Funda 5 Answer Key

FUNDAMENTALS OF NURSING TEST V

Content Outline

1. Oxygenation
2. Nutrition

1. Which one of the following is NOT a function of the Upper airway?

A. For clearance mechanism such as coughing
B. Transport gases to the lower airways
C. Warming, Filtration and Humidification of inspired air
D. Protect the lower airway from foreign mater

2. It is the hair the lines the vestibule which function as a filtering mechanism for foreign objects

A. Cilia
B. Nares
C. Carina
D. Vibrissae

3. This is the paranasal sinus found between the eyes and the nose that extends backward into the skull

A. Ehtmoid
B. Sphenoid
C. Maxillary
D. Frontal

4. Which paranasal sinus is found over the eyebrow?

A. Ehtmoid
B. Sphenoid
C. Maxillary
D. Frontal

5. Gene De Vonne Katrouchuacheulujiki wants to change her surname to something shorter, The court denied her request which depresses her and find herself binge eating. She accidentally aspirate a large piece of nut and it passes the carina. Probabilty wise, Where will the nut go?

A. Right main stem bronchus
B. Left main stem bronchus
C. Be dislodged in between the carina
D. Be blocked by the closed epiglottis

6. Which cell secretes mucus that help protect the lungs by trapping debris in the respiratory tract?

A. Type I pneumocytes
B. Type II pneumocytes
C. Goblet cells
D. Adipose cells

7. How many lobes are there in the RIGHT LUNG?

A. One
B. Two
C. Three
D. Four

8. The presence of the liver causes which anatomical difference of the Kidneys and the Lungs?

A. Left kidney slightly lower, Left lung slightly shorter
B. Left kidney slightly higher, Left lung slightly shorter
C. Right kidney lower, Right lung shorter
D. Right kidney higher, Right lung shorter

9. Surfactant is produced by what cells in the alveoli?

A. Type I pneumocytes
B. Type II pneumocytes
C. Goblet cells
D. Adipose cells

10. The normal L:S Ratio to consider the newborn baby viable is

A. 1:2
B. 2:1
C. 3:1
D. 1:3

11. Refers to the extra air that can be inhaled beyond the normal tidal volume

A. Inspiratory reserve volume
B. Expiratory reserve volume
C. Functional residual capacity
D. Residual volume

12. This is the amount of air remained in the lungs after a forceful expiration

A. Inspiratory reserve volume
B. Expiratory reserve volume
C. Functional residual capacity
D. Residual volume

13. Casssandra, A 22 year old grade Agnostic, Asked you, how many spikes of bones are there in my ribs? Your best response is which of the following?

A. We have 13 pairs of ribs Cassandra
B. We have 12 pairs of ribs Cassandra
C. Humans have 16 pairs of ribs, and that was noted by Vesalius in 1543
D. Humans have 8 pairs of ribs. 4 of which are floating

14. Which of the following is considered as the main muscle of respiration?

A. Lungs
B. Intercostal Muscles
C. Diaphragm
D. Pectoralis major

15. Cassandra asked you : How many air is there in the oxygen and how many does human requires? Which of the following is the best response :

A. God is good, Man requires 21% of oxygen and we have 21% available in our air
B. Man requires 16% of oxygen and we have 35% available in our air
C. Man requires 10% of oxygen and we have 50% available in our air
D. Human requires 21% of oxygen and we have 21% available in our air

16. Which of the following is TRUE about Expiration?

A. A passive process
B. The length of which is half of the length of Inspiration
C. Stridor is commonly heard during expiration
D. Requires energy to be carried out

17. Which of the following is TRUE in postural drainage?

A. Patient assumes position for 10 to 15 minutes
B. Should last only for 60 minutes
C. Done best P.C
D. An independent nursing action

18. All but one of the following is a purpose of steam inhalation

A. Mucolytic
B. Warm and humidify air
C. Administer medications
D. Promote bronchoconstriction

19. Which of the following is NOT TRUE in steam inhalation?

A. It is a dependent nursing action
B. Spout is put 12-18 inches away from the nose
C. Render steam inhalation for atleast 60 minutes
D. Cover the client’s eye with wash cloth to prevent irritation

20. When should a nurse suction a client?

A. As desired
B. As needed
C. Every 1 hour
D. Every 4 hours

21. Ernest Arnold Hamilton, a 60 year old American client was mobbed by teen gangsters near New york, Cubao. He was rushed to John John Hopio Medical Center and was Unconscious. You are his nurse and you are to suction his secretions. In which position should you place Mr. Hamilton?

