FORMATIVE 6

PALMER (10)

Prof Ad (2) 1. Resignation is a formal act of quitting one’s position.The nurse has made a decision to resign from a staff nurse position because of

dissatisfaction with the present working conditions. Which action should the nurse take first?a. Write a letter of resignation.b. Review the organizational policies for resignation.c. Notify the charge nurse that the nurse has accepted another position and is leaving.d. Constructively share concerns about the working environment in an exit interview

Answer: B. Prior to resigning from a position, the nurse should familiarize himself or herself with the policies of the organization. Organizational policy should address the notification time frame for resignation, whether a resignation letter is required, how accrued benefits are managed, and whether an exit interview is performed. When resigning from a position, the nurse should consider that future employers will be contacting the employer for references and handle the dissatisfaction in a constructive manner.

ResignationHow to go about in resigning from a nursing position:

Determine your date of resignation Consult your facility employee handbook for the required resignation notice time frames. Rule of thumb: two weeks’ notice for a

staff position and four weeks’ notice for a management position. Also check for other resignation policy in your institution such as need for resignation letter, exit interview, etc. Resignation letters should be made in writing; however, leaving the letter for your manager to find is the last resort. Make an

appointment, if possible, and discuss your resignation. Explain your reasons briefly but do not use the meeting to complain about your co-workers or the manager.

Inform manager before you tell your co-workers. Keep a copy of the resignation paperwork and of your resignation letter.

(Source: Nursing Career Plan Guide by Turner, S., p. 152; NCLEX-RN Review Guide by Chernecky, C., p. 176, p. 201)

2.Nowadays, foreign nurses from developing countries seek opportunities abroad, to fill the nursing shortage of developed nations to pursue their own economic, career, and lifestyle interests.Newly graduate nurse, Channing Tatum, is seeking for a nursing job in his hometown in Cebu that will give him the experience he needs so he can qualify to apply for a nursing position in a hospital in London, where his 3 older sisters are currently working as staff nurses. He is joined by Rachel McAdams and Anne Hathaway, also fresh graduates, who also want to apply for nursing positions in Canada. This nursing trend of pursuing professional opportunities outside their own country is called:

a. Nurse departureb. Nurse immigrationc. Nurse migrationd. Nurse deportation

Answer: C. Nurse Migration.Nurse migration trendsMigration flow tends to be from rural to urban areas, from lower to higher income urban neighborhoods,and from developing to industrialized countries. International migration flow is changing in that the ‘supplier’ countries are increasingly among the less-developed countries. Recruitment is no longer between relatively rich countries and regions (North America and Western Europe) but includes Asia, Africa, and the Caribbean. Migration within a given geographical area is often determined by economic factors, e.g. in sub-Saharan Africa. The single and most pervasive cause of migration in many developing countries is economic.

There is widespread consensus that nurses migrate in search of incentives that usually fall within three categories: Improved learning and practice opportunities Better quality of life, pay and working conditions, and/or Personal safety

International migration has always existed. It is now being further facilitated because of shortages of skilled labour in industrialized countries and through international trade agreements. The pros and cons of international migration are summarized below:

INTERNATIONAL NURSE MIGRATIONPROS CONS Educational opportunities Professional practice opportunities Professional and occupational safety Better working conditions Improved quality of life Trans-cultural nursing workforce (racial and

ethnic diversity) Cultural sensitivity / competence in care Stimulation of nurse-friendly recruitment and

contract conditions Personal development Global economic development Improved knowledge base Sustained maintenance and development of

family members in the country of origin

Brain and / or skills drain Closure of health facilities due to nursing

shortages in a given area Overwork of nurses practicing in depleted

areas Potentially abusive employment practices Vulnerable status of migrants Loss of national economic investment in

human resource development

(Source: Career Moves and Migration: Critical Questions by International Council of Nurses [ICN]; retrieved from: http://www.intlnursemigration.org/assets/pdfs/CareerMovesMigangl.pdf)

Leadership (1)

3.Nurses who function as leaders in clinical practice are not necessarily in positions of authority. They are not necessarily the charge nurses, nurse managers, or chief nursing officers. Nurse leaders, regardless of the position they hold in an organization, are the individuals who continually question the status quo, offer suggestions about how to improve patient care, and entice (not demand or require) colleagues to work toward a new level of excellence. Nurse Megan Fox is correct when he differentiates a leader from a manager when he states the following, except:

a. Leaders are more interested in effectiveness while managers emphasize philosophy, core values and shared goalsb. Managers operate within organizational rules, regulations, policies and procedures while leaders challenge the status quo.c. Leaders do the right thing while managers do things rightd. Managers focus on systems and structures while leaders develops vision and strategies

Answer: A. Both descriptions are attributed to leaders. Leaders are more interested in effectiveness and emphasize more on philosophy, core values and shared goals while managers are more interested in efficiency, and emphasize more on tactics, structure and systems.

LEADERS MANAGERSDo the right thing (C) Do things right (C)Are interested in effectiveness (A) Are interested in efficiencyInnovate AdministerDevelop MaintainFocus on people Focus on systems and structure (D)Rely on trust Rely on controlAlign people with a direction Organize and staffEmphasize philosophy, core values and shared goals (A) Emphasize tactics, structure and systemsHave a long-term view Have a short-term viewAsk what and why Ask how and whenChallenge the status quo (B) Accept the status quoFocus on the future Focus on the presentHave their eyes on the horizon Have their eyes on the bottom lineDevelop visions and strategies (D) Develop detailed steps and timetablesSeek change Seek predictability and orderTake risks Avoid risksInspire people to change Motivate people to comply with standardsUse person-to-person influence Use position-to-position (superior-to-subordinate) influenceInspire others to follow Requires others to complyOperate outside of organizational rules,regulations, policies and procedures

Operate within of organizational rules,regulations, policies and procedures (B)

Take initiative to lead Are given a position

Management (3)4. Decision making is one of the most frequent activities performed by a professional nurse. Driven by critical thinking and using a

multidisciplinary knowledge base, nurses need to make decisions that are appropriate to the context of the situation and considerate of the culture where the services are being provided. When the nurse manager of a busy rehabilitation unit decided the best way to reward staff was to give a monetary bonus rather than time off, many of the staff became upset and went to administration with complaints. This manager skipped which step of the critical thinking process?

a. Obtaining a majority consensus of all of the staff. b. Considering the context and meaning of the issues to each individual c. Not asking the staff how much money would be considered an adequate reward. d. Identifying assumptions underlying the issue.

Answer: B. The nurse manager fail to identify that the context of the stressor of the situation for the staff is not the compensation for the busyness of the unit but the busyness of the rehabilitation unit, itself and that they would like some time off to prevent further burnout.

A – This choice falls under data collectionC – This choice falls under data collection.D – The nurse manager is correct to identify the assumption that the situation in the rehabilitation unit is causing extra stress to the staff as manifested by her decision to provide rewards to the staff. She fails however to identify the context of the stressor is not on the need of monetary compensation or reward for the busyness of the unit, but on the rest periods for the staff from the busyness that may further lead to burn out.

Critical thinking is a process that entails 1) identifying assumptions, 2) considering context and meaning of issues, and 3) gathering data to consider alternatives and outcomes

Identifying AssumptionsThe critical thinking process begins by exploring the assumptions underlying a situation. These assumptions may be beliefs that influence how an individual will reason or understand a situation and may reflect a person’s point of view or perspective. These assumptions may not necessarily be grounded in reality.

Considering the ContextThe critical thinking process involves considering the context of the present problem or situation. Analysis and interpretation of the meanings of the present issue or situation are essential to developing a conclusion.

Data Collection Data collection is the next step in the critical thinkingprocess. All too frequently, snap decisions aremade based on first impressions. Leaders who usecritical thinking skills do consider first impressions,but they are always careful to continue to gatherdata and carefully evaluate all the alternatives andpossible outcomes. Nurses are often faced with clinicalsituations that require gathering assessmentdata and considering various alternative interventionswhile balancing the needs of the individualpatient and predicting potential outcomes.

(Source: Understanding the Theory of Leadership, Following and Managing by Jones, Rebecca. P336-33)

5. Conflicts can arise whenever two or more people disagree on an issue. Small or large, they seem to be a daily occurrence in the life of a nurse manager, and they can interfere with getting the work done. Nurse Scarlett Johansson, a nurse manager, wants to identify

potential conflict generators among the nursing and non-nursing staff in the hospital. She is correct to identify the following as conflict generators, except:

a. Competition between groupsb. Scarcity of sourcesc. Threats to safety and securityd. Respect for personal space

Answer: D. Respect for personal space is not a factor that can contribute to conflicts.An increase in tension between or among various groups of people within the workplace has been the subject of much interest in the media. Crowded conditions and the constant interactions that occur at a busy nurses’ station can increase interpersonal tension and lead to battles over precious work space. Respect for personal space avoids conflicting because there are no personal invasions involved. Inadequate money for pay raises, equipment, supplies, or additional help can increase competition between or among departments and individuals as they scramble to get their share of the little there is to distribute. When roles are blurred, cost constraints are emphasized, and staff members face layoffs, individuals’ economic security is threatened. This can be a source of considerable stress and Tension. (Source: Tappen, pages 100-101)

6. Conflict management styles are behavioral approaches used to regulate or resolve the conflict. When these behaviors are used together over time, they become patterned responses. Nurse Anne Hathaway works the afternoon shifts with Nurse Jake Gylennhal. Nurse Anne would notice that Nurse Jake would frequently be gone for longer periods during his breaks, leaving Nurse Anne doing some of his responsibilities during his absence. Nurse Anne is afraid to talk to Nurse Jake about the situation because she fears that Nurse Jake would respond negatively to the confrontation so shejust tolerates the situation. Nurse Anne is utilizing which conflict management style?

a. Avoidingb. Accommodatingc. Competingd. Compromising

Answer: B. Accommodating. Anne is tolerating the situation thus obliging to Nurse Jake’s misbehavior. She is cooperating with the situation by doing Jake’s left responsibilities without being assertive for her own needs. Win situation: Jake. Lose situation Anne.

A – Anne is not using avoiding because she is tolerating the situation, trying to make up for the Jake’s left responsibilities. It can be avoiding if she ignores the situation and leaves the left responsibilities alone. C – Anne is not challenging Jake; she even fears the idea of confronting JakeD – There is no compromise become Anne is making up for the left responsibilities of Jake without Jake giving anything for Anne’s gain.

Styles of Conflict management: Avoiding – or withdrawing refers to avoiding the conflict so that it cannot be resolved. The results may be categorized as a lose-lose

situation Accommodating – or smoothing or obliging refers to being cooperative yet unassertive so that only the other person’s needs are

met. The results may result to a lose-win outcome. Competing – forcing or dominating, refer to a behavioral pattern of being uncooperative and demanding one’s one way. Achieving

goals takes place by blocking the opponent’s goal. In this scenario, only one goal can be achieve, thus resulting to a win-lose scenario.

Compromise – or sharing, suggests that each party relinquishes something, which might be described as a no-win, no-lose resolution because no one gains or loses everything she or he wanted.

Collaboration – or problem solving, is considered a win-win situation in which new ideas are generated that resolves most of the issues in the conflict.

(Source: Understanding the Theory of Leadership, Following and Managing by Jones, Rebecca. P336-337)

Ethico-Legal (2)7. Nursing jurisprudence is the branch of law which deals with the nursing laws, lawsuits, liabilities, legal principles, rules and

regulations, case laws and doctrines affecting the nursing practice. Republic Act 9502 is known as the:a. Dangerous Drug Act b. Generics Actc. Universally Accessible Cheaper and Quality Medicines Actd. Philippine Medicare Act

Answer: C. RA 9502 is the Universally Accessible Cheaper and Quality Medicines Act

A –RA 6425 Dangerous Drug ActB – RA 6675 Generics ActD – RA 6111 Philippine Medicare Act (Source: Balita, pages 459-460)

8. The importance of traditional medicine in providing essential health care to the people should be recognized. The practice of traditional medicine has gained a deep significance in our country's health care delivery, considering that western medical treatment is expensive and most Filipinos could not afford it. ZacEfron, a resident of Barangay Masakitin, was invited to a government-funded seminar on the different traditional and alternative modalities such as homeopathy, chiropractic, chelation therapy, macrobiotics and colonic detoxification. These seminars and community-based trainings as well as the promotion of traditional and alternative health modalities are advocated by which law?a. RA 9439b. RA 9502c. RA 8749d. RA 8423

Answer: D. RA 8423 – “Traditional and Alternative Medicine Act (TAMA) of 1997” which aims to advocate the use, encourage scientific research and formulate standards, guidelines and codes of ethical practice for traditional and alternative health care modalities.

A – RA 9439 is the Patient’s Illegal Detention Law which is the act prohibiting the detention of patients in hospitals and medical clinics on grounds of nonpayment of hospital bills or medical expenses.B – RA 9502 is the Universally Accessible Cheaper and Quality Medicines Act

C – RA 8749 is the Clean Air Act

(Source: http://www.pitahc.gov.ph - Philippine Institute of Traditional and Alternative Health Care website; Balita, pages 459-460)

Research (2)9. Population is the entire aggregate of cases in which a researcher is interested. Sampling is the process of selecting a portion of the

population to represent the entire population and this subset of the population is termed as the sample . Nurse researcher Bradley Cooper, teaches a group of students on the difference between probability and non-probability sampling. She is not to be corrected when she describes probability sampling as the following, except:a. It involves random selection of elements from a populationb. Elements has an equal and independent chance of being selected c. Types of probability sampling include Simple Random Sampling, Purposive Sampling, Stratified Random Sampling, and Systematic

Samplingd. It is more respected sampling approach because of the greater confidence in the representativeness of probability samples

Answer: C. Types of probability sampling include Simple Random Sampling, Stratified Random Sampling, Systematic Sampling and Cluster or Multi-Stage Sampling. Purposive sampling belongs under non-probability sampling.

Options A, B and D all describe probability sampling.Probability samplinginvolves: A) random selection of elements where researchers can specify the probability that an element of the population will be included in the sample. D) It is more respected because of the greater confidence can be placed in the representativeness of the probability samples. B) Each element in the population has an equal, independent chance of being selected.

Non-Probability sampling is a sampling method where elements are selected in nonrandom methods where there is no way to estimate the probability that each element has of being included in the sample. Every element usually does not have an equal chance of inclusionthus, it is least likely to produce accurate and representative samples.

Probability Sampling Non-probability Sampling Simple Random Sampling – fishbowl method, most

basic probability design. A sample frame (list of elements) is developed, from which sample will be randomly chosen.

Stratified Random Sampling –population is first divided into two or more strata. Stratified sampling designs subdivide the population into homogenous subsets from which an appropriate number of elements are selected at random.

Cluster Sampling or Multi Staged–Successive random sampling of elements where the first unit is a large group or cluster and then subdivided into smaller clusters that can be further subdivided by stages.

Systematic Sampling – Uses a sampling interval which is a standard gap between the elements chosen in the sampling frame. It is a selection of every kth case from the list (ie every 7th person, every 20th person)

Convenience Sampling – or accidental sampling, use of most conveniently available people as study participants. Weakest form of sampling.

Snowball Sampling – or referral, network or chain sampling, where early sample members are asked to refer other people who meet the eligibility criteria. Used when population is people with characteristics that are difficult to identify

Quota Sampling – one where researchers identify population strata and determine how many participants are needed in each stratum

Purposive Sampling – or judgmental sampling based on the researcher’s knowledge of the population can be used to hand-pick sample members.

