ T!e nurse res*onds t!era*eutica$$+ "+: A. ad1onis!ing !i1 ,it!8 =Ako ang nurse dito. *apat sumunod ka sa akin. B. Ac#no,$edging !is "e!a2ior8 !o,e2er8 *ut !i1 in !is rig!t senses ? res*ond ,it!8 Oo nga( galit ka sa nurse pero 'indi tama na naniniga% ka. #. A#&nowle)"in" his beha(ior an) respon)/ Nagaga it ka sa nurse at nawawa a ka ng $ontro sa sari i mo." *. Ignoring t!e "e!a2ior of t!e *atient Situation 9 > Nicanor ,as disc!arged for1 t!e !os*ita$ and reco2ered fro1 a 1anic e*isode of <i*o$ar 5isorder NIcanor ,as read1itted ,it! an entire$+ different "e!a2ior !e ,as 2er+ de*ressed 3C T!e defense 1ec!anis1 uti$i7ed "+ 1anic *atients to co2er u* de*ression is: A rea#tion *or'ation C dis*$ace1ent < co1*ensation 5 denia$ 3D T!e *s+c!od+1anics of de*ression is: A $a0 su*erEego < ,ea# su*erEego C. internali@e) hostility *eelin"s 5 narcissistic *ersona$it+ 3F :!ic! of t!ese drugs is $i#e$+ to indicated to NicanorA A Serenace .@a$o*erido$/ < 4a$iu1 .5ia7e*a1/ C. To*ranil CI'ipra'ine 2ClD 5 Tri$aton .P!er*ena7ine/ 3G T!era*eutic use of se$f is essentia$ in re$ating ,it! *s+c!iatric *atients T!is is <EST de1onstrated in: A s+1*at!i7ing ,it! t!e 1isera"$e fee$ings of Nicanor < engaging Nicanor in *roducti2e acti2it+ C engaging NIcanor in intros*ecti2e t!in#ing +. suppressin" her own *eelin"s towar) NI#anor 6% After t!ree da+s of antide*ressant 1edication8 Nicanor sti$$ 1anifests de*ression T!e nurse e2a$uates t!is as:

61
A unusua$ "ecause action of antide*ressant drug is i11ediate %. e<pe#te) be#ause it ta&es about two wee&s *or the 'e)i#ation to be e**e#ti(e C une0*ected "ecause it ta#es ,it!in one ,ee# for t!e 1edication to "e effecti2e 5 ineffecti2e "ecause *er!a*s t!e drugHs dose is inade&uate Situation 7 Ninet+ +ear o$d Purita is confined at t!e 1edica$ unit for res*irator+ ai$1ent for ,!ic! a "reat!ing a**aratus is *rescri"ed for !er to use ,!i$e s!e s$ee*s S!e refuses to ,ear it continuous$+ t!oug! s!e fu$$+ understands t!e 1edica$ indication for it 61 :!ic! of t!ese etica$ *rinci*$es can guide t!e nurse in !er actionA A <eneficence C. Autono'y < Fide$it+ 5 Non1a$eficence 6' Purita !as si0 c!i$dren ,!o are a$read+ adu$ts T!e+ differ in t!eir o*inion ,!et!er or not to a$$o, t!eir 1ot!er to decide for !erse$f T!e nurse ,ou$d encourage fa1i$+ conference for: A t!e e$dest c!i$dHs o*inion to "e gi2en *riorit+ < 1a;orit+ of t!e c!i$dren to decide C a$$o,ing t!e 1edica$ staff to decide in t!eir "e!a$f