A. High fowlers
B. Semi fowlers
C. Prone
D. Side lying

22. You are about to set the suction pressure to be used to Mr. Hamilton. You are using a Wall unit suction machine. How much pressure should you set the valve before suctioning Mr. Hamilton?

A. 50-95 mmHg
B. 200-350 mmHg
C. 100-120 mmHg
D. 10-15 mmHg

23. The wall unit is not functioning; You then try to use the portable suction equipment available. How much pressure of suction equipment is needed to prevent trauma to mucus membrane and air ways in case of portable suction units?

A. 2-5 mmHg
B. 5-10 mmHg
C. 10-15 mmHg
D. 15-25 mmHg

24. There are four catheter sizes available for use, which one of these should you use for Mr. Hamilton?

A. Fr. 18
B. Fr. 12
C. Fr. 10
D. Fr, 5

25. Which of the following, if done by the nurse, indicates incompetence during suctioning an unconscious client?

A. Measure the length of the suction catheter to be inserted by measuring from the tip of the nose, to the earlobe, to the xiphoid process
B. Use KY Jelly if suctioning nasopharyngeal secretion
C. The maximum time of suctioning should not exceed 15 seconds
D. Allow 30 seconds interval between suctioning

26. Which of the following is the initial sign of hypoxemia in an adult client?

1. Tachypnea
2. Tachycardia
3. Cyanosis
4. Pallor
5. Irritability
6. Flaring of Nares

A. 1,2
B. 2,5
C. 2,6
D. 3,4

27. Which method of oxygenation least likely produces anxiety and apprehension?

A. Nasal Cannula
B. Simple Face mask
C. Non Rebreather mask
D. Partial Rebreather mask

28. Which of the following oxygen delivery method can deliver 100% Oxygen at 15 LPM?

A. Nasal Cannula
B. Simple Face mask
C. Non Rebreather mask
D. Partial Rebreather mask

29. Which of the following is not true about OXYGEN?

A. Oxygen is odorless, tasteless and colorless gas.
B. Oxygen can irritate mucus membrane
C. Oxygen supports combustion
D. Excessive oxygen administration results in respiratory acidosis

30. Roberto San Andres, A new nurse in the hospital is about to administer oxygen on patient with Respiratory distress. As his senior nurse, you should intervene if Roberto will:

A. Uses venture mask in oxygen administration
B. Put a non rebreather mask in the patient before opening the oxygen source
C. Use a partial rebreather mask to deliver oxygen
D. Check for the doctor’s order for Oxygen administration

31. Which of the following will alert the nurse as an early sign of hypoxia?

A. Client is tired and dyspneic
B. The client is coughing out blood
C. The client’s heart rate is 50 BPM
D. Client is frequently turning from side to side

32. Miguelito de balboa, An OFW presents at the admission with an A:P Diameter ratio of 2:1, Which of the following associated finding should the nurse expect?

A. Pancytopenia
B. Anemia
C. Fingers are Club-like
D. Hematocrit of client is decreased

33. The best method of oxygen administration for client with COPD uses:

A. Cannula
B. Simple Face mask
C. Non rebreather mask
D. Venturi mask

34. Mang dagul, a 50 year old chronic smoker was brought to the E.R because of difficulty in breathing. Pleural effusion was the diagnosis and CTT was ordered. What does C.T.T Stands for?

A. Chest tube thoracotomy
B. Chest tube thoracostomy
C. Closed tube thoracotomy
D. Closed tube thoracostmy

35. Where will the CTT be inserted if we are to drain fluids accumulated in Mang dagul’s pleura?

A. 2nd ICS
B. 4th ICS
C. 5th ICS
D. 8th ICS

36. There is a continuous bubbling in the water sealed drainage system with suction. And oscillation is observed. As a nurse, what should you do?