10. Sampling design is the sampling scheme that specifies the number of samples drawn from the population, the criteria for selection, and the type of sampling method. A group of students would like to conduct a qualitative study on the experiences of homosexual nurses practicing in their profession in the hospital setting. Since there is no known database of all the homosexual nurses, the researchers rely on the referrals and recommendations of their subjects to other homosexual nurses. The researchers utilized a type of sampling called:a. Probability sampling – purposive samplingb. Non-probability sampling – purposive samplingc. Probability sampling – network samplingd. Non-probability sampling – network sampling

Answer: D. Network sampling, also called as chain sampling, referral sampling or snowball sampling where early sample members are asked to refer other people who meet the eligibility criteria. Used when population is people with characteristics that are difficult to identify. It is a form of non-probability sampling.

A and B - Purposive sampling or judgmental sampling based on the researcher’s knowledge of the population can be used to hand-pick sample members. Purposive sampling is a form of non-probability sampling.C – Network sampling is not a form of probability sampling.

FUNDAMENTALS (15)11. Postural drainage is the drainage by gravity of secretions from various lung segments. Secretions that remain in the lungs or

respiratory airways promote bacterial growth and subsequent infection. The attending prescribes chest physiotherapy to a patient who has copious lung secretions. Upon auscultation, it was determined that the lower lobes contain mostly of the secretions. Considering the patient’s case, which of the following holds true?

a. All positions involved in postural drainage should be performed by the patient.b. There is no need for postural drainage because secretions in the lower lobes drain by gravity.c. It is advised for the patient to take bronchodilators or to nebulize right after the procedure to counteract its exhausting effect.d. The procedure may be done during the late afternoon.

Answer: D. Postural drainage treatments are scheduled two or three times daily, depending on the degree of lung congestion. The best times include before breakfast, before lunch, in the late afternoon, and before bedtime. It is best to avoid hours shortly after meals because postural drainage at these times can be tiring and can induce vomiting.

A - A wide variety of positions is necessary to drain all segments of the lungs, but not all positions are required for every client. Only those positions that drain specific affected areas are used. B - The lower lobes require drainage most frequently because the upper lobes drain by gravity. C - Before postural drainage, the client may be given a bronchodilator medication or nebulization therapy to loosen secretions.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp. 1373)

12. Chest physiotherapy is a dependent nursing action which involves three procedures: postural drainage, percussion and vibration. CPT enables mobilization and elimination of secretions, re-expansion of lung tissue and promotion of efficient use of respiratory muscles in patients who expectorate large amounts of sputum. Nurse Chanel is observing a student nurse performing CPT to a patient with cystic fibrosis. She is to reprimand the student if she does which of the following:

a. She keeps the patient in his indicated position for postural drainage for 10-15 minutes.b. With hands in cupped shape, she percusses over the patient’s sternum producing a hollow sound.c. Encouraged patient to cough after every vibration.d. Percussed each all affected lung segment for maximum of 2 minutes.

Answer: B. Percussion is contraindicated and avoided over the breasts, sternum and spinal column. Percussion is done by holding hands in a cupped shape and if done correctly, produces a hollow, popping sound when done correctly.

A – Each position in postural drainage is usually assumed for 10-15 minutes although beginning treatments may start with shorter times and gradually increases.C – After each vibration, patients are encouraged to cough and expectorate secretions into a sputum container.D –Each affected lung segment is percussed for 1-2 minutes.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp. 1371-1372)

13. Safety precautions are essential during oxygen therapy. Although oxygen by itself will not burn or explode, it facilitates combustion . Kate Moss is prescribed to have home oxygen therapy. What nursing action is not essential in having oxygen administration at home?

a. Placing “No Smoking” signs on client’s door, foot of the bed and on the oxygen equipment.b. Assist family in making sure that all electric equipment and machines are electrically grounded.c. Instruct patient to avoid materials that generate static electricity like woolen blankets. Blankets made of synthetic fibers should be

used instead.d. Make known the location of fire extinguishers, and train the family how to use them.

Answer: C. Materials that generate static electricity include wool and synthetic fibers. Cotton blankets should be used and clients and caregivers should be advised to wear cotton.

Oxygen Safety Precautions: For home oxygen use or when facility permits smoking, teach family members and roommates to smoke only outside or in provided

smoking rooms away from the client and the oxygen equipment. Place cautionary signs reading “No Smoking: Oxygen in Use” on the client’s door, foot of the bed and on the oxygen equipment

– A Instruct clients and visitor on the hazards of smoking with oxygen in use. Make sure that electric devices are in good working conditions to prevent the occurrence of short-circuit sparks. Avoid materials that

generate static electricity like woolen blankets and synthetic fibers. Cotton blankets should be used and clients and caregivers should be advised to wear cotton.

Avoid use of volatile, flammable materials, such as oils, grease, alcohol, ether, and acetone near clients receiving oxygen Be sure electric equipment, devices and machines are all electrically grounded - B Make known the location of fire extinguishers, and make sure personnel are trained in their use. - D

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp. 1373)

14. Oxygen administration from a cylinder or wall-outlet system is dry. Dry gases dehydrate the respiratory system thus; humidifying devices that add water vapor to inspired air are essential adjunct to the therapy . Correctly arrange the steps in setting up and oxygen wall outlet:

1. Attach the humidifier bottle to the flow meter2. Attach the prescribed oxygen tubing and delivery device to humidifier3. Attach the flow meter to the wall outlet4. Regulate the flow meter to the prescribed rate

a. 3, 1, 2, 4b. 1, 3, 2, 4c. 2, 1, 3, 4d. 3, 2, 1, 4

Answer: A. Correct sequence: (3) Attach the flow meter to the wall outlet. The flow meter should be in the off position If humidifier is not prefilled, fill humidifier with distilled or tap water (1) Attach the humidifier bottle to the flow meter (2) Attach prescribed oxygen tubing and delivery device to humidifier (4) Regulate the flow meter to the prescribed rate. The line for the prescribed flow rate should be in the middle of the ball in the flow meter.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp. 1373)

15. Clients with conditions that increase secretions or impair mobilization of secretions such as chest surgery, COPD, or cystic fibrosis often require encouragement to cough and breathe deeply. Alessandra Ambrosio,a client with COPD, is to undergo a thoracentesis in the morning. Her nurse currently conducting a health teaching session to him on coughing and deep breathing. Which of the following statements, if provided by the nurse, would indicate an incorrect teaching?

a. “You may practice pursed-lip breathing by blowing on a candle flame so it bends without going out.”b. “Normal forceful coughing does not offer any help, and therefore, should be avoided.”

c. “Be sure to exhale with a “huff” sound in mid-exhalation.”d. “Purse the lips as is you are to whistle and slowly and purposefully blow.”

Answer: B. Normal forceful coughing is highly effective, but some clients may lack the strength or ability to cough normally. Normal forceful coughing involves the client inhaling deeply and then coughing twice while exhaling.

A - Clients may practice pursed lip breathing by blowing on a candle flame so it bends without going out, or blowing a ping-pong ball across a tableC - A client with a pulmonary condition (e.g.. COPD) is instructed to exhale through pursed lips and to exhale with a "huff' sound in mid-exhalation. The huff cough helps prevent the high expiratory pressures that collapse diseased airways.D - The client is taught to purse the lips as if about to whistle and blow slowly and purposefully, tightening the abdominal muscles to assist with exhalation.(Source: Kozier, page 1390)

16. Breathing exercises are frequently indicated for clients with restricted chest expansion, such as people with COPD or clients recovering from chest surgery. Nurse Twiggy instructs a client diagnosed with COPD to use pursed-lip breathing. The client inquires the nurse about the advantage of this kind of breathing. The nurse answers, that the main purpose of pursed-lip is to:

a. Prevent bronchial collapseb. Strengthen the intercostal musclec. Achieve maximum inhalationd. Allows air trapping

Answer: A. Pursed-lip breathing helps the client develop control over breathing. The pursed-lips creates resistance to the air flowing out of the lungs, increasing the pressure within the bronchi, thereby prolonging exhalation and preventing airway collapse by maintaining positive airway pressure.

B – The exercise focuses on preventing airway collapse by putting resistance on the exhaled air and prolonging exhalation, not on strengthening the intercostal muscles.C – Pursed-lip breathing focuses on the exhalation, not the inhalation. In pursed lip breathing, client usually inhales to a count of 3 and exhales to a count of 7. Exercise that help achieve maximum inhalation is incentive spirometer.D – Air trapping is the main problem in emphysema (a form of COPD) and is not promoted in pursed-lip breathing.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp. 1368)

17. Many post-operative patients avoid coughing because it can be very painful and because of the fear of tearing up stitched incisions; however, coughing and deep breathing post-operatively is essential to keep the lungs clear prevent lung complications like pneumonia. To prevent post-op complications, Nurse Candice Swanepoel assists the client with coughing and deep breathing exercises. This is best achieved by?

a. Coughing exercises 1 hour before meals and deep breathing 1 hour after mealsb. Forceful cough as many times as toleratedc. Huff coughing every 2 hours or as neededd. Diaphragmatic and pursed-lip breathing 5-10 times four times a day

Answer: C. Huff coughing is done by leaning forward and exhaling sharply with a “huff” sound. This technique helps keep your airways open while moving secretions up and down the lungs. It is encouraged to cough twice – first cough loosens the mucus. Second expels the secretions.

A- Deep breathing and coughing should be performed at the same time, as often as possible. Only at around meal times is not enough.B – Forceful cough may fatigue the patient if done many timesD – Diaphragmatic breathing and pursed-lip breathing are techniques used for clients with obstructive airway disease.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp. 1369, p. 1398, p.1526)

18. Incentive spirometers are designed to mimic natural sighing or yawning by encouraging the client to take long, slow, deep breaths. There are two general types of spirometers, the flow-oriented spirometer and the volume-oriented spirometer. Nurse Heidi Klum is to teach a client how to use the incentive spirometers correctly. She is correct to include the following, except?

a. Reiterate the importance of refraining from coughing to avoid exhausting the patientb. Instruct the patient to assume a sitting position during the procedurec. If there is trouble in breathing through the mouth during the incentive effort, nose clips may be usedd. Teach the patient to take a slow deep breath to raise the cylinder

Answer: A. Coughing is encouraged after the incentive effort. Deep ventilation may have loosened the secretions and coughing can facilitate its removal.

B – Client is assumed in any position as long as the spirometer is kept at an upright position. Sitting position is ideal because this position can also facilitate maximum lung expansion.C – Nose clips can be used when there is difficulty breathing in the mouthD - Ask the patient to take in a slow, deep breath to elevate the balls or cylinder, and then hold the breath for 2 seconds initially, increasing to 6 seconds (optimum), to keep the balls or cylinder elevated if possible.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp. 1371)

19. After Nurse Heidi Klum’s health teaching on the use of incentive spirometers, she tries to evaluate her patient’s learning. The patient demonstrates proper knowledge on incentive spirometer when which of the following statements is made?

a. “I should breathe out as fast and hard as possible in to the device.”b. “I should inhale slowly and steadily to keep the balls up.”c. “I should use the device three times a day, after meals.”d. “The entire device should be washed thoroughly in sudsy water once a week.”

Answer: B. This is the only correct statement. Proper use of incentive spirometer requires client to take slow, deep breath to elevate the balls or cylinder that is sustained for 2 seconds initially, increasing to 6 seconds (optimum).

A – Proper use requires inhaling in to the device slowly and deeply.C – It is recommended to perform incentive spirometry every 5-10 times every 1-2 hours.D – Only the mouthpiece is successfully rinsed or wiped after every use. The entire device should not be submerged in water.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, p. 1371; p.1399; p.1526)

20. The metered-dose inhaler (MDI), a handheld nebulizer, is a pressurized container in which the force of air that moves through the container cause large particles of medication to break up into finer particles, forming a mist. Nurse Adriana Lima teaches a patient about administering medications through MDI. Arrange the steps in using an inhaler chronologically.

1. Press the canister down with your fingers as you breathe in.2. Wait one minute between puffs if more than one puff is prescribed.3. Inhale the mist hold your breath at least 5 to 10 seconds before exhaling.4. Remove the cap and shake the inhaler

a. 4, 1, 3, 2b. 3, 4, 2, 1c. 4, 1, 2, 3d. 1, 2, 3, 4

Answer: A. 4-1-3-2Steps in using a metered-dose inhaler:

1. Remove the mouthpiece cap. Shake inhaler vigorously for 3-5 seconds to mix the medication evenly. - 42. Hold the MDI 2-4 cm from the open mouth OR Put the mouthpiece far enough into the mouth with its opening toward the throat such that

the lips can tightly close around the mouthpiece.3. Press the canister down while simultaneously inhaling using the mouth - 14. Hold breath for 10 seconds or as long as possible to allow aerosol to reach deeper airways - 35. Exhale slowly through pursed lips. Controlled exhalation keeps the small airways open during exhalation6. If second dose is needed, wait 1-2 minutes before taking another dose - 27. Rinse mouth with tap water to remove any remaining medication and prevent irritation8. Clean the mouthpiece of MDI

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 2, pp 897)

21. If two inhalers are to be used, bronchodilators should be given first before the other medications. Although bronchodilators act to open the airways in the short term, it is the inhaled steroids that act as “chemical Band-aids” to keep the airway inflammation under control.To prevent oral complications when using a metered-dose inhaler, a nurse should instruct the client to:

a. Keep the head of the bed at 30-degree angleb. Use of inhaler before mealsc. Rinse mouth after using the inhalerd. Use the inhaler as needed

Answer: C.To prevent mouth sores and any other oral irritation, instruct client to rinse mouth to remove any remaining medications.

A – Although an upright position is ideal in using MDI, it is not necessary to keep bed at 30 degree angle. There is no specified positioning in using MDI.B – Use of inhaler before meals does not prevent oral complications. If food is introduced to the mouth while remaining medications are present, it may still cause irritation and crystallized medications may mix with the food that the person swallows which may also cause some irritation in the GI, as well as produce adverse effects. Rinsing after using MDI is the best way to prevent oral complicationsC – Inhalers may be PRN, especially for asthmatics. This is not a consideration that helps prevent oral complications.

(Source: Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed., by Taylor, C., p. 809)

22. A pulse is a wave of blood created by contraction of the left ventricle of the heart. A peripheral pulse is a pulse located away from the heart while the apical pulse, in contrast, is the central pulse located at the apex of the heart . Pulse rate varies according to a number of factors. Which of the following factors can be attributed to increase pulse:

i. Increase in ageii. Feveriii. Perception of severe painiv. Standing positionv. Taking digoxin

a. ii, iii, vb. i, ii, ivc. ii, iiid. ii, ii, iii

Answer: B. Fever, perception of severe pain and standing position can increase pulse Fever – Pulse rate increases in response to the lowered blood pressure secondary to peripheral vasodilation associated with elevated

body temperature, and because of increased metabolic rate Perception of severe pain – SNS activation in response to stress increases overall activity of the heart. Perception of severe pain, fear

and anxiety can stimulate the SNS. Standing position – When person is standing (or sitting), blood pools in dependent vessels of the venous system. Pooling results in a

transient decrease in venous blood return to the heart and a subsequent reduction in blood pressure and increase in heart rate.