+. #onsensus buil)in" 6- <reat!ing treat1ents are to "e gi2en to Purita In antici*ation t!at Purita 1ig!t refuse8 5inio8 one of t!e c!i$dren re&uests t!at !e "e t!e one to sign t!e consent in "e!a$f of t!eir 1ot!er T!e nurse e0*$ains t!at Purita is rationa$ in !er t!in#ing and ,!ic! of t!ese c$ientHs rig!t 1ust "e regardedA A. Ri"ht to re*use treat'ent < Rig!t to *ri2ac+ C Rig!t to infor1ed consent 5 Rig!t of !a"eas consent 63 :!ic! of t!ese ,ou$d "e t!e nurseHs *riorit+ fo$$o,ing t!e treat1ent *rinci*$e of $east restricti2e a$ternati2eA A 3ne o* one sta**in" C P!+sica$ restraint < Use of on site guard9,atc!er 5 Sec$usion 66 Purita ta$#s a"out !er ;o+ in !a2ing res*onsi"$e and acco1*$is!ed c!i$dren and reca$$s c!a$$enging career as a $a,+er S!e is de1onstrating a sense of: A e"o inte"rity C generati2it+ < industr+ 5 autono1+ Situation 4 > )arina8 'C +ears o$d8 is a$oof in re$ating ,it! ot!er *atients and 1e1"ers of t!e staff S!e c$ai1s t!at t!e 1edications "eing gi2en !er are 1eant to *oison !er S!e is a$so sus*icious a"out t!e food "eing ser2ed for !er 6C <asica$$+8 )arina is sus*icious "ecause of !er ina"i$it+ to de2e$o* a sense of: A Inti1ac+ C. Trust < Generati2it+ 5 Intiati2e 6D )arina uti$i7es *ro;ection "+ "eing sus*icious T!is 1eans t!at s!e: A. un#ons#iously re*uses to a##ept a *eelin"/ thou"ht or i'pulse an) attributes it to so'eone else < ;ustifies "e!a2ior8 attitudes and fee$ings ,it! e0cuses C in2o$untari$+ refuses to ac#no,$edge rea$it+ 5 in2o$untari$+ e0c$udes ,is!es8 i1*u$ses8 1e1ories and fee$ings fro1 a,areness

62
6F :!ic! of t!ese nursing a**roac!es is )OST a**ro*riate for t!e nurse to "egin ,it!A A Engage )arina for at $east one !our in a oneEtoEone interaction dai$+ < In2ite !er to socia$i7e ,it! ot!er *atients C. ?a&e sel* a(ailable while 'aintainin" )istan#e until patient shows rea)iness to intera#t 5 Refer !er for acti2it+ t!era*+ 6G :!en s!e resists to ta#e !er 1edication8 it is "est to: A $et !er read t!e drug $iterature to con2ince !er t!at it is t!era*eutic < force !er to ta#e t!e drug to 1aintain t!era*eutic effecti2eness of t!e drug C. ha(e the sa'e nurse/ who she intera#ts with re"ularly/ a)'inister the )ru" 5 re&uest t!e doctor to gi2e !er 1edication C% Anot!er reason ,!+ s!e refuses to ta#e T!ora7ine is "ecause s!e co1*$ains of ro"ot $i#e 1o2e1ent and s$urred s*eec! T!e nurseHs action is: A decrease t!e dosage of t!ora7ine %. e<plain the e<trapyra'i)al si)e e**e#ts an) a)'inister %ena)ryl C a2oid gi2ing foods t!at are ric! in t+ra1ine 5 ,it!!o$d 1edication unti$ referra$ is 1ade to t!e doctor Situation 6 > T!e su*er2ising nurse recei2ed re*ort t!at a staff nurse is dis*$a+ing fre&uent irritation8 anger8 and e2en indifference to,ard c$ients and coE,or#ers C1 T!e initia$ action of t!e su*er2isor ,ou$d "e to: A *ost guide$ines on *ro*er decoru1 of nurses in t!e "u$$etin "oard < ,rite a 1e1o of ,arning to t!e nurse C re&uest anecdota$ re*ort for1 nurseHs coE,or#ers

+. #all the nurse *or a one on one #on*eren#e C' T!e nurse e0*ressed increasing fee$ings of dissatisfaction T!e su*er2ising nurse inter2enes t!era*eutica$$+ "+ ta#ing t!e ro$e of: A ad1inistrator "+ re$ie2ing !er of res*onsi"i$ities < t!era*ist "+ de$2ing into t!e nurseHs interna$ conf$icts C. #ounselor by a#ti(ely listenin" 5 educator "+ reorienting !er of !er ro$e as a nurse C- Cou*$ed ,it! *oor ,or# *erfor1ance8 1enta$ and *!+sica$ fatigue and actua$ ,it!dra,a$ fro1 c$ient contact and nursing duties8 t!e nurse can "e said to "e suffering fro1: A *s+c!otic an0iet+ %. sta** burnout C *ersona$it+ 1a$ad;ust1ent 5 neurotic de*ression C3 A *riorit+ in t!e nurseHs *ersona$ de2e$o*1ent ,ou$d "e to: A address !er *!+sica$ ,e$$E"eing < "oost !er se$fEconfidence C *ro2ide socia$ su**ort +. help her *in) (alue an) 'eanin" in her wor& C6 T!e 1ost re$e2ant *rofessiona$ *rogra1 for !er ,ou$d "e: A asserti2eness training %. stress 'ana"e'ent C grou* d+na1ics and tea1 "ui$ding 5 "e!a2ior 1odification