A. Consider this as normal findings
B. Notify the physician
C. Check for tube leak
D. Prepare a petrolatum gauze dressing

37. Which of the following is true about nutrition?

A. It is the process in which food are broken down, for the body to use in growth and development
B. It is a process in which digested proteins, fats, minerals, vitamins and carbohydrates are transported into the circulation
C. It is a chemical process that occurs in the cell that allows for energy production, energy use, growth and tissue repair
D. It is the study of nutrients and the process in which they are use by the body

38. The majority of the digestion processes take place in the

A. Mouth
B. Small intestine
C. Large intestine
D. Stomach

39. All of the following is true about digestion that occurs in the Mouth except

A. It is where the digestion process starts
B. Mechanical digestion is brought about by mastication
C. The action of ptyalin or the salivary tyrpsin breaks down starches into maltose
D. Deglutition occurs after food is broken down into small pieces and well mixed with saliva

40. Which of the following foods lowers the cardiac sphincter pressure?

A. Roast beef, Steamed cauliflower and Rice
B. Orange juice, Non fat milk, Dry crackers
C. Decaffeinated coffee, Sky flakes crackers, Suman
D. Coffee with coffee mate, Bacon and Egg

41. Where does the digestion of carbohydrates start?

A. Mouth
B. Esophagus
C. Small intestine
D. Stomach

42. Protein and Fat digestion begins where?

A. Mouth
B. Esophagus
C. Small intestine
D. Stomach

43. All but one is true about digestion that occurs in the Stomach

A. Carbohydrates are the fastest to be digested, in about an hour
B. Fat is the slowest to be digested, in about 5 hours
C. HCl inhibits absorption of Calcium in the gastric mucosa
D. HCl converts pepsinogen to pepsin, which starts the complex process of protein digestion

44. Which of the following is NOT an enzyme secreted by the small intestine?

A. Sucrase
B. Enterokinase
C. Amylase
D. Enterokinase

45. The hormone secreted by the Small intestine that stimulates the production of pancreatic juice which primarily aids in buffering the acidic bolus passed by the Stomach

A. Enterogastrone
B. Cholecystokinin
C. Pancreozymin
D. Enterokinase

46. When the duodenal enzyme sucrase acts on SUCROSE, which 2 monosaccharides are formed?

A. Galactose + Galactose
B. Glucose + Fructose
C. Glucose + Galactose
D. Fructose + Fructose

47. This is the enzyme secreted by the pancrease that completes the protein digestion

A. Trypsin
B. Enterokinase
C. Enterogastrone
D. Amylase

48. The end product of protein digestion or the “Building blocks of Protein” is what we call

A. Nucleotides
B. Fatty acids
C. Glucose
D. Amino Acids

49. Enzyme secreted by the small intestine after it detects a bolus of fatty food. This will contract the gallbladder to secrete bile and relax the sphincter of Oddi to aid in the emulsification of fats and its digestion.

A. Lipase
B. Amylase
C. Cholecystokinin
D. Pancreozymin

50. Which of the following is not true about the Large Intestine?

A. It absorbs around 1 L of water making the feces around 75% water and 25% solid
B. The stool formed in the transverse colon is not yet well formed
C. It is a sterile body cavity
D. It is called large intestine because it is longer than the small intestine

51. This is the amount of heat required to raise the temperature of 1 kg water to 1 degree Celsius

A. Calorie
B. Joules
C. Metabolism
D. Basal metabolic rate

52. Assuming a cup of rice provides 50 grams of carbohydrates. How many calories are there in that cup of rice?

A. 150 calories
B. 200 calories
C. 250 calories
D. 400 calories

53. An average adult filipino requires how many calories in a day?

A. 1,000 calories
B. 1,500 calories
C. 2,000 calories
D. 2,500 calories

54. Which of the following is true about an individual’s caloric needs?

A. All individual have the same caloric needs
B. Females in general have higher BMR and therefore, require more calories
C. During cold weather, people need more calories due to increase BMR