Age and Digoxin decreases pulse Age. As age increases, pulse rate gradually decreases. Taking digoxin. Digoxin is a cardiac glycoside that increases intracellular calcium and allow more calcium to enter myocardial cells during

depolarization causing a positive inotropic effects (increased force of myocardial contraction) and that same time a negative chronotropic effect (slowed heart rate because of the slowing of the rate of cellular repolarization).

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8 thed, vol. 1, pp 537-538; Focus on Nursing Pharmacology, 4thed by Karch, p.716)

23. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. Because blood pressure can vary considerably among individuals, it is important for the nurse to know a specific client’s baseline blood pressure . Nurse Miranda Kerr is caring for a patient in the ICU. She needs to monitor vital signs every 15 minutes specifically the blood pressure. In assessing blood pressure, nurse Miranda will not be reprimanded if she performs which of the following except:a. She releases that valve of the cuff, allowing pressure to decrease at the rate of 2-3 mmHg per minute.b. She waits for at least 1-2 minutes before repeating another measurementc. She supports the patient’s forearm at the heart level before repeating another measurementd. She places the bell side of the amplifier of the stethoscope over the brachial pulse site

Answer: A.Cuff is released at 2-3 mm Hg per second, not at 2-3 mmHg per minute. If cuff is deflated to quickly, there is a false low systolic and high diastolic reading. If cuff is deflated to slowly, there is a false high diastolic reading.

Answers B, C, and D are correct statements.B – 1-2 minutes before the next repetition of BP measurement is provided to allow trapped blood in the veins to be released.C – Proper positioning in BP taking:

Sitting position (unless otherwise specified). Both feet flat on floor, crossing of legs at the knees result in elevated systolic and diastolic blood pressures.

Elbow is slightly flexed with palm of hand facing up and forearm supported at heart level. BP increases when arm is below the heart level and decreases when arm is above heart level.

Expose upper armD – Korotkoff’s sound is a low frequency sound, thus best heard with the bell of the stethoscope.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 1, pp 556-557)

24. Nurse Shakira is supervising a group of nursing students in the medical surgical ward. As the student nurses are taking their patient’s BP, Nurse Shakira is right to correct which of the following students, except:

a. Student Nurse Blake, who placed the lower border of the BP cuff at about 2.5 in above his patient’s antecubital space.b. Student Nurse Usher, who positioned his patient with extensive burns on the trunk and upper extremities in a prone position and placed

the cuff around the patient’s lower-thigh with the compression bladder over the anterior aspect of the thigh and bottom edge above the knee.

c. Student Nurse Carson, who took the initial BP of a newly admitted patient on both the client’s arms. He recorded 130/90 mmHg on the left arm and 140/90 mmHg on the right arm, and then used the patient’s left arm for subsequent blood pressure examinations.

d. Student Nurse Adam, who placed the bell side of the stethoscope over the brachial pulse site

Answer: D. This is the only correct answer because the Korotkoff’s sound is low pitched, thus bell is ideally used to better hear the sound

A – The lower border of the cuff is positioned at 2.5 centimeters or 1 inch above the antecubital space.B – In taking for the popliteal blood pressure, the cuff is wrapped at the mid-thigh with the compression bladder over the posterior aspect of the thigh and bottom edge above the knee.C - During the initial examination, BP is taken on both the client’s arms. The arm with the higher pressure should be used for subsequent examinations. Nurse Carson used the patient’s left arm (130/90 mmHg) for subsequent BP taking instead of the right arm (140/90) which recorded a higher BP reading, which made it incorrect.

(Source: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice, 8thed, vol. 1, pp 556-557)

25. Antibiotics are chemicals that inhibit specific types of bacteria. The goal of antibiotic therapy is to decrease the population of the invading bacteria to a point in which the human immune system can effectively deal with the invader. Nurse BehatiPrinsloo is providing discharge teachings regarding take home antibiotic therapy to Adam Levine, a 34 year old patient who was diagnosed with UTI. Adam displays correct understanding of the antibiotic therapy when he states:

a. “Whenever I feel new symptoms, I can just buy OTC drugs to relieve it.”b. “I must stop taking the antibiotics once symptoms disappear because prolonged use can cause tolerance”c. “Diarrhea and presence of thrush in the oral cavity and around my anal area is expected when taking these medications”d. “It is beneficial for me to take probiotics like yogurt while I’m on antibiotic therapy”

Answer: D. Antibiotics have the ability to kill bacteria – both pathogenic and good bacteria. It can attack the good bacteria in the gut leaving the body defenseless against opportunistic, fast-growing Candida yeast. Taking probiotics during antibiotic treatment can help slow the growth of Candida by filling the intestines with beneficial bacteria. Because probiotics maintain the balance in the digestive system, they also reduce the side effects of the antibiotics.

A – Patients are encouraged to report to their physician about new symptoms and avoid self-medicating with over the counter drugs because they might cause drug-to-drug interactionsB – Advise patients to complete the full-course of antibiotic therapy despite absence of the signs and symptoms. Absence of symptoms does not mean complete absence of bacteria. Under dosing can cause bacteria to develop resistance to the drug while over dosing can lead to superinfectionC – Diarrhea and thrush is not expected when taking antibiotics. They are adverse effects that need to be reported to the doctor.

(Source: Davis’ Drug Guide, 12th ed. p54)

CHN/PHN (15)26. Community health nursing, as defined by Dr. ArceliMaglaya, is the utilization of the nursing process to benefit the individual, family

and the community. In community health nursing, the family is considered as the:a. Point of entry in the communityb. Unit of servicec. Primary clientd. All of the above

Answer: B. Unit of service.

A – The individual is the point of entry in the community.B – Thefamily is the unit of service.C – Thecommunity is the primary client.D – Not applicable

27. To determine the appropriateness of nursing intervention, the nurse and the family should gain a clearer understanding of themselves and the role that they portray in the family. In SitioMalamok, several cases of dengue have been reported over the past weeks. During a home visit to the Potter family, the nurse was able to assess that Harry, the eldest child, searched the internet for information on Dengue and printed out this information to educate his family members. The nurse identifies Harry is acting as the:

a. Feelerb. Communicatorc. Thinkerd. Doer

Answer: C. Thinker. The thinker makes the information, data or knowledge readily available and accessible for ease and confidence in understanding the current situations in health and illness.

A –Feeler: the family needs to develop or strengthen its affective competencies in order to appropriately acknowledge and understand emotions generated by family life or health and illness situation. By doing so, such emotions can be transformed into growth-promoting choices and actions.D – Doer: enhances confidence in carrying out the needed interventions to initiate and sustain change for health promotion and maintenance, and accurate disease/ problem management.

(Source: Nursing Practice in the Community; 2009. 5th edition. Araceli S. Maglaya. pp. 84-85)

28. The family is two or more individuals living in a household because of the blood, marriage, or adoption. They interact with each other, have their respective roles & create & maintain a culture. After the marriage of Tonks and Remus Lupin, the couple decided to live with the husband’s family in efforts to save for their upcoming firstborn. This arrangement in residence is described as:

a. Patrilinealb. Matrilinealc. Patrilocald. Matrilocal

Answer: C. Patrilocal describes a residence arrangement that stay with or near the husband’s family.

A – Patrilineal is when the family associates with or adapts the cultural norms of the husband’s decentB – Matrilineal is when the family associates with or adapts the cultural norms of the wife’s decentD – Matrilocaldescribes a residence arrangement that stay with or near the husband’s family.

29. A family is a unit in which the action of any member may set of a whole series of reaction within a group, and entity whose inner strength may be its greatest single supportive factor when one of its members is stricken with illness or death. In the Lovegood family, Mr. & Mrs. Lovegood make sure that conflicts are handled by consulting all the family member and no decision is made until a consensus is made by all the family members. The authority in this family is described as:

a. Egalitarianb. Democraticc. Bilaterald. Centripetal

Answer: B. Democratic family (in terms of authority) is one where everybody is involved in decision making.

Types of family according to authority: Patriarchal – full authority on the father or any male member of the family e.g. eldest son, grandfather Matriarchal – full authority of the mother or any female member of the family, e.g. eldest sister, grandmother Egalitarian- husband and wife exercise a more or less amount of authority, father and mother decides Democratic – everybody is involve in decision making Laissez-faire- “full autonomy” Matricentric- the mother decides/takes charge in absence of the father (e.g. father is working overseas) Patricentic- the father decides/ takes charge in absence of the mother

A – Egalitarian is where there is equal authority between mother and fatherC – There is no bilateral type of family according to authorityD – There is no centripetal type of family according to authority

(Source: http://www.rnpedia.com/home/notes/community-health-nursing-notes/family-health-nursing)

30. Family structure is the composition and membership of the family and the organization and patterning of relationships among individual family members. Fleur who divorced her first husband 2 years ago is in a relationship with Bill, a widower with 3 children. They decided to re-marry and are now living in Fleur’s home with her son from her past marriage. This type of family structure is called:

a. Cohabitingb. Communalc. Compoundd. Blended

Answer: D. Blended / Reconstituted - a combination of two families with children from both families and sometimes children of the newly married couple. It is also a remarriage with children from previous marriage.

Types of family structures: Nuclear- a father, a mother with child or children living together but apart from both sets of parents Extended- composed of two or more nuclear families economically and socially related to each other. Multi- generational, including married

brothers and sisters, and the families. Single parent-divorced or separated, unmarried or widowed male or female with at least one child.

Blended / Reconstituted-a combination of two families with children from both families and sometimes children of the newly married couple. It is also a remarriage with children from previous marriage.

Compound-one man/woman with several spouses Communal-more than one monogamous couple sharing resources Cohabiting / Live-in-unmarried couple living together Dyad—husband and wife or other couple living alone without children Gay/ Lesbian- homosexual couple living together with or without children No-kin- a group of at least two people sharing a relationship and exchange support who have no legal or blood tie to each other Foster- substitute family for children whose parents are unable to care for them

(Source: http://www.rnpedia.com/home/notes/community-health-nursing-notes/family-health-nursing)

31. The family is a very important social institution that performs two major functions- reproduction and socialization. It is generally considered as the basic unit of care in community health nursing. Nurse Draco is conducting home visit to the Malfoy family. He noticed that the youngest child has Scabies infection that the other members are unaware of. Nurse Draco concludes that Malfoy family is unable to meet which of the following health tasks?

a. Seek health careb. Make appropriate decisions about taking actionsc. Recognize interruptions in healthd. Provide care to the sick, disabled or dependent member of the family

Answer: C. Health Tasks of the Family:

Recognize interruptions of health or development Seeking health care Managing health and non-health crises Providing nursing care to the sick, disabled, and dependent member Maintaining a home environment conducive to good health and personal development Maintaining a reciprocal relationship with the community and health institutions

(Source: Maglaya, 4th ed., pg. 8)

32. The home visit is a family-nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities.Minerva McGonagall is a Public Health Nurse assigned to conduct a home visit to Barangay Iring. It is correct for Minerva to consider the following as purpose of home visit, except:

a. To care to the sickb. To assess the living conditions of the patient and his familyc. To make careful evaluation of past services given to the familyd. To make use of the inter-referral system and to promote utilization of community service

Answer: C. This is not a purpose of a home visit, but a guideline to consider regarding the frequency of home visits

Purpose of Home visit includes: To give nursing care to the sick, postpartum mother and her newborn with the view to teach a responsible family member to give the

subsequent care The assess the living conditions of the patient and his family and their health practices in order to provide the appropriate health

teaching To give health teachings regarding the prevention and control of diseases To establish close relationships between the agencies and the public for the promotion of health To make use of the inter-referral system and to promote the utilization of community services

(Source: DOH book, p.51)

33. In performing home visits, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of the desired outcomes. Correctly arrange the steps in performing home visits:

1. Perform the bag technique2. State the purpose of the visit3. Record all data, observation and care rendered4. Assess health needs5. Greet the patient and introduce self6. Perform nursing care and give health teachings7. Make appointment for a return visit

a. 5, 2, 4, 6, 1, 3, 7b. 5, 2, 4, 1, 6, 3, 7c. 5, 4, 2, 6, 1, 7, 3d. 5, 2, 4, 1, 6, 7, 3

Answer: B. 5-2-4-1-6-3-7Steps in performing the bag technique

(5) Greet the patient and introduce self(2) State the purpose of the visit(4) Assess health needs(1) Perform the bag technique(6) Perform nursing care and give health teachings(3) Record all data, observation and care rendered(7) Make appointment for a return visit

(Source: ULG, Balita, p.371)

34. A family nursing care plan is the blueprint of care that the nurse designs to systematically minimize or eliminate the identified health and family nursing problems through explicitly formulated outcomes of care. Nurse Dumbledore is about to make a FNCP for the Grindewald family. All of the following are incorrect qualities of a FNCP, except:

a. Prepared by the nurse for the family to help find solutions to the identified problems b. Does not have to be a formal, written form as long as it is made with and accepted by the family c. Should be based on clear, explicit definitions of the problemsd. A good plan is flexible and can include care that is beyond the tangible resources available

Answer: C. FNCP should be based on clear, explicit definitions of the problems.

A - Prepared by the nurse for the family to help find solutions to the identified problemsFNCP is made by the nurse jointly WITH the family.B - Does not have to be in a formal, written form as long as it is made with and accepted by the family FNCP is most useful when in written form.D - A good plan is flexible and can include care that is beyond the tangible resources available FNCP should be a realistic plan

Desirable Qualities of a FNCP: It should be based on clear, explicit definition of the problem A good plan is realistic The NCP is prepared jointly with the family The NCP is most useful in written form

(Source: Maglaya, 4thed, pg 52)

35. Nursing Assessment is the first major phase of the nursing process. It includes data collection, data analysis, or interpretation and problem definition. The public health nurse starts to assess her adopted family. In data collection for first level assessment, the nurse appropriately gathers which of the following data:

a. Structure of the familyb. Values and practices of the familyc. Family’s perception about a problemd. Health status of each family member

Answer: C. Data collection for first level assessment involves gathering of five types of data which will generate the categories of health conditions of the family. These data include:

Family structure, characteristics and dynamics Socio-economic and cultural characteristics Home and environment Health status of each member Values and practices on health promotion/ maintenance and disease prevention

Second-level assessment data include those that specify or describe the family’s realities, perceptions about and attitudes related to the assumption or performance of family health tasks on each condition or problem identified during the first level assessment.

The family’s perception of the problem Decisions made and appropriateness; if none, reasons, and Actions taken and results Effects of decisions and actions on other family members

(Source: Maglaya, 4thed, pg 55)

36. The nurse is concerned about two important things to ensure effective and efficient data collection in family nursing practice.Firstly, she has to identify the types or kinds of data needed. Secondly, she needs to specify the methods of data-gathering and the necessary tools to collect such data. The public health nurse is assessing for the socio-economic and cultural characteristics of her adopted family. She is correct in including which of the following in this type of data?

1. Immunization status2. Decision-making patterns3. Educational attainment4. Housing and sanitation facilities5. Religious affiliation6. Occupation

a. 2, 5, and 6b. all except 1, 5, and 6c. 3, 5, and 6d. 5 and 6

Answer: C. Socio- economic and cultural characteristics include occupation, place of work, and income of each working member; educational attainment of each family member; ethnic background and religious affiliation; significant others and the other roles they play in the family’s life; and the relationship of the family to the larger community.