63
Situation 5 > T!e *ur*ose of t!e nursing care *$an is to identif+ t!e care for an indi2idua$ *atient "ased on !is *ro"$e1s T!e nurse ,rites a nursing care *$an for a *atient "ased on nursing care standards CC Gi2en t!is e0a1*$e of a *ro"$e18 =An0iet+ due to a ;o" inter2ie,> T!e =due to> or t!e reason for t!e *ro"$e1 s!ou$d "e inc$uded if it is #no,n T!e initia$ ste* in identif+ing *ro"$e1s is: A. "ather )ata about the patient < deter1ine if t!e *ro"$e1s are usua$ or unusua$ C ana$+7e t!e data 5 ana$+7e t!e *ro"$e1s as concise$+ as *ossi"$e CD Gi2en t!is e0a1*$e of an e0*ected outco1e: =O*en$+ 2er"a$i7e an0iet+ a"out ;o" inter2ie, Identif+ !o, !e can *re*are for t!e ;o" inter2ie, > :!ic! of t!ese is not a criterion of e0*ected outco1esA A An e0*ected outco1e is stated in ter1s of ,!at t!e *atient ,i$$ do %. An e<pe#te) out#o'e is state) in ter's o* what the nurse will )o C E2er+ outco1e 1ust "e 1easura"$e 5 E2er+ outco1e ans,ers t!e &uestion =@o, ,i$$ +ou #no, ,!en t!e *ro"$e1 is reso$2edA> CF T!e fo$$o,ing are reasons for setting dead$ines ,it!in ,!ic! to ac!ie2e outco1es of care E(CEPT: A Indicate s*ecific ti1es to re2ie, *rogress or $ac# of *rogress %. +oes not allow plans to be #han"e) C A$$o, *$ans t!e need to "e c!anged 5 Set t!e ti1e "+ ,!ic! t!e e0*ected outco1e s!ou$d "e reac!ed CG :!ic! of t!ese is not a re$e2ant nursing orderA A. As& the patient any untowar) si)e e**e#ts o* 'e)i#ations he is ta&in" < @a2e *atient ro$e *$a+ inter2ie, situation C 5iscuss ,it! a *atient ,it! s*ecific 1eans !e 1ig!t *re*are for t!e ;o" inter2ie, 5 As# t!e *atient ,!at !e is fee$ing a"out t!e ;o" inter2ie,

D% :!ic! of t!ese *ractices on e2a$uation su**ort nursing careA Re2ie, of care *$an is: A. a nursin" tea' responsibility < t!e so$e res*onsi"i$it+ of t!e *ri1ar+ nurse C t!e res*onsi"i$it+ of *eers 5 t!e so$e res*onsi"i$it+ of t!e su*er2isor Situation ; > A nurse assigned in t!e neuro$ogic unit is ta#ing care of c$ients ,it! 2ar+ing degrees of degenerati2e disorders D1 )a A ,it! 1+ast!enia gra2is is !a2ing difficu$t+ s*ea#ing :!at co11unication strategies s!ou$d t!e nurse a2oid ,!en interacting ,it! )r AA A Re*eating ,!at t!e c$ient sa+s for "etter understanding < Using *a*er and *enci$ in co11unicating ,it! t!e c$ient C Encouraging t!e c$ient to s*ea# s$o,$+ +. En#oura"in" the #lient to spea& ,ui#&ly D' :!en *$anning for nursing care for )r < ,!o !as Par#insonHs disease8 ,!ic! of t!e fo$$o,ing goa$s ,ou$d "e )OST a**ro*riateA A to i1*ro2e 1usc$e tone < to start re!a"i$itation as 1uc! as *ossi"$e C to treat t!e disease