1. Immunization status Values and practices on health promotion/ maintenance and disease prevention

2. Decision – making patterns Family structure, characteristics &dynamics3. Educational attainment Socio- economic and cultural characteristics4. Housing and Sanitation facilities Home and environment5. Religious affiliation Socio- economic and cultural characteristics6. Occupation Socio- economic and cultural characteristics

(Source: Maglaya, 4th ed, pg 57)

37. Data collection for first level of family assessment involves gathering of five types of data which will generate the categories of health conditions of the family. These conditions are then categorized to the typology of nursing problems they belong. Hermoine is assigned as the nurse in Barangay Tempura. She conducted home visits in several families and decided to concentrate on the family which concerns her most. Living in a 30 sq. bungalow house with one room, one door and one window is the Weasley family. The head of the family, Albert (60 years old) was recently diagnosed with active Tuberculosis.The symptoms made him really ill so her wife Assunta, (45 years old) took over all the responsibilities. She accepts laundry from the neighbors and sells vegetables in the market. Her eldest son, Arlo (20), already has his own family with three children to support, but still lives in the house of his parents and recently lost his job for the fifth time this month.Arnold (18) accompanies his mother to the market while Alyssa (12) helps in doing the laundry service.Eight months pregnant Augo (15), stays in the house and has no pre-natal check-up yet.Ar-B (10) and Amy (8) takes care for their father and their younger siblings Adele (5) and Abby (3).None of the children has received immunization. And none of them even reached the 3rd grade. Which among the following will Nurse April consider as threats to the health of the family?

1. Active Tuberculosis of Albert 2. Loss of job3. Eight children, three grandchildren4. Pregnancy in teen years5. Inadequate living space6. Lack of immunization7. Inappropriate role assumption8. Improper garbage disposal

a. All except ii, iv, viiib. All except i, ii, ivc. All except i, iii, v, vi, viid. All except iii, v, vi , vii, viii

Answer: A.Typology of Nursing Problems in Family Nursing Practice:

Wellness condition is a clinical or nursing judgment about a client in transition from a specific level of wellness or capability to a higher level

Health threats are conditions conducive to disease and accident, or may result to failure to maintain wellness or realize health potential. Health deficit is an instance of failure in health maintenance. Foreseeable crisis are anticipated periods of unusual demand on the individual or family in terms of adjustment of family resources.

1. Active Tuberculosis of Albert1.

Tuberculosis is considered a deficit but the word “active” poses as threat of cross infection of a communicable disease to other family members

2. Loss of job Foreseeable crisis3. Eight children, three grandchildren Family size beyond what family resources can adequately provide4. Pregnancy in teen years Foreseeable crisis5. Inadequate living space Poor environmental status – Inadequate living space6. Lack of immunization Inadequate or Lack of immunization status especially among children7. Inappropriate role assumption Inappropriate role assumption8. Improper garbage disposal There is no improper garbage disposal stated in the situation

(Source: Maglaya 2004, pp. 68-70)

38. The typology of nursing problems in family health is based from health tasks of a family in the community as described by Freeman.Nurse Luna conducts a home visit to the Longbottom family. Upon interview with the family members, Nurse Luna identifies that the current stressor of the family is the hospitalization of their only son, Neville for dengue. Nurse Luna is correct to understand that the hospitalization of Neville is a form of:

a. Wellness conditionb. Health threatc. Health deficitd. Foreseeable crisis

Answer: D. Hospitalization of a family member falls under foreseeable crisis. Neville diagnosed with dengue is the health deficit but demands of financial stress and financial burden in the event of hospitalization becomes an unusual demand in the adjustment of family resources.

Foreseeable crisis or Stress Points include: Marriage Pregnancy, labor, puerperium Parenthood Additional member Abortion Entrance to school Adolescence Divorce or separation Menopause Loss of job Hospitalization of a family member Death Resettlement to a new country Illigitimacy Others

(Source: Maglaya 2004, pp. 68-70)

39. Health workers in general should be guided by the principle “the greatest good for the greatest number” or “distributive justice” in prioritizing health services and activities, primarily because resources are limited . In prioritizing family health problems, Nurse Eugene should assign the highest weight on:

a. Present wellness state or potential, health threat, health deficit or foreseeable crises b. Probability of success in enhancing wellness state, improving the condition, minimizing or totally alleviating or totally eradicating the

problem through interventionc. Preventive potentiald. Client’s perception and evaluation of the condition or problem in terms of seriousness and urgency of attention needed or readiness

Answer: B. Modifiability of the problem has the greater weight among the criteria in prioritizing family health problems.Scale for Ranking Health Conditions and Problems According to Priorities.

CRITERIA DESCRIPTION WEIGHTA. Nature of the Problem Present wellness state or potential, health threat, health deficit or foreseeable

crises 1

B. Modifiability of the Condition/Problem

Probability of success in enhancing wellness state, improving the condition, minimizing or totally alleviating or totally eradicating the problem through intervention

2

C. Preventive Potential Nature and magnitude of future problems that can be minimized or totally prevented if intervention is done on the condition or problem under construction

1

D. Salience perception and evaluation of the condition or problem in terms of seriousness and urgency of attention needed or readiness

1

(Source: Maglaya, 2009: p. 77, 80)

40. After identifying the health problems in the family, these problems need to be prioritized to determine which one must be attended first. One of the problems that you identified in Snape family is the inadequate living space which is a condition conducive to easy communicability of contagious diseases. Upon assessment, there is partial modifiability of the problem due to lack of resources to increase living space. Preventive potential is moderate. The family is able to acknowledge the problem however, don’t consider it as an immediate concern. What is the score of the problem?

a. 2.84b. 4.17c. 3.83d. 3.84

Answer: A. 4.17Criteria Score Computation Actual ScoreNature of the problem Health threat = 2 (2÷3 ) x 1 0.67

Modifiability of the problem Partial = 1 (1÷2 ) x 2 1

Preventive Potential Moderate = 2 (2÷3 ) x 1 0.67

Salience Not immediate concern = 1 (1÷2 ) x1 0.5

TOTAL SCORE 2.84

COMMUNICABLE DISEASES (5)41. Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a characteristic cluster of

clinical, biochemical and cellular changes. To date, there are 5 definitive types of viral hepatitis: Hepatitis A, B, C, D and E. Nurse Ted is planning a community education program on how to prevent the transmission of viral hepatitis. Which of the following types of hepatitis have oral-fecal route as mode of transmission?

1. Hepatitis A2. Hepatitis B3. Hepatitis C4. Hepatitis D5. Hepatitis E

a. 1 and 3b. 1 and 4c. 1 and 5d. All except 2 and 4

Answer: C. (1) Hepatitis A and (5) Hepatitis E are both oral-fecal in route.1 – Hepatitis A or Infectious Hepatitis: oral-fecal route2 – Hepatitis B or Serum Hepatitis: blood-borne, oral-oral3 – Hepatitis C or Non-A, non-B Hepatitis: blood-borne 4 – Hepatitis D: follows Hep B, blood-borne5 – Hepatitis E: oral-fecal route

(Source: Brunner and Suddarth 12thed, p. 1139)

42. Portal of entry of all diarrheal pathogens is oral ingestion. Although food is far from sterile, the high acidity of the stomach and the antibody-producing cells of the small bowel generally serve to decrease the potential of pathogens.Nurse Barney receives in the ER 7 grade schoolers, all with complaints of severe stomach pain, diarrhea and fatigue. History reveals that all of them came from play date in one of the children’s house earlier that day. They reportedly ate fried chicken and carbonara and wereall served with water. Laboratory results reveal Salmonella poisoning. Nurse Barney would suspect that the probable source of the salmonella poisoning was the:

a. Drinking waterb. Fried chickenc. Mayonnaise from the carbonarad. Pasta from the carbonara

Answer: B. Fried chicken. Salmonella is gram-negative bacilli that are prevalent in animal food sources (protein sources) like commercially available chicken and chicken products and more frequently in eggs.

A – Drinking water. Common diarrheal pathogens that are found in water are Giardia lamblia (Giardiasis) and Vibrio cholera (Cholera)C and D – A food-borne communicable disease that produces more or less similar manifestations with Salmonella is Staphylococcus poisoning. However, staphylococci are more frequently found in carbohydrate rich foods such as pasta and mayonnaise.

(Source: Brunner and Suddarth 12thed, p. 2140-2141)

43. Nurse Robin documents that five (5%) percent of school-aged children in Barangay Bulate Elementary School have been inflicted with Ascarislumbricoides. After identifying elementary pupils affected by this parasite, the school nurse conducts deworming by giving Albendazole 400 mg. Who among the following identified school children will she not give Albendazole to?

a. Uno, 5 y/o who is underweight and having diarrheab. Dos, 6 y/o who has experienced abdominal pain 2 days ago c. Tri, 12 y/o who turned positive under Kato thick smear testd. Forr, 10 y/o who had measles two months ago

Answer: A.Administrative Order No. 2010-0023 and 2006-002 8of the Department of Health, provides for the Guidelines on Deworming Drug Administration and the Management of Adverse Events Following Deworming (AEFD) as follows:

TARGET GROUP DOSE CONTRAINDICATIONSChildren aged 1 year to 12 years old

For children 12 – 24 months oldAlbendazole - 200 mg, single dose every 6 months. Since the preparation is 400mg, the tablet is halve and can be chewed by the child or taken with a glass of waterOrMebendazole - 500 mg, single dose every 6 monthsFor children 24 months old and aboveAlbendazole - 400 mg, single dose every 6 monthsOrMebendazole - 500 mg, single dose every 6 months

Note: If Vitamin A and deworming drug are given simultaneously during the GP activity, either drug can be given first.

Seriously ill childChild with abdominal painChild with diarrheaChild who previously suffered hypersensitivity to the drugSeverely malnourished (underweight) child

44. Typhoid fever is an infection characterized by continued fever and involvement of lymphoid tissues, enlargement of spleen, Rose spots on trunk and diarrhea. Nurse Lily is educating family members of a patient with Typhoid fever of appropriate home care considerations. She is correct to state:

a. “Always use a mask when inside the same room with the patient.”b. “Patient should be kept at NPO until diarrhea subsides.”c. “Keep the lids of trash cans close, cover unattended food and make use of door and window screens to prevent attracting flies into

the household.”d. “Monitor that patient completes full-course of praziquantel (Biltricide) even after signs and symptoms of typhoid fever abate.”

Answer: C. Fly control and screening to prevent transmission of the disease since flies are known vectors of typhoid bacillus.

A –Masks are not necessary. Typhoid fever is transmitted via direct or indirect contact with patient or carrier. B – Patients are encouraged to increase oral fluids during diarrhea and vomiting in efforts to replace lost fluids.D – Praziquantel is an anthelmintic effective against flatworms and is the treatment of choice for paragonomiasis and schistosomiasis. Treatment of choice for typhoid fever is chloramphenicol which should be taken for its full-course even after signs and symptoms of typhoid fever is no longer present.

(Source: DOH Book, p280-282)

45. Pinworms are small, thin worms that commonly infect young children, although anyone can be infected. The best way to diagnose this infection is through a tape test. Nurse Marshall has been unsuccessful in performing the tape test. Marshall has been incorrectly performing the test because he:

a. Firmly presses 1 inch cellophane tape directly over the anal area for a few seconds onlyb. Performs the test at night after the patient has had a bowel movementc. Transfers the tape to a glass slide, sticky side downd. None of the above

Answer: B. Scotch tape test is performed in the morning because pinworms lay their eggs at night. When the client is asleep, the pinworms emerge from the rectum to lay its eggs. However, it is ideally done before bathing or bowel movement because the eggs may be evacuated by water during these activities.

How to perform the Scotch tape test: Ideally done the morning before bathing, because pinworms lay their eggs at night. Firmly press the sticky side of a 1-inch strip of cellophane tape over the anal area for a few seconds. The tape is then transferred to a glass slide, sticky side down. Health care providers needs examine the slide to confirm that there are

eggs. The tape test is done on three separate days to improve the chances of detecting the eggs.

(Source: Mosby’s Comprehensive Review of Nursing for NCLEX-RN)

OBSTETRIC NURSING (10)46. A pregnancy compounds iron-deficiency anemia because the mother must now supply enough iron for fetal growth and her

increasing blood volume.Princess Kate, a 29 year-old primigravid was prescribed with iron supplement by her obstetrician after developing iron-deficiency anemia. You want to assess her adherence to the treatment. All of the following may help in assessing the patient’s devotion to the supplementation, except?

a. Obtaining a stool swabb. Regularly checking her serum iron levelc. Looking for a decline in reticulocyte countd. Checking for increased in the number of immature RBCs

Answer: C. Reticulocyte counts are expected to rise after 2 weeks of adherence to iron supplementation. A continued decline in reticulocyte count may mean that the mother is non-compliant to her supplementation

A – Taking a stool swab for the black tinge of an iron supplement can be a method of assessing adherenceB – Reassessing serum iron levels can be a method of assessing adherenceD - As soon as the body has iron, it will begin forming immature red blood cells rapidly. A reticulocyte count may be obtained in 2 weeks to evaluate these levels and provide evidence that the iron supplement is being taken.

(Source: Pilliteri, page 471)47. Typically substance-dependent women are thought to be in the younger age group, as overall incidence of drug use is the highest in

this group. However, any woman could be substance dependent. Therefore, all pregnant women need to be assessed for the possibility of substance abuse. You are planning to make counseling sessions to Mrs. Pepper, a multigravid client, who has history of abusing cocaine. Which of the following should not be included in the discussion?

a. Several illegal drugs cross the placenta readily.b. Breastfeeding is still advised because unlike with the placenta, illicit drugs do not affect breast milk production.c. A substance-dependent pregnant client may be reported to child protective organizations.d. Risk for hepatitis B infection increases with drug use.

Answer: D. Breastfeeding is usually not encouraged for women with substance abuse because, just as all drugs cross the placenta to some extent, they also are excreted into breast milk.

A - Illicit drugs tend to be of small molecular weight, so they cross the placenta readily. C – A woman who is still abusing a drug at this time needs additional referral so she can secure help. In some states, women who test positive for drug abuse, either during pregnancy or at the time of birth, are reported to state child protective agencies; they may be accused of child abuse and jailed; and their infant may be placed in foster care. D - If a woman uses injected drugs, the risk for hepatitis B or human immunodeficiency virus infection rises. A

(Source: Pilliteri, page 481)

48. Approximately 2-3% of women who do not begin pregnancy with diabetes become diabetic during pregnancy, especially during the midpoint of the pregnancy when insulin resistance becomes most noticeable. This is termed as gestational diabetes mellitus. Symptoms however, fade away at the completion of the pregnancy. A client with gestational diabetes had a cesarean birth because the fetus was determined to be large for gestational age. The nurse should assess for which postsurgical complications?

1. Wound-edge separation2. Fever after the first 24 hours postpartum3. Lochia odor4. Purulent drainage from incision5. Temperature of 37.9C during the first 24 hours postpartum

a. 1, 2, 3, 4, 5b. All except 1 and 2c. All except 5d. All except 2

Answer: C. Fever on the first 24 hours postpartum that does not exceed 38C is an expected post-partum change in relation to the dehydration secondary to blood loss. Temp however normalizes within a few hours after.

Post-Surgical complications:1 – Wound edges should be closely approximated.2 – Fever after the first 24 hours or above 38C on the first 24 hours postpartum may indicate maternal infection3 – Lochia should have no odor 4 - Drainage from the incision should be minimal and clear

(Source: Pilitteri, p. 577)

49. Hyperemisisgravidarum is nausea and vomiting of pregnancy that is prolonged past week 12 of pregnancy or can be so severe that dehydration and severe weight loss happen during the first 12 weeks of pregnancy.Kim Kardashian, a 27-year-old primigravida is in for hyperemesis gravidarum. You would expect her laboratory findings to reveal:

a. Hct: 39%b. Serum potassium: 6.7 mEq/L (up)c. Urinalysis: (+) Ketonesd. Serum sodium: 149mEq/L

Answer: C. Urine may test positive for ketones in hyperemesis gravidarum because as the woman vomits her gastric contents, there becomes less amount of food that is successfully digested and used in the body. Ketones in the urine becomes evident when the woman’s body is now breaking down fat and protein for cell growth.

A – Hematocrit level given is within normal range. In hyperemesis gravidarum, hematocrit levels are high because of her inability to retain fluid has resulted to hemoconcentration.

B – Potassium level given is above the normal range. In HG, potassium is more expected to be low because of the continuous vomiting, decrease intake of potassium-rich food and hypokalemic alkalosis that results when vomiting is severe.D – Sodium level given is above the normal range. In HG, sodium is expected to be low because of the continuous vomiting and decrease intake of sodium.

(Source: Pilliteri, p. 318)

50. Abortion is the medical term for any interruption of a pregnancy before a fetus is viable. A viable fetus is usually defined as a fetus of more than 20-24 weeks of gestation. Andi is on her 10 weeks gestation with her 3rd baby. She has history of spontaneous abortion and spotting. She told the nurse that she had profuse vaginal bleeding, passage of placenta with embryonic sac and severe uterine cramping. However upon examination, the physician on duty determines that her cervix is closed and UTZ reveals that placenta and embryonic sac is still inside the uterine cavity. Andi is probably exhibiting signs of:

a. Threatened abortionb. Missed abortionc. Complete abortiond. Incomplete abortion

Answer: A. Threatened abortion.Although Andi claims that she had profuse vaginal bleeding, passage of placenta with embryonic sac and severe uterine cramping (all describing to a complete abortion), these are all subjective data because these are just verbalized by the patient. Objective data (via examination) shows that cervix is still intact and placenta and embryonic sac are still in the uterine cavity. Objective data is more reliable than subjective data.

A – Threatened abortion: bleeding, cramping and softening of uterus with closed cervixB – Missed abortion: fetus dies in utero and has not been expelled since the cervix may still be closed and presents with intermittent bleedingC – Complete abortion: entire product of conception is expelledD – Incomplete abortion: expulsion of some parts of the conception. Massive bleeding since placental fragments remain*Inevitable abortion: Unpreventable cervical dilation with persistent hemorrhage and severe cramping with opening of cervix

(Source: Pilliteri, p. 555-557)

51. Gestational trophoblastic disease (Hyatidiform Mole) is an abnormal proliferation and then degeneration of the trophoblast. As they degenerate, they become fluid-filled appearing as grape-like vesicles. You are assessing a patient diagnosed with H-mole. It would be correct to expect all of the following findings from the patient, except:

a. Uterine size reaching its landmarks before expected timeb. Exaggerated HCG levelsc. Complaints of marked nausea and vomitingd. Diminished fetal movements

Answer: D. You would not expect diminished fetal movements because there is certainly NO fetal movements because there is no formation of a fetus.

A – Proliferation of the trophoblasts occurs so rapidly in H-mole that the uterus tends to expand faster than normally. This causes the uterus to reach its landmarks before expected time. However, this assessment cannot be conclusive to H-mole because this may also happen in multiple gestation or even in miscalculated due date.B – Because HCG is produced by overgrown trophoblasts cells, serum or urine HCG level is notably higher than normal pregnancy levelsC – High levels of HCG may cause marked nausea and vomiting

(Source: Pilliteri, page 561-562)

52. Slight spotting late in pregnancy can be caused by trauma from a pelvic examination or coitus, so this could be an innocent finding. Bleeding during late pregnancy usually occurs, however, from placenta previa, premature separation of the placenta (abruption placentae), or preterm labor, all of which are serious conditions.A woman at 38-week gestation comes to the ER with complaints of vaginal bleeding. Which of the following remarks, if made by the client would suggest placenta previa as potential cause of bleeding?

a. “I feel fine, but the bleeding scares me.”b. “I’ve been experiencing severe abdominal cramps.”c. “I feel nauseated more during the past few weeks.”d. “The bleeding started after I carried 4 bags of groceries.”

Answer: A. Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally. It is a painless bleeding in the third trimester of pregnancy. Complaints in placenta previa will be bleeding that is not accompanied with any other discomfort. The verbalization of “I feel fine” signify that the patient is not experiencing any other complains. The bleeding that occurs is usually abrupt, painless, bright red and sudden enough to frighten a woman

B – There is no abdominal cramping that accompanies with placenta previa. This is more likely to describe abruption placenta or the premature separation of placenta.C – Feelings of nausea is not a characteristic of placenta previa. D – Placenta previa is not associated with increased activity or participation in sports.

(Source: Pilliteri, p.564)

53. A client at 35 weeks’ gestation complains of severe abdominal pain and passing clots. The client’s vital signs are BP: 150/100 mmHg, HR: 95 BPM, RR: 25 CPM, and FHT 160 BPM. The admitting nurse must determine the cause of the bleeding and respond appropriately to this emergency. What should be the immediate nursing action?

a. Examine the vagina to determine whether client is in laborb. Assess the location and consistency of the uterusc. Perform an ultrasound to determine placental placementd. Prepare for immediate vaginal birth

Answer: B. The nurse must determine whether placenta previa or abruption placenta is the problem. 50% of all clients with hypertension will develop abruption placenta. In this case, the presenting symptoms is highly suggestive of an abruption, so the nurse must determine the level of the

uterus and mark that level on the client’s abdomen. She must also check the consistency of the uterus; a uterus that is filling with blood because placenta is detached early is rigid (Couvalaire uterus). Bleeding is usually painless.

A – A vaginal examination is contraindicated in the presence of bleeding. B – It is not under the nurses’ scope of duty to perform an ultrasound on patients. Nurses may prepare patients for ultrasound but the procedure itself is done by Sonographic technicians or doctors.D – If the client has placental abruption, choice for delivery will most likely be by cesarean birth.

(Source: Pilliteri, p.416)

54. Preterm rupture of membranes is rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks. The cause of preterm rupture is unknown, but is associated with infection of the membranes (chorioamnionitis). Brittany S. Pears, G5P4 is suspected to have premature rupture of membranes. Upon inspection, the nurse observed a sudden gush of transparent fluid from the patient. Which findings indicate the PROM has occurred:

1. Fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry2. Acidic pH of fluid when tested with Nitrazine paper3. Presence of amniotic fluid in the vagina4. Cervical dilation of 6cm5. Alkaline pH of fluid when tested with Nitrazine paper6. Contractions occurring every 5 minutes

a. All except 4, 5 , 6b. All except 5 and 6c. All except 2, 4, 6d. All except 2 and 4

Answer: C. Correct answers are statements 1-3-5. So, ALL are correct statements except 2-4-6.

Correct statements:1- Amniotic fluid is tested for ferning, or the typical appearance of a high estrogen fluid on microscopic examination. Urine does not have a ferning appearance because it does not contain estrogen3 – The presence of amniotic fluid in the vagina results from the expulsion of the fluid from the amniotic sac5 - Amniotic fluid is slightly alkaline, thus causes a nitrazine paper to turn blue. (Acidic reaction: yellow, like in urine which is acidic)

Incorrect statements:2 - Amniotic fluid is not acidic but slightly alkaline, thus causes a nitrazine paper to turn blue. (Acidic reaction: yellow, like in urine which is acidic)4 and 6 – Cervical dilation and regular contractions are signs of progressing labor but don’t indicate PROM

(Source: Pilliteri, page 425)

55. Eclampsia is the most severe classification of Pregnancy-Induced Hypertension when edema reaches the brain and the cerebral edema is so acute that it produces grand-mal seizures. Nurse Beyoncé is caring for an eclamptic mother. In planning for her care, which nursing action does not contribute in preventing complications of eclampsia:

a. Encourage mother to eat low-sodium food like peas, rice, celery, carrotsb. Assigning the patient in a bed in quiet private room with a window that keeps the room well-lightedc. Providing mother with clear explanations of activities around her and activities that involve herd. Leaving side rails up to prevent injury if seizures occur

Answer: B. Eclamptic patients are admitted in a private room so she can be undisturbed as possible. The room is darkened as possible because a bright light can also trigger seizures. But not too dark that caregivers need to use flashlights because flashing light beams into a woman’s eyes can be a sudden stimulation.

A – Sodium moderation to help control the increased blood pressureC – Clear explanations of the activities around her will give her understanding and relieve her of the stress and anxiety of unfamiliar procedures going on around her. Stress and anxiety can also pose as triggersD – This is helpful to promote safety of the mother.(Source: Pilliteri, p.578)

PEDIATRIC NURSING (10)56. Children are at high risk for iron-deficiency anemia because they need more daily iron in proportion to their body weight to maintain

an adequate an adequate iron level than do adults. A 7-year old male child is rushed into the hospital with presenting signs and symptoms of fatigue, paleness of mucous membranes, and was generally irritable. Iron-deficiency anemia has been established. Which of the following is not true in relation to the patient’s diagnosis?

a. Minimizing the child’s daily activities especially before mealtime. b. Counsel the mother to increase the child’s intake of milk and milk products.c. Meat can be substituted to egg products, vegetables, and cheese.d. An increased in reticulocyte count means that the anemia has been or is being corrected.

Answer: B. Overfeeding with milk is one of the major causes of IDA in children. Iron, when taken into the body, has only 10% absorption rate and is ideally absorbed in an acidic environment. With high bulk in the diet, large amounts of milk and antacids, iron absorption rate is further decreased.

A - When planning care for an infant with iron-deficiency anemia, it is helpful to minimize the child’s activities to prevent fatigue, particularly at mealtime, as fatigued child will not be able to eat, let alone eat iron-rich foods. C - Counsel parents on measures to improve their child’s diet, such as adding iron-rich foods while decreasing milk intake to maintain iron levels and prevent recurring anemia. If the child is not fond of meat, suggest parents substitute cheese, eggs, green vegetables, or fortified cereal. D - After 7 days of iron therapy, a reticulocyte count is usually done. If elevated, this means the child is now receiving adequate iron and the rapid proliferation of new erythrocytes is correcting the anemia.

(Source: Pilliteri, 1394)

57. Aplastic anemia results from depression of hematopoietic activity in the bone marrow. The formation and development of WBCs, platelets, and RBCs can all be affected. A child was recently diagnosed with Fanconi’s syndrome, one type of aplastic anemia. You know that the ultimate treatment for the patient is:

a. Stem cell transplantationb. Administration of colony-stimulating factorsc. Testosteroned. Oral corticosteroid

Answer: A. Congenital aplastic anemia (Fanconi’s syndrome) is inherited as an autosomal recessive trait. A child is born with a number of congenital anomalies such as skeletal and renal abnormalities, hypogenitalism, and short stature. The ultimate therapy for both congenital and acquired aplastic anemia is stem cell transplantation. An RBC-stimulating factor may be helpful. Colony-stimulating factors may also improve bone marrow function. Some children show improvement with a course of an oral corticosteroid (prednisone). Testosterone to stimulate RBC growth may be tried. For children who receive a stem cell transplant, chances of complete recovery are good. For other, the course is uncertain.

(Source: Pilliteri, page 1390)

58. Vitamin B12 is necessary for maturation of RBCs. Pernicious anemia results from deficiency or inability to use the vitamin. Karen, 5 year-old post-operative patient, has been diagnosed with pernicious anemia due to the absence of intrinsic factor in the stomach. You expect that Karen is most likely to receive which of the following?

a. Monthly intramuscular injections of B12 vitamins for a lifetimeb. Temporary injections of Vitamin B12c. Lifelong administration of Oral Vitamin B12 dailyd. Temporary oral doses of Vitamin B12

Answer: A. If the anemia is caused by a B12-deficient diet, temporary injections of B12 will reverse the symptoms. If the anemia is caused by lack of the intrinsic factor, lifelong monthly intramuscular injections of B12 may be necessary. Parents and the child need to understand the lifelong therapy is necessary.

(Source: Pilliteri, page 1395)

59. Sickle-cell anemia is the presence of abnormally shaped RBCs. Sickle-cell crisis is the term used to denote a sudden, severe onset of sickling. Upon reading the chart of a patient who has sickle-cell anemia, you determined that she has had a megaloblastic crisis. You know this crisis:

a. Occurs when there is an increased destruction of erythrocytesb. Develops if the patient has had a folic acid deficiencyc. Is characterized by severe anemia because of an abrupt fall in RBC productiond. Happens when there is splenic sequestration of RBCs

Answer B.A megaloblastic crisis may occur if the child has folic acid or vitamin B deficiency (new RBCs cannot be fully formed due to lack of these ingredients. Less frequent forms of crisis may occur when there is splenic sequestration of RBCs or severe anemia occurs due to pooling and increased destruction of sickled cells in the liver and spleen. A hyperhemolytic crisis can occur when there is increased destruction of RBSs. An aplastic crisis is manifested by severe anemia due to a sudden decrease in RBC production. This form usually occurs with infection.

(Source: Pilliteri, page 1397)

60. The thalassemias are autosomal recessive anemias associated with abnormalities of the beta chain of adult hemoglobin (HgbA). Although these anemias occur most frequently in the Mediterranean population, they also occur in children of African and Asian heritage. You are assigned to care for a patient who has been diagnosed with Thalassemia Minor. You expect that all of the following treatment modalities would be helpful to the patient’s condition, except?

a. Lifetime iron supplementationb. Blood transfusion of PRBCs every 4 weeksc. Administration of digitalis and diureticsd. Low sodium-diet

Answer: A.Rationale: Digitalis, diuretic and a low sodium-diet may be prescribed to prevent heart failure, which could result from the decompensation that accompanies anemia, and from myocardial fibrosis caused by invasion of iron (hemosiderosis). Transfusion of packed RBCs every 2 to 4 weeks will maintain hemoglobin between 10 and 12 g/100 mL. With this level of hemoglobin, erythropoiesis is suppressed and cosmetic facial alterations, osteoporosis, and cardiac dilatation are minimized. Children may receive an iron chelating agent to remove this excessive storage of iron, such as deferoxamine. They should not receive a routine iron supplement because their inability to incorporate it well into hemoglobin may cause them to accumulate too much iron.

(Source: Pilliteri, pages 1401-1402)

61. Polycythemia is an increase in the number of RBCs. Plethora (marked reddened appearance of the skin) occurs because of the increase in total RBC volume. You are to give an exchange transfusion to a patient with polycythemia. You know that all but one of the following are probable results of this disease:

a. Tetralogy of Fallotb. COPDc. Twin transfusion at birthd. Increased level of oxygen in the intrauterine life

Answer: D.Rationale: The condition results from increased erythropoiesis, which occurs as a compensatory response to insufficient oxygenation of the blood in order to help supply more oxygen to body cells. Chronic pulmonary disease and congenital heart disease are the usual causes of polycythemia in childhood. Also, it may occur from the lower oxygen level maintained during intrauterine life in newborns or with twin transfusion at birth (one twin receives excess blood while a second twin is anemic.