64
+. to 'aintain opti'al bo)y *un#tion D- For t!e *ast 1% +ears8 A$1a8 3' +ears o$d8 !as !ad 1u$ti*$e sc$erosis C$ients ,it! 1u$ti*$e sc$erosis e0*erience 1an+ different s+1*to1s As *art of t!e re!a"i$itation *$anned for A$1a8 t!e nurse suggested t!era*+ and !o""ies to !e$* !er: A. stren"then 'us#le #oor)ination < esta"$is! routine C de2e$o* *erse2erance and 1oti2ation 5 esta"$is! good !ea$t! !a"its D3 On !is second da+ of !os*ita$i7ation8 )r Santos ,as una"$e to stand and is !a2ing difficu$t+ s,a$$o,ing and ta$#ing :!ic! of t!e fo$$o,ing is t!e *riorit+ of t!e nurse in assisting )r SantosA A To *re2ent "$adder distention < To *re2ent decu"itus u$cer C To *re2ent contracture +. To pre(ent aspiration pneu'onia D6 T!e ,ife of a se2ent+ t,o .D'/ +ear o$d 1a$e ,it! a diagnosis of A$7!ei1erHs disease "egins to cr+ and te$$s t!e nurse8 =I cou$d not understand 1+ !us"and an+1ore @e !as c!anged drastica$$+ > :!ic! of t!e fo$$o,ing res*onses of t!e nurse is )OST a**ro*riateA A =T!e *!+sician and t!e staff ,i$$ 1a#e sure t!at +our !us"and ,i$$ "e co1forta"$e and safe !ere > %. !This has been a )i**i#ult ti'e *or you. .et us wal& an) *in) a ,uiet pla#e where we #an tal&.$ C =@e ,i$$ soon reco2er in !is condition > 5 =Bou need not ,orr+8 ,e are doing t!e "est ,e cou$d > Situation A > Annie !as a 1or"id fear of !eig!ts S!e as#s t!e nurse ,!at desensiti7ation t!era*+ is: DC T!e accurate infor1ation of t!e nurse of t!e goa$ of desensiti7ation is: A to !e$* t!e c$ients re$a0 and *rogressi2e$+ ,or# u* a $ist of an0iet+ *ro2o#ing situations t!roug! i1ager+ < To *ro2ide correcti2e e1otiona$ e0*eriences t!roug! a oneEtoEone intensi2e re$ations!i* C To !e$* c$ients in a grou* t!era*+ setting to ta#e on s*ecific ro$es and reenact in front of an audience8 situations in ,!ic! inter*ersona$ conf$ict is in2o$2ed 5 To !e$* c$ients co*e ,it! t!eir *ro"$e1s "+ $earning "e!a2iors t!at are 1ore

functiona$ and "e "etter e&ui**ed to face rea$it+ and 1a#e decisions DD It is essentia$ in desensiti7ation for t!e *atient to: A !a2e ra**ort ,it! t!e t!era*ist < use dee* "reat!ing or anot!er re$a0ation tec!ni&ue C assess oneHs se$f for t!e need of an an0io$+tic drug 5 ,or# t!roug! unreso$2ed unconscious conf$icts DF In t!is $e2e$ of an0iet+8 cogniti2e ca*acit+ di1inis!es Focus "eco1es $i1ited and c$ient e0*eriences tunne$ 2ision P!+sica$ signs of an0iet+ "eco1e 1ore *ronounced A se2ere an0iet+ C 1i$d an0iet+ < *anic 5 1oderate an0iet+ DG Antian0iet+ 1edications s!ou$d "e used ,it! e0tre1e caution "e cause $ong ter1 use can $ead to: A Par#insonian $i#e s+ndro1e