(Source: Pilliteri, page 1403)

62. Idiopathic thrombocytopenic purpura is the result of a decrease in the number of circulating platelets in the presence of adequate megakaryocytes (precursors to platelets). Mrs. Matsunaga brought her daughter to the hospital due to complaints of joint pain. Upon examination, there were areas of ecchymosis over the thighs. The child has had epistaxis episodes. It turned out that the child has idiopathic thrombocytopenic purpura. Which of the following would not become a part of the therapeutic treatment for the child?

a. Administration of prednisoneb. Intravenous immunoglobulinc. Platelet transfusion for temporary used. Aspirin

Answer: D.Rationale: Oral prednisone to reduce the immune response and intravenous immunoglobulin (IVIG) or, in RH-positive children, anti-D immunoglobulin to supply anti-ITP antibodies are used to treat ITP. Platelet transfusion will temporary increase the platelet count, but because the life span of platelets is relatively short, a platelet transfusion will have limited effect. If the child experiences joint pain from bleeding, do not give salicylates or ibuprofen. These agents will increase the chances for bleeding as they prevent the aggregation of platelets at wound sites.

(Source: Pilliteri, page 1404)

63. Henoch-Schonleinpurpura (also called anaphylactoidpurpura) is caused by increased vessel permeability. Although no definite allergic correlation can be identified, it is generally considered to be a hypersensitivity reaction to an invading allergen. Randy, 7-years old, was diagnosed with Henoch-Schonleinpurpura. As the nursing that will be assigned to him, you expect to find all of the following, except?

a. Rashes seen on thighs, extensor muscles of the extremities, and buttocksb. Marked thrombocytopeniac. Elevated ESR and WBC levelsd. Dysentery and abdominal pain

Answer: B. The purpural rash in Henoch-Schonleinpurpura occurs typically on the buttocks, posterior thighs, and extensor surface of the arms and legs. The tips of the ear may be involved. The child may have gastrointestinal symptoms such as abdominal pain, vomiting, or blood in stools. Laboratory studies show a normal platelet count. Sedimentation rate, WBC count, and eosinophil count are elevated.

(Source: Pilliteri, page 1405)

64. Hemophilia is an inherited interference with blood coagulation. There are numerous hemophilia types, each involving deficiency of a different blood coagulation factor. Suri, 6-year old, was diagnosed with Von Willebrand’s disease after being admitted because of episodes of epistaxis. This condition involves an inability of the platelets to aggregate and a deficiency in which of the following clotting factors?

a. VIIb. VIIIc. IXd. XI

Answer: B.Along with a factor VIII defect, there is also an inability of the platelets to aggregate. In addition the blood vessels cannot constrict and aid in coagulation. Bleeding time is prolonged, with most hemorrhages occurring from mucous membrane sites. Christmas disease (Hemophilia B) is caused by deficiency in factor IX. Hemophilia C or plasma thrombolplastin antecedent deficiency; caused by factor XI deficiency, is transmitted an autosomal recessive trait occurring in both sexes.

(Source: Pilliteri, page 1405)

65. Hemophilia is often recognized first in the infant who bleeds excessively after circumcision. If the disease has not shown itself for several generations in the family, the parents may be unaware of its existence. A child with hemophilia complains of severe joint pain. Upon assessment, the joints were swelling and warm to touch. All of the following should help in maintaining the pain at a tolerable level, except?

a. Administration of Ibuprofen as prescribedb. Performing passive ROM exercises as orderedc. Provide reading materials for the child to enjoyd. Maintaining proper alignments of immobilized joints

Answer: A.Ibuprofen, as an NSAID, blocks Cyclooxygenase which also functions for the synthesis of thromboxane, which is needed for platelet aggregation. Ibuprofen can prolong bleeding.

B - As soon as the acute bleeding episode has halted, perform passive range of motion as ordered to maintain function. C – Providing reading materials as a form of divertional activity is a non-pharmacologic management for pain because it can divert one’s focus from the intensity of painD - Immobilization of the affected joints helps to decrease bleeding and also provides relief. Be certain that immobilized joints are in good alignment.

MS (20)66. Spinal cord injuries are more common in C5-7, T12 and L1. These vertebrae are more susceptible because there is a greater range of

mobility in the vertebral column in these areas. You are caring for a patient who suffered a fall from a ladder while trying to change their light bulbs. You ask your patient to raise his legs one at a time and the patient is unable to comply. You then ask the patient to close his eyes and tell you which leg you are pressing with the pointed end of the reflex hammer. The patient is unable to tell you correctly which leg you are pressing with the verbalization of, “I don’t feel anything in my leg. I can’t feel it being pressed by the pointed rod.” Further assessment reveals that patient does not feel any tactile stimulation in his legs. The patient is probably suffering from:

a. Complete spinal cord lesionb. Brown-Sequard Syndromec. Anterior Cord Syndromed. Central Cord Syndrome

Answer: A.Complete spinal cord lesion where there is total loss of sensation and voluntary muscle control below the lesion. This kind of lesion can result in paraplegia

B, C and D are classifications of Incomplete spinal cord lesion where either the sensory fibers or motor fibers, or sometimes, even both, are preserved below the lesion.

Central Cord Lesion: Motor deficits in the upper extremities compared to the lower extremities. Sensory deficits vary but are more pronounced in the upper extremeties.

Anterior Cord Syndrome: Loss of pain, temperature and motor function is noted below the level of the lesion. Light touch, position and vibration sensation remain intact.

Brown-Sequard Syndrome (Lateral Cord Syndrome): Ipsilateral paralysis or paresis is noted together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature.

(Source: Brunner and Suddarth, 12th ed. p.1934-1935)

67. Management of spinal cord injuries varies from the acute management phase through rehabilitation.The nurse faces challenges how to maximize health status to preserve quality of life. In taking care of clients with spinal cord injury, the nurse must observe which of the following nursing interventions?

a. Promoting adequate breathing, improving mobility, adaptation to sensory and perceptual alteration, maintaining skin integrity and elimination, and providing comfort measures.

b. Maintaining immobility, adequate nutrition and elimination, comfort measures, pharmacological and respiratory, therapy and adapting to sensory and perceptual alterations

c. Improving elimination, adapting to sensory and perceptual alteration, pharmacological and respiratory therapy and maintaining skin integrity

d. Adapting to sensory and perceptual function, maintaining immobility, providing comfort measures and improving bowel functions

Answer: A.Nursing Interventions in Patient with SCI:

Promote adequate breathing and airway clearance Improving mobility Maintaining adaption to sensory and perceptual alteration Maintaining skin integrity Maintaining urinary elimination Proving bowel function Providing comfort measures Monitoring and managing potential complications Promoting home and community-based care

B and D – Immobility should not be maintained. Contractures develop rapidly with immobility.D – The correct choice is more complete than this choice.

(Source: Brunner and Suddarth, 12th ed. p.1939-1942)

68. The patient’s vital organ functions and body defenses must be supported and maintained until the neurologic system has recovered from the traumatic insult, which can take up to 4 months.Nurse P. Brain is caring for a client in the ER with a spinal cord injury at T4. Assessment reveals BP 76/48 with heart rate of 52. No reflex activity below T4 area. Nurse P. Brain should further assess the client for which of the following complications?

a. Neurogenic Shockb. Autonomic dysreflexiac. Hypovolemic shock secondary to internal hemorrhaged. Increased ICP

Important points in answering the question: Hypotension with 76/48 mmHg and bradycardia with 52 BPM.

Answer: A. Neurogenic shock.Neurogenic shock is the only form of shock that does not follow the Hypo-tachy-tachy (inverse triange) symptoms of shock. Neurogenic shock displays hypotension with bradycardia.

The patient experiences a predominant parasympathetic stimulation in NS that causes vasodialation lasting for an extended period of time leading to a relative hypovolemic state. Because the vasculature is dilated, blood volume is displaced producing a hypotensive state. The overriding parasympathetic stimulation that occurs with neurogenic shock causes a drastic decrease in the patient’s systemic vascular resistance and bradycardia.

B – Autonomic dysreflexia is a life threatening emergency in SCI patients that causes hypertensive emergencyC – Hypovolemic shock – hypotension – tachycardia – tachypnea D – Increased ICP triggers the Cushing reflex to stimulate an increased arterial systolic pressure as a mechanism to compensate for decreased cerebral blood flow. Cushing reflex: Hypertension –bradycardia–bradycardia

(Source: Brunner and Suddarth, 12th ed. pp. 323-331; p1918)

69. Autonomic dysreflexia is an exaggerated sympathetic response to noxious stimuli below the level of cord lesion and usually occurs in injuries in the T6 level. During morning care, a nurse notes that a client who had a spinal cord injury has experienced a change in LOC and isn’t answering questions appropriately. The nurse checks the client’s vital signs and measures his BP at 180/100 mmHg and his heart rate 125 beats per minute. She determines that the client may be experiencing autonomic dysreflexia. What are the priority assessments that the nurse should make?

1. Most recent bowel movement2. Urine output3. Percentage of meals taken4. Medications ordered for hypertension5. Pain level

a. 1, 2, 4b. 2, 3, 5c. 1, 2, 5d. 2, 3, 4

Answer: C. Priority assessments in autonomic dysreflexia would focus on identifying the noxious stimuli in order to remove the triggering event and prevent complications.

Common causes (noxious stimuli) include: Distended bladder(2 - Assessment of urine output) Constipation or impaction(1 – Assessment of most recent bowel movement) Excessive rectal stimulation Skin stimulation like pressure ulcers Spasm, pain, ingrown toenails Pressure on penis (5 – Pain level assessment)

3 – Percentage of meals taken isn’t a priority assessment4 – The increased BP is a reaction to the autonomic dysreflexia. Removing the trigger event is the main priority because treating the dysreflexia by removing the triggers can prevent the complications (increase BP, HR, etc). Medication assessment is of lesser priority.

(Source: Brunner &Suddarth’s, 11th ed. p. 2259)

70. A nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 160/100 mmHg. The client reports severe, pounding headache. Which nursing intervention is inappropriate in the care for this client?

a. Elevating the head of bed at 90 degreesb. Loosening constrictive clothingc. Use a fan to help reduce diaphoresisd. Administer antihypertensive medication as prescribed

Answer: C. Client is exhibiting signs and symptoms of autonomic dysreflexia. The condition is a potentially life-threatening emergency caused by an uninhibited response from the SNS, resulting from a lack of control over the autonomic nervous system. A fan shouldn’t be used because any cold drafts may contribute as trigger autonomic dysreflexia.

A- Elevation of head of bed to 90 degrees and placing the extremities in a dependent position can help decrease venous return to the heart and increase venous return from the brain.B – Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened.D – If removing triggering event doesn’t reduce the client’s BP, I.V. antihypertensives should be administered.

(Source: Brunner &Suddarth’s, 11th ed. p. 2259)

71. Spinal disk herniation is a medical condition affecting the spine in which a tear in the outer, fibrous ring of an intervertebral disc allows the soft, central portion to bulge out beyond the damaged outer rings. Jack Pott, who works as a delivery boy for a cement company has been complaining pain and tingling sensation in his lower back. His MRI results show that he is suffering from a herniated lumbar disk. Which of the following signs and/ or symptoms does not support the diagnosis of a herniated disk:

a. Pain aggravated by sneezing and relieved by bed restb. A presence of postural deformityc. Low back pain that radiates to the truncal aread. Pain that radiates to the entire leg as leg is straightened while lying down

Answer: C. Low back pain associate with herniated lumbar disk is associated with muscle spasms followed by pain that radiates to the hips and lower into the leg.

A – Pain in herniated disk is aggravated by actions that increase intraspinal fluid pressure, such as bending, lifting, or straining (sneezing or coughing) and is usually relieved by bed restB – Usually, there is some type of postural deformity in herniated disk because pain causes an alteration of the normal spinal mechanics.D – This describes the straight leg-raising test for herniated disk. This test stretches the sciatic nerve and is positive when upon lying down, any attempts to raise a leg in a straight position cause pain that radiates into the leg

72. Alzheimer’s disease is a progressive, irreversible, degenerative neurologic disease that begins insidiously and is characterized by gradual loses of cognitive function and disturbance in behavior and affect . A client with Alzheimer’s disease is admitted for hip surgery after falling and fracturing the right hip. The client’s spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up and doing odd things. Which nursing diagnosis is most appropriate for the client’s spouse?

a. Relocation stress syndrome related to hospitalizationb. Defensive coping related to diagnosis of Alzheimer’s diseasec. Risk for caregiver role strain related to increased client care needsd. Decisional conflict related to lack of relevant treatment information

Answer: C. The client’s spouse is at risk for caregiver role strain because the client has started to exhibit care needs beyond the spouse’s capacity to provide.

A – Appropriate for a client with inadequate preparation for hospital admission, transfer or discharge; however, this client is confused and may be unable to grasp the meaning of such preparation. B and D – Those are not pertinent nursing diagnosis in this situation because the client’s spouse is aware of and has accepted the client’s disease.

(Source: Brunner and Suddarth, 11th ed. p.246)

73. A client in a nursing home is diagnosed with Alzheimer’s disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing and occasional incontinence. This client is in what stage of Alzheimer’s disease?

a. I

b. IIc. IIId. IV

Answer: B. Staging of Alzheimer’s disease

STAGE SYMPTOMSI Memory loss, poor judgment, problem-solving, difficulty adapting

to new environment and challenges, agitation, apathyII Difficulty with recent and remote memory, irritability, depression,

restlessness, communication difficulties, motor disturbance, forgetfulness and psychosis, difficulty swallowing and occasional incontinence

III Loss of all mental abilities and ability to self care

*D – There is no stage IV in Alzheimer’s disease

74. Nursing interventions for dementia are aimed at promoting patient function and independence for as long as possible. Happy Home is an Elderly Home that caters to many Alzheimer’s patients. Which considerations must be incorporated in the care for patients with Alzheimer’s:

a. Providing various non-stimulating activities every day to divert patient to productive outlets of energy b. Uniform door colors to prevent confusion and prevent difficulty in locating the doorsc. Keeping lights off when night starts to fall to help orient patients between night and dayd. None of the above

Answer: D. None of the above statements are helpful in caring for a patient with Alzheimer’s Dementia.

A – A calm, predictable environment helps patient with dementia interpret their surroundings and activities. A changing routine of various activities everyday can only further cause confusion among the patients. Environmental stimuli are ideally limited and a regular routine is established.B – Doors are ideally color-coded to help patients who have difficulty locating their rooms. Uniform colored doors may only confuse patients on their location and in locating their rooms.C – Nightlights are used at night to help patients prevent the increasing confusion at night time that is associated with AD (Sundowning).

(Source: Brunner and Suddarth, 12th ed., p.218-219)

75. Viral conjunctivitis is a highly contagious eye infection. It can easily spread from one person to another. Nurse Ella Vader is to conduct a health teaching session with Viola, a patient with conjunctivitis and her family. Which of the following will you exclude from the health teaching?

a. Use artificial tears for the sandy sensation in the eyes and mild pain medications such as acetaminophen.b. Light cold compresses may be used over the eyes for about 10 minutes to soothe the pain.c. Management of conjunctivitis will only include symptomatic management because conjunctivitis is self-limiting and will resolve on its

own.d. Discard all make up articles. A person with conjunctivitis must not apply make up until infection is resolved.

Answer: C. Some forms of conjunctivitis require antibiotic therapy (like gonoccocal[chlamydia] and staphylococcal conjunctivitis) or corticosteroid therapy. Not all forms of conjunctivitis are self-limiting, although it almost always is. If left untreated, conjunctivitis can lead to corneal perforation and blindness.

Options A, B and D are correct health teachings on conjunctivitis.

(Source: Brunner and Suddarth, 12th ed. p.1789)

76. Blindness is defined as a best corrected visual acuity that ranges from 20/400 to no light perception. Legal blindness is defined as a vision of 20/200 or less in the better eye with best the correction possible. Tom A. Toe comes to the clinic to have his vision tested. His results reveal that he has a vision of 20/100. As the nurse assisting Tom, you are to understand that 20/100 means:

a. Tom is only able to read at the distance of 20 feet what an individual with normal vision can read at 100 feet.b. An individual with normal vision can read at 20 feet what Tom is only able to read at 100 feetc. That Tom is already considered legally blind.d. All except B

Answer: A. The numerator (above number) is the distance in feet the patient is from the eye chart. The denominator (lower number) represents the distance an eye with “normal” vision can read the same line. Legally blind is to have a vision of 20/200 or less.

(Source: Brunner and Suddarth, p.1764)

77. A person who is blind or severely visually impaired requires strategies for adapting the environment. You are caring for Ty Coon, a blind patient suffering with pneumonia. You are aware that in caring for patients with sensory deficits, there are some considerations you have to include in your care. Which of the following is incorrect to consider in taking care of patient Ty?

a. Make sure that all objects the person will need is close at handb. Refrain with using words like “see” and “look” around the patient because this can offend the patientc. Use clock directions when communicating with the patient the location of objects d. Keep all furniture in the same position throughout the patient’s stay in the hospital

Answer: B. Guidelines in interacting with people who are blind or with low vision includes that talking with them should be like talking to any other individual, honesty and without pity. There is no need to be concerned about using words like “look” and “see”.

GUIDELINES FOR INTERACTING WITH PEOPLE WHO ARE BLIND OR HAVE LOW VISION Remember that the only difference between you and people who are blind or have low vision is that they are not able to see through their eyes

what you are able to see through yours Do not be uncomfortable when in their company. Talk with the person like you would talk with any other individual, honestly and

without pity. Do not be concerned about using the words like “see” and “look”. And there is no need to raise your voice unless person asks you to.

Identify yourself as you approach the person and before you make physical contact. When you leave the room, be sure to tell the person you are leaving and if anyone else is in the room.

It is often appropriate to touch the person’s hand or arm to indicate that you are about to speak. When talking, face person and speak directly using normal tone of voice. Be specific when communicating direction. Mention a specific distance or use clock cues when possible. When you assist, allow the person to hold on to your arm just above the elbow and to walk a half step behind you. Make sure environment is free of obstacles. Close doors and cabinets so they are not in the pathway. Offer to read written information, such as a menu. Make sure all objects the person will need are at close hand. All assistive devices the person uses are placed close at hand. Let the person feel the device so he knows their location Do not distract the service animal unless the owner has given permission

(Source: Brunner and Suddarth, 12th ed. p.1767)

78. The ability to differentiate colors has a dramatic effect on the activities of daily living. Alterations in color vision sometimes indicate conditions of the optic nerve. Patient Ray Gunn is suffering from color blindness. The nurse understands that Ray has a problem with his:

a. Rodsb. Conesc. Lensd. Aqueous humor

Answer: B. Cones provide daylight color vision and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs.

A – Rods are sensitive to low levels of illumination but can’t discriminate color.C – Lens is responsible for focusing imagesD – Aqueous humor is a clear watery fluid and isn’t involved with color perception.

(Source: Brunner and Suddarth’s. 11th ed. p.2049)

79. Cataract is a lens opacity or cloudiness that can develop in one or both eyes at any age as a result of a variety of causes. A patient with cataract on both her eyes approaches you and asks you about the things she needs to know when considering surgical management for her cataracts. The nurse would need to re-evaluate her knowledge on surgical managements for cataract when she states:

a. “If reduced vision from cataract does not interfere with normal activities, surgery may not be indicated. However, no nonsurgical treatment cures cataracts.”

b. “Surgery is performed on an outpatient basis and you can be discharged in 30 minutes or less afterwards.”c. “Ideal anesthetics used for cataract surgeries keeps awake where they can communicate and cooperate during the surgery.”d. “If both eyes have cataracts, it is ideal to perform the procedure to both eyes at the same time to ensure faster healing and regain of

vision.”

Answer: D. When both eyes have cataracts, one eye is treated first, with at least several weeks, preferably months, separating two procedures. Because cataract surgery is performed to improve visual functioning, the delay for the other eye gives time for the patient and surgeon to evaluate whether the results of the first surgery are adequate to preclude the need for a second operation. The delay also provides time for the first eye to recover; if there are any complications, the surgeon may decide to perform the second procedure differently.

A – It is true that no nonsurgical treatment (medications, eye drops, eye glasses) cures cataracts or prevents age-related cataracts. However, if reduced vision from cataract does not interfere with normal activities, surgery may not be needed.B – Surgery for cataracts can be performed in an outpatient basis and usually takes less than 1 hour, with the patient being discharged 30 minutes or less afterwardsC – For cataract surgeries, ideal anesthetics used are injection-free topical and intraocular anesthesia applied to the surface of the eyes. This eliminates the hazards of regional anesthesia. Furthermore, patients can communicate and cooperate during the surgery.

(Source: Brunner and Suddarth, 12th ed. p1773)

80. The degree of lens opacity in cataracts does not always correlate with the patient’s functional status. Some patients can perform normal activities despite clinically significant cataracts.You are caring for a patient who has had a cataract surgery on his right eye in an out-patient basis. As part of discharge planning, it is important to reiterate to the patient:

a. To engage in weight lifting to avoid neglect syndromeb. To sleep in the right side lying position c. To maintain strict bed rest for at least a weekd. Not to bend below her waist level

Answer: D. After a cataract surgery, patients are advised to avoid bending their head below the waist or stooping over an extended period because it may result to an increase tension on the fine sutures used to close the incision and to the intraocular lens implant if present.

A – Lifting, pushing or pulling object heavier than 15 lbs can increase intra-ocular pressure and is contraindicatedB - Lying on the stomach or lying on the side of the affected eye after the surgery can increase intra-ocular pressure and is contraindicated.D - Bed rest for 1 week is not necessary.

(Source: Brunner and Suddarth, 12th ed. p. 1776)

81. In deciding which cataract surgery is to be performed, the patient’s functional and visual status should be a primary consideration . A patient has had phacoemulsification for cataract. Which of the following complaints from the patient wouldalarm the nurses?

a. Complaints of unbearable itchiness on the operated eyeb. Bloodshot appearance of the affected eyec. The patient sees bright flashing lights immediately after the surgeryd. Morning discharge and slight swelling

Answer: C. Cataract surgery increases the risk of retinal detachment. Signs of retinal detachment such as new floaters in the vision, flashing lights and decrease in vision should immediately be reported to the physician.

A – An itchy feeling is expected for a few days after the surgeryB – It is normal for the affected eye to appear reddish after the surgery. Report however, progressing redness in the eye.D – Morning discharge is expected. It is when there is a change in the amount or color of the discharge that the condition becomes abnormal.

(Source: Brunner and Suddarth, 12th ed. p. 1775)

82. Glaucoma is a term describing a group of ocular disorders with multi-factorial etiology united by a clinically characteristic intraocular pressure-associated optic neuropathy. Earl E. Bird is a patient in your ward diagnosed with glaucoma. Upon reviewing the patient’s chart, you would question the order that would prescribe which drug?

a. A beta-blockerb. A mioticc. An adrenergic agonistd. A mydriatic

Answer: D. Mydriatic. Mydriatics are contraindicated for glaucoma because its parasympatholytic (stimulates SNS response) can cause pupil dilation which can further increase intra-ocular pressure.

A – Beta-blockers are the preferred initial topical medications for glaucoma.B – Cholinergics (miotics) increase the outflow of the aqueous humor by affecting ciliary muscle contraction and pupil constriction, allowing flow through a larger opening between the iris and the trabecular meshwork.C – Adrenergic agonist increase aqueous outflow but primarily decrease aqueous production with an action similar to beta-blockers and carbonic anhydrase inhibitors.

(Source: Brunner and Suddarth. 12th ed. p.1769-1770, Nursing Pharmacology by Karch, A., p526)

83. Retinal detachment refers to the separation of retinal pigment epithelium from the sensory lens. The rhegmatogenous detachment is the most common form where a hole or tear develops in the sensory retina allowing some of the liquid to seep through the sensory retina and detach. Abbie Birthday, 68 years old, comes in for a check-up. While taking the client’s history, which of the following statements from the patient would lead you to suspect that she is suffering from retinal detachment?

a. “I have been having blurred vision and I see “halos” around lights. Most of the time, there is a painful sensation around my eyes, along with the headache.”

b. “My vision seems dimmer lately. Sometimes I wonder if it’s my eyes or it’s just my eyeglasses that need cleaning.”c. “I don’t feel pain, but lately, I have been experiencing sudden flashing of bright lights.” d. “It seems that I can’t clearly see the center of my vision lately. Nowadays, I just go around by using the peripheral sides of my vision.”

Answer: C. Inretinal detachment, patients may report sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights and the sudden onset of a great number of floaters. Patients do not complain of pain.

A – The set of complaints are more likely linked to glaucoma. Most patients with glaucoma are unaware they have the condition until they experience vision loss and other visual changes. They usually experience blurred vision, “halos” around the lights, difficulty focusing, difficulty adjusting the eyes in low lights, loss of peripheral vision, aching or discomfort around the eyes and headache.B – The set of complaints are more likely linked to cataract. Cataract manifests as a painless, blurry vision where patients perceive the surroundings are dimmer as if his glasses continually need cleaning. Light scattering is common and the person also experiences reduced contrast sensitivity, sensitivity to glare and reduced visual acuity.D – Loss of central vision is more likely linked to macular degeneration.

(Source: Gerontological Nursing, 2nd ed. by Mauk, K. p.243; Brunner and Suddarth’s, 12th ed., pp. 1767-1773)

84. Common ocular medications include topical anesthetic, mydriatic, and cycloplegic agents that reduce IOP; anti-infective medications, corticosteroids, NSAIDS, anti-allergy medications, eye irrigants, and lubricants. Nurse Marshall Law is proving discharge teachings on Chris P. Bacon regarding her take home ocular medications. Nurse Marshall would need to provide further teachings if Chris states:

a. “I must occlude the puncta while instilling the medication.”b. “It is ideal that I wait for at least 5 minutes before instilling another successive drop into my eye.”c. “I must report stinging and burning sensation immediate because these indicate systemic reaction to the drugd. “In instilling the eye drops, I need to ensure that the tip of the eye bottle does not touch any part of my eye”

Answer: C. Before the administration of ocular medications, the nurse should warn the patient that blurred vision, stinging, and a burning sensation are symptoms that ordinarily occur after instillation and are temporary.

A - Absorption of eye drops by the nasolacrimal duct is undesirable because of the potential systemic side effects of ocular medications. To diminish systemic absorption and minimize the side effects, it is important to occlude the puncta. This is especially important for patients most vulnerable to medication overdose, including elderly people, children, infants, women who are lactating or are pregnant, and patients with cardiac, pulmonary, hepatic, or renal disease. B – A 5-minute interval between successive administrations allows adequate drug retention and absorption.C - The tip of the eye drop bottle or the ointment tube must never touch any part of the eye. The medication must be recapped immediately after each use.

(Source: Brunner and Suddarth, 12th ed., p. 1797)

85. Ocular trauma is the leading cause of blindness among the children and young adults, especially male trauma victims. An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigated his eyes with water for 20 minutes then took him to the emergency department of a nearby ER for corneal care. He was prescribed dexamethasone, 2 gtts of 0.1% solution into the conjunctival sacs of both eyes every hour. The nurse knows that dexamethasone exerts its therapeutic effect by:a. Increasing the exudative reaction of ocular tissueb. Decreasing leukocyte infiltration at the site of ocular inflammationc. Inhibit the action of carbonic anyhydrased. Produce a miotic reaction by stimulating and contracting the sphincter muscles of the iris

Answer: B. Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation through its anti-inflammatory properties. This action reduces exudative reaction of diseased tissue, lessening edema, redness and scarring.

A – Dexamethasone reduces exudative reaction of ocular tissueC - Dexamethasone doesn’t inhibit the action of carbonic anyhydraseD – Dexamethasone doesn’t produce any type of miotic reaction.

(Source: Springhouse Nurse’s Drug Guide, p.401)

PSYCHIATRIC NURSING (15)86. Alcohol is a central nervous system depressant that is absorbed rapidly into the bloodstream. Initially the effects are relaxation and

loss of inhibitions. Steven Tyler, who was rushed into the ER presented with hypertension, tachycardia, and appears to be anxious. Upon assessment, he is revealed to have a history of alcoholism. This patient was also observed to sweat profusely with coarse hand tremors on both hands. These manifestations lasted for 4 days. Steven most likely suffered from:

a. Alcohol intoxicationb. Alcohol withdrawalc. Alcohol/substance abused. Alcohol overdose

Answer: B.Alcohol withdrawal is a development of substance specific syndrome which usually begins 4 to 12 hours after cessation of or reduction of the intake of the substance which usually begins 4-12 hours. Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium—called delirium tremens (DTs). Alcohol withdrawal usually peaks on the second day and is over in about 5 days.

A – Alcohol intoxication is the development of substance specific syndrome due to a recent ingestion of the substance. With intoxication, there is slurred speech, unsteady gait, lack of coordination, and impaired attention, concentration, memory, and judgment. Some people become aggressive or display inappropriate sexual behavior when intoxicated. The person who is intoxicated may experience a blackout. C – Alcohol or Substance Abuse is a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following:

1. Failure to fulfill major role obligations at work, school or at home2. Recurrent substance use in hazardous situations3. Recurrent substance-related legal problems4. Continued substance use despite problems

D – Alcohol overdose is an excessive alcohol intake in a short period (blood levels more than 200 mg/dl) , can result in vomiting, unconsciousness, and respiratory depression. This combination can cause aspiration pneumonia or pulmonary obstruction.

(Source: Keltner, page 497; Videbeck, page 409)

87. Co-dependence is a maladaptive coping pattern of family members of addicts and alcoholics reflecting the process of participating in behaviors that maintain addiction or allowing it to continue without holding the addict or alcoholic accountable for his or her addictions.All of the following situations characterized co-dependence, except?

a. Gerry who continually calls in to report that her father is sick when his husband is really drunk or hangoverb. Victoria who encourages her husband recovering from long-term alcoholism to start drinking againc. Melissa C who covers up for the responsibilities that her alcoholic husband should have doned. Emma who continually brings her brother to rehabilitation centers every time he goes back to drinking excessively again

Answer: D.Emma does not display characteristics of co-dependence because she does not tolerate the behavior of alcoholism as manifested by continually bringing her brother to rehabilitation centers to reform the behavior.

Characteristics of codependence are 1) poor relationship skills, 2) excessive anxiety and worry, 3) compulsive behaviors, and 4) resistance to change.