65
< @+*ertensi2e crisis C @e*atic fai$ure 5 Ris# of addiction F% T!e nursing 1anage1ent of an0iet+ re$ated ,it! *ost trau1atic stress disorder inc$udes a$$ of t!e fo$$o,ing E(CEPT: A encourage *artici*ation in recreation or s*orts acti2ities < reassure c$ientHs safet+ ,!i$e touc!ing c$ient C s*ea# in a ca$1 soot!ing 2oice 5 re1ain ,it! t!e c$ient ,!i$e fear $e2e$ is !ig! Situation B > For *ersona$ and *rofessiona$ de2e$o*1ent8 t!e nursing staff decided to !o$d a staff de2e$o*1ent *rogra18 =Se$fEen!ance1ent t!roug! Asserti2eness> F1 An a**ro*riate assess1ent too$ to 1a0i1i7e gat!ering of needs of nurses is t!roug!: A inter(iew o* nurses C o"ser2ation < sur2e+ 5 "rainstor1ing session F' A *riorit+ o";ecti2e of t!e *rogra1 is: A de2e$o* t!e art of *u"$ic s*ea#ing < *ro;ect a *ositi2e i1age of t!e nursing *rofession C. )e(elop art an) s&ills o* therapeuti# use o* sel* 5 earn continuing education units F- T!e 1ost effecti2e ,a+ to *ractice asserti2eness s#i$$s is t!roug!: A ,ritten e2a$uation for1 C descri*ti2e re*ort < *rocess recording +. role play F3 T!e $east satisfactor+ 1et!od to e2a$uate t!e effecti2eness of t!e *rogra1 is t!roug!: A grou* discussion and re*ort < return de1onstration C. atten)an#e 5 indi2idua$ inter2ie,s F6 :!ic! of t!ese feed"ac# fro1 indi2idua$ *artici*ants indicate 1a0i1u1 gain fro1 t!e staff de2e$o*1ent *rogra1A A =I ,i$$ ,rite a *$an for *ersona$ de2e$o*1ent *rogra1 > < =I fee$ 2er+ good T!e *rogra1 ins*ired 1e a $ot > C =I $earned a $ot I !o*e to !a2e 1ore se1inars of its #ind > +. !I ha(e a !+o it Now$ pro=e#t *or 'ysel* i.e. to approa#h 'y #lini#al super(isor re"ularly to )is#uss nursin" #are o* our #lients.$ Situation 8 > A 2e!ic$e !it so1e *edestrians ,!i$e ,aiting for a "us ride So1e of t!e 2icti1s suffered in;uries in t!e different *art of t!eir "odies T!e 2icti1s ,ere "roug!t to t!e near"+ !os*ita$ One of t!e 2icti1s8 Kose*!ine ,as confir1ed to !a2e a fractured $eft ar1 :!i$e ,aiting for t!e *$aster cast to "e a**$ied8 Kose*!ine a**ears to "e an0ious

FC To reduce an0iet+8 t!e nurse teac!es t!e *rocedure to t!e c$ient ,!ic! of t!e fo$$o,ing to*ics s!ou$d NOT "e inc$uded in t!e teac!ing *$anA A Lea2e t!e cast unco2ered to *ro1ote dr+ing %. %ear wei"ht on the plaster #ast *or one hour. A sto#&inet will be pla#e) o(er the le*t ar' to be pla#e) in #ast. C @and$e !ardening cast ,it! *a$1 of !ands 5 Tri1 and res!a*e finis! cast ,it! #nife or cutter

66
FD Cast ,as a**$ied on Kose*!ineHs $eft ar1 In assessing t!e neuro2ascu$ar status of t!e c$ient8 ,!ic! of t!e fo$$o,ing assess1ent findings s!ou$d "e re*orted to t!e *!+sicianA A Pain on t!e $eft ar1 < S,e$$ing of t!e fingers C S#in a"rasions on t!e edges of t!e *$aster cast +. Nail be) #apillary re*ill ti'e o* 9 se#on)s FF One of t!e 2icti1s8 a si0t+ +ear o$d ,o1an sustained !i* fracture Prior to surger+8 a <uc#Hs e0tension traction is to "e a**$ied T!e rationa$e of traction is *ri1ari$+ "ased on t!e understanding t!at <uc#Hs e0tension traction: A. re)u#es 'us#le spas's an) helps to i''obili@e the *ra#ture < a$$o,s reduction of t!e fracture site for "one !ea$ing C Secures t!e fracture site to *re2ent da1age to t!e 1usc$e tissues 5 Secures t!e fracture site for rigid i11o"i$i7ation FG P!i$$i* ,as *$aced in s#e$eta$ $eg traction ,it! an o2er"ed fra1e @e is not a$$o,ed 1o2e fro1 side to side :!ic! of t!e fo$$o,ing nursing inter2entions is usefu$ in 1aintaining effecti2e tractionA A Assist t!e c$ient "+ !o$ding t!e tra*e7e and raising t!e !i*s off t!e "ed %. Che#& the apparatus/ that wei"hts han" *ree an) &nots in the rope are tie) se#urely C Sus*end t!e tra*e7e ,it!in eas+ reac! of t!e c$ient 5 Su**ort t!e affected e0tre1it+ ,!i$e t!e ,eig!ts are re1o2ed G% To *re2ent co1*$ications ,!en a c!i$d is in <uc#Hs traction8 t!e nurse s!ou$d> A c$ean t!e e0tre1it+ and #ee* t!e s#in dr+ %. assess any s&in an) #ir#ulatory )isturban#es C c$ean t!e *in sites as necessar+ 5 *ro2ide !ig! fi"er s1a$$ 1ea$s G1 A$$ of t!e fo$$o,ing conce*ts are true E(CEPT: A @osti$it+ is destructi2e < Frustration de2e$o*s in res*onse to un1et needs8 ,ants and desire C. An"er is in#o'patible with lo(e 5 Aggression can "e e0*ressed in a constructi2e as ,e$$ as a destructi2e 1anner G' Car$o is acting out !osti$e and aggressi2e fee$ing "+ #ic#ing t!e c!airs in t!e roo1 t!e )OST effecti2e ,a+ to dea$ ,it! Car$oHs "e!a2ior is initia$$+ to: A. set li'its on the beha(ior by (erbal #o''an) < ad1inister PRN tran&ui$i7er C re1o2e t!e c!airs fro1 t!e roo1 5 restrain t!e *atient and *$ace !i1 in t!e =Iso$ation Roo1> G- )rs 5i7on ,as 2isiting !er son at t!e Ps+c!iatr+ :ard :!ic! of t!e fo$$o,ing ite1s ,i$$ t!e nurse not a$$o, to "e "roug!t inside t!e ,ardA A string rosar+ "race$et C. bottle o* #o&e < "o0 of ca#e 5 ru""er s!oes G3 :!ic! of t!e fo$$o,ing ,i$$ *ro"a"$+ "e 1ost t!era*eutic for a *atient on a "e!a2iora$ 1odification ,ardA A if t!e c$ient is agitated8 discuss t!e fee$ings es*ecia$$+ anger < insist to sto* o"scene $anguage "+ 2er"a$ re*ri1and

C. "i(e #lient support an) positi(e *ee)ba#& *or #ontrollin" use o* obs#ene lan"ua"e 5 Pro2ide a *unc!ing "ag as an a$ternati2e to e0*ress u*set e1otions

67
G6 :!ic! of t!e fo$$o,ing 1ust "e considered ,!i$e *$anning acti2ities for t!e de*ressed *atientA A acti2ities ,!ic! re&uire e0ertion of energ+ < c!a$$enging acti2ities to get !i1 out of !is de*ression C. (ariety o* stru#ture) a#ti(ities 5 2ariet+ of unstructured acti2ities Situation 49 7 Ki18 age '68 reca$$ed t!at !is *ro"$e1 "egan around age 16E1C @e ,ou$d count *enci$s in a 1ug o2er and o2er ,it! t!e t!oug!t t!at sto**ing cou$d resu$t in so1et!ing "ad !a**ening GC T!ere are 1an+ t!ings Ki1 see1s !e !as to do to #ee* !i1se$f fro1 fee$ing: A confused C e0cited < sus*icious +. an<ious GD @e !as c!ange c$ot!es '% ti1es "efore ,or#8 c!e, eac! "ite !e east '3 ti1es and go u* and do,n t!e stairs four to fi2e ti1es "efore it fee$s rig!t @e is de1onstrating: A ideas of reference < denia$ and *ro;ection C. obsession an) #o'pulsion 5 rationa$i7ation and o2er reaction GF T!e o";ecti2e of nursing care for Ki1 is to de2e$o* or increase fee$ings of: A sel*7'astery C se$fEactua$i7ation < se$f ,ort! 5 se$fEdeter1ination GG A$$ of t!ese are t!era*eutic inter2entions E(CEPT: A i1*ose $i1its e2er+ ti1e t!e "e!a2ior "eco1es re*etiti2e < esta"$is! a routine for !i1 C. assi"n tas& that #an be )one repetiti(ely 5 faci$itate se$fEe0*ression 1%% Ki1 is a,are of !is "e!a2ior +et rea$i7es t!at it is 2er+ distur"ing to !i1 T!is is a *attern of: A *ersona$it+ disorder C. neurosis < *s+c!osis 5 !a"itua$ disorder

SU%?IT T2IS TEST %33E.ET T3GET2ER 0IT2 T2E ANS0ER S2EET T3 F3UR 0ATC2ERS. %RINGING T2E TEST %33E.ET 3UT 38 T2E R33? 0I.. %E A GR3UN+ 83R CANCE..ATI3N 38 F3UR EGA?INATI3N. NNNEN5NNN