A – Gerry allows her father to continue his addiction by covering up for him to prevent him from having to face the true implications and repercussions of his behavior.B – Victoria becomes resistant to change. Some co-dependents find it hard when these recovering addicts begin to participate in family functions that have been taken over by other family members. Sometimes, co-dependents become so adapted to the role, even if they were initially adopted out of necessity. There are many reported stories where after abstinence was achieved, the addict or alcoholic was encouraged by codependent family members to start using again or the spouse separated from the addict or alcoholic. ( Keltner, p521 – really good discussion on Co-dependence)C – Melissa C tolerates her husband’s behavior by covering up for him. What appears to be a helpful action really just assists the husband to avoid the consequences of his behavior and to continue the abuse.

(Source: Keltner, p521; Videbeck, page 424)

88. Establishing a trusting relationship with the patient is the benchmark for working with chemically dependent individuals. Because denial is the most predominant defense mechanism of the alcoholic, treating it appropriately is important. Nurse Katy is assigned to Russell Brand, a recovering alcoholic. Russell has been absent from treatment for one week. The day he came back for his treatment, Russell strongly smelled like alcohol. Nurse Katy tells Russell, “I hear you saying that you are in treatment because you believe you need help, so help me understand how you see your need, given your absence from treatment without medical excuse.You also tell me you have not been drinking, but I can smell alcohol on your breath, Russell.” This communication technique is:

a. Therapeutic because it is a form of confrontationb. Non-therapeutic because it is a form of challengingc. Therapeutic because it is a form of presenting realityd. Non-therapeutic because it is a form of passing judgment

Answer: A. Confrontation is a technique used to break the denial process of alcoholics. Confrontation includes telling a patient what is observed through supportive but reflective listening techniques, irrespective of a patient’s denial.

B – Challenging is giving a response that makes clients prove their statement of point of view. C – Presenting reality is offering a view of what is real and what is not without arguing with the patient.

D – Passing judgment is giving opinions and approving or disapproving responses, moralizing or implying one’s own values.

(Source Keltner, 526)

89. Pharmacologic treatment in substance abuse has two main purposes: to permit safe withdrawal from alcohol, sedative/hypnotics, and benzodiazepines and to prevent relapse. David Guetta, an alcoholic, was prescribed with cyanocobalamin and folic acid supplement by his physician. These are given primarily to prevent or treat which of the following?

a. Wernicke’s syndrome b. Nutritional deficienciesc. Alcohol withdrawald. Korsakoff’s syndrome

Answer: B. Cyanocobalamin (vitamin B12) and folic acid (B9) are often prescribed for clients with nutritional deficiencies secondary to alcoholism because alcohol competes with the absorption of these B vitamins. A and D - For clients whose primary substance is alcohol, vitamin B1 (thiamine) often is prescribed to prevent or to treat Wernicke’s syndrome and Korsakoff’s syndrome, which are neurologic conditions that can result from heavy alcohol use. C - Alcohol withdrawal usually is managed with a benzodiazepine anxiolytic agent, which is used to suppress the symptoms of abstinence. (Source: Videbeck, page 419)

90. Nurses can encourage clients to identify problem areas in their lives and to explore the ways that substance use may have intensified those problems. The physician ordered Disulfiram (Antabuse) to be given to an alcoholic patient as a form of aversion therapy to maintain his abstinence. Nurse Bruno Mars knows that the following are nursing considerations of Disulfuram, except?

a. Avoiding the use of cough syrup, vinegar, and other products that contain alcohol.b. Before initiation of the drug, nurse must ensure that patient is free from alcohol for at least 12 hours c. Emphasize the importance of oral hygiene, flossing, and the use of mouthwash.d. Client’s consent should be obtained before starting the therapy

Answer: B. Mouthwash has alcohol content.

Disulfiram (Antabuse) is prescribed to recovering alcoholics to maintain a long-term abstinence. If a client taking disulfiram drinks alcohol, adverse reaction occurs with flushing, a throbbing headache, sweating, nausea, and vomiting. The unpleasant response to alcohol is intended to help reinforce the alcoholic’s efforts to stop drinking (a form of aversion therapy).

A - Client also avoid a wide variety of products that contain alcohol such as cough syrup, lotions, mouthwash, perfume, aftershave, vinegar, and vanilla and other extracts. Clients must be encouraged to read product label carefully because any product containing alcohol can produce symptoms. B – Ensure clearance of alcohol from the system because traces of alcohol may react with the drug and produce unpleasant symptoms.C – Client must be informed about the drug therapy and consent must be obtained (verbal) because if the therapy is initiated without the patient’s knowledge, patient may continue to consume alcohol or alcohol containing products that may cause to severe reactions which may even lead to severe hypotension, confusion, coma, and even death. Patient’s understanding of the therapy can ensure better patient cooperation.

(Source: Keltner, 505; Videbeck, page 419)

91. Recovery from alcoholism is usually a gradual process. In the early stages of change, denial is a huge obstacle.Nurse Rihanna is assisting in the discharge planning for Chris Brown, a client with alcoholism. Which actions should be included in the discharge plan?

i. Strongly encourage participation in Alcoholics Anonymous (AA).ii. Provide nutritional information and counselingiii. Establish an exercise programiv. Discuss relapse preventionv. Have the client slowly re-introduce himself to the people in his former “drinking” lifestyle

a. i, ii, iv, vb. i, ii, iii, ivc. i, ii, iii, iv, vd. i, iii, iv, v

Answer: B. Correct teachings:

i. Alcoholics Anonymous is an outpatient support group for recovering alcoholics. It allows clients to share their problems and gain support from members of the group to avoid further alcohol abuse. The nurse should strongly encourage the client to participate in this support group

ii. The nurse should provide client with nutritional information and counseling, particularly if client is underweight or malnourishediii. Establishing exercise program is appropriate for the client’s physical healthiv. Discussing relapse prevention is essential to prevent recurrence of problems related to alcoholism

Incorrect teaching: v. Nurse should discourage the client from reestablishing relationships with former “drinking friends” because this could lead to relapse.

(Source: Videbeck, 3rd ed. ,p. 392)

92. No single factor can predict whether a person will become addicted to drugs. Risk for addiction is influenced by a combination of factors that include individual biology, social environment, and age or stage of development.A college student client states that his addiction to morphine is due to chemical imbalance. The nurse understands through research that these points to a biochemical theory of addiction. It supports that people who abuse drugs have stimulation to which of the following neurotransmitter?

a. Norepinephrineb. Serotoninc. Acetylcholined. Dopamine

Answer: D. Dopamine. Investigators have hypothesized that cocaine and many other drugs produce their effects by increasing the action of dopamine in the nucleus accumbens, which is said to be one of the brain’s key pleasure areas. (Psychiatric Nursing 5th ed., Keltner, p. 73)

93. Cannabis sativa is the hemp plant that is widely cultivated for its fiber used to make rope and cloth and for oil from its seeds. It has become widely known for its psychoactive resin. Nurse Taylor Swift is conducting a health teaching on a group of third year nursing students about Cannabis sativa. At the end of the session, she tries to evaluate the students’ learning about Cannabis sativa. Which student would need further teachings?

a. Joe Jonas who states, “It is known to decrease intra-ocular pressure.”b. John Mayer who states, “It helps in relieving nausea and vomiting associated with chemotherapy.”c. Taylor Lautner who states, “It is a clinically approved treatment for glaucoma.”d. Harry Styles who states, “Cannabis can be eaten.”

Answer: C. Researchhas shown that cannabis has short-term effects of lowering intraocular pressure, but it is not approved for the treatment of glaucoma.

A – Cannabis is known for short term effects of lowering intra-ocular pressure.B - It also has been studied for its effectiveness in relieving the nausea and vomiting associated with cancer chemotherapy and the anorexia and weight loss of AIDS. Currently two cannabinoids:dronabinol (Marinol) and nabilone (Cesamet) have been approved for treating nausea and vomiting from cancer chemotherapy. D - Cannabis is most often smoked in cigarettes (“joints”), but it can be eaten (like mixing in brownies or pancakes).

(Source: Videbeck, pages 415-416)

94. Drug addiction is a complex disease, and quitting takes more than good intentions or a strong will.One night, Kanye West began tearing his house down, locked himself in the bathroom and kept screaming about getting himself killed. He was brought by his daughter, North West, to the ER where he was observed to be suicidal, having auditory hallucinations, delusions of persecution, disorganized thinking and agitation. Upon your rapid physical assessment, you noticed several puncture marks in his arms. With these collected data, Kanye West was probably under the influence of what illicit drug?

a. Morphineb. Cocainec. Marijuanad. Toluene

Answer: B. Cocaine. Symptoms in the situation (increased strength (ability to tear his house down), auditory hallucination, delusions of persecution, agitation and disorganized thinking) are attributed to a stimulant or “upper” influence. The puncture marks on his arm indicate that the drug that influenced the behavior was probably administered via IV. Among the choices, cocaine is the only upper that can be administered via IV.

A – Morphine can be administered via IV but its physiologic effect is a depressant. Behavior of Kanye in the situation suggests influence of a stimulant drug. B – Marijuana is a hallucinogen or a psychedelic that is administered by smoking or eating.C – Toluene is an inhalant classified as volatile solvent. Inhalants generally have a depressant effect.

95. Hallucinogens, also referred to as psychedelics, cause hallucinations. It can heighten awareness of reality or can cause a terrifying psychosis-like reaction.Cee Lo Green who was actively hallucinating was brought to the hospital by his friends. They tell the nurse that he used angel dust (phencyclidine [PCP]) at a concert. In planning care for a client who ingested PCP, the nurse’s highest priority should be meeting the:

a. Client’s physical needsb. Client’s safety needsc. Client’s psychosocial needsd. Client’s medical needs

Answer: B. The highest priority for a client who ingested PCP is meeting his safety needs, as well as the safety of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, physical, medical and psychosocial needs may be addressed.

(Source: Videbeck, 3rd ed. P. 386)

96. The most common goal of treatment for the chemically dependent person is abstinence from the substance. It is believed that a person who is dependent on one substance can easily become dependent to another . Clonidine (Catapres) can be used to treat hypertension as well as:

a. Cannabis withdrawalb. Alcohol withdrawalc. Opioid withdrawald. Cocaine withdrawal

Answer : C. Clonidine is used as adjunctive therapy in opioid withdrawal.

A – There is no real withdrawal from cannabisB – Benzodiazepines such as chlordiazepoxide (Librium) are used to treat alcohol withdrawalC – Antidepressants and medications with dopaminergic activity in the brain, such as fluoxetine (Prozac) are used to treat cocaine withdrawal

Tip: In answering for symptoms or treatment for withdrawal: It is always the opposite of the effect of the drug. Example: Withdrawal of upper drugs is downer symptoms. Withdrawal of downer drugs is upper symptoms. In this situation, clonidine is a treatment for hypertension (an upper symptom). If you are to find what withdrawal it treats, find a downer drug because this medicine treats an upper symptom (withdrawal for downer drug).

97. Detoxification from sedatives, hypnotics, and anxiolytics is often managed medically by tapering the amount of the drug the client receives over a period of days or weeks, depending on the drug and the amount the client had been using. Tapering should be done to:

a. Avoid hypoglycemiab. Manage hallucinationsc. Prevent coma or deathd. Eliminate the possibility of drug resistance

Answer: C. Tapering, or administering decreasing doses of a medication, is essential with barbiturates to prevent coma and death that will occur if the drug is stopped abruptly. For example, when tapering the dosage of a benzodiazepine, the client may be given Valium 10 mg four times a day; the dose is decreased every 3 days, and the number of times a day the dose is given also is decreased until the client is safely withdrawn from the drug.

(Source: Videbeck, pages 414-415)

98. Professionals working with chemically dependent individuals realize their patient’s vulnerability and they tend to view treatment as an ongoing, lifelong process. The term recovering indicates a current and dynamic process but also indicates the ever-present possibility of slipping. Patient Avicii, with a history of substance abuse has regularly been attending a group therapy in the psychiatric unit. One afternoon he tells a nurse, “I am not going to those meetings anymore. I’m not like the rest of those people. I’m not an addict!” What is the most appropriate response?

a. “If you aren’t an alcoholic, what leads you to keep drinking and ending up in the hospital?”b. “It is your decision. If you don’t want to go, you don’t have to.”c. “The meetings are a part of your treatment. You seem upset about attending them.”d. “You have to go to the meetings even if you don’t like attending them.”

Answer: C. The substance abuser uses the substance to cope with feelings and may deny the abuse. Presenting information in a matter-of-fact manner conveys the nurse’s expectation of the client. Acknowledging the client’s mood about attending the meetings encourages him to identify and deal with his feelings instead of bottling them up.

A – A form of challenging – a non-therapeutic response that makes the client prove his statement or point of view. B – Saying the client doesn’t have to go to meetings if he doesn’t want to isn’t a therapeutic behavior because it plays down the importance of attending meetings.D – Arguing with the client about the substance abuse or insisting that the client attend the meetings wouldn’t help him identify the reasons behind his resistance to treatment.

(Source: Videbeck, 3rd ed. p. 393)

99. Although older adults do not have a significant problem with illicit drug use, problems result from over-use and misuse of prescription and OTC medications. Nurse John Lennon is incorrect to identify a major factor that contributes to this problem among older adults as:

a. Many older adults see multiple physiciansb. Poor vision and hearingc. Attempts to self-diagnosisd. Symptoms of over use and misuse of medications are easily detectible

Answer: D. This statement is incorrect because symptoms of overuse and misuse of medications are not easily detected among older adults and in fact, these symptoms are often mistaken as part of the aging process or diseases making it a barrier to the identification of the problem.

A – Statement is correct because many older adults see multiple physicians, each of whom might prescribe drugs without reliable information about medications the others prescribed.B – Poor vision and hearing, along with physical deficits, confusion, mental disorder and inadequate instructions contribute the non-compliance of the older adults. Confusion among the names of the medicines or the appearances may result in them taking the wrong medication or the same medication twice at the same time. C – Older adults may take any new symptom as a new illness and self-diagnose themselves with medications specific for the new symptom: “A pill for every ill” mentality.

(Source: Keltner, p669)

100. Drug addiction among health care professionals is not uncommon because of the easy access to addictive medications. Nurse Supervisor Hayley Williams has been receiving many patient complains of pain and insomnia from the Surgical Ward. After some investigation, Nurse Supervisor Hayley noted that although many narcotics and sedatives have been documented as administered, patient complaints still kept coming. She also noted inaccurate drug counts upon inventory. She suspected Nurse Pete Wentz, the nurse assigned to the ward, to be taking the drugs for his personal use. Which following behaviors would not heighten Nurse Hayley’s suspicion on Nurse Pete’s drug addiction?

a. Nurse Pete has been volunteering to work extra shifts especially the graveyard shiftsb. Increased reports of vial breakage and drug wastage during Nurse Pete’s shiftsc. Nurse Pete is noted to spend more time at the patient’s bedside conversing and interacting with his patientsd. Nurse Pete always looks disheveled when reporting to duty

Answer: C. This is not a behavior that indicates an “Impaired Nurse”.Behavioral clues noticeable in an Impaired Nurse:

More clients complain of pain and insomnia even though many narcotics and sedatives have been documented as administered Inaccurate drug counts, increased vial breakage and drug wastage Discrepancies in documentation More accidents or unusual occurrence when on duty Leaves the floor a lot or spends a great deal of time in the restroom Personal appearance and job performance will likely be affected Lapses in judgment may occur Verbal and energetic, or slow thinking Have increased appetite or no appetite at all May appear extremely happy or sad

(Source: Keltner, p531; Videbeck, p531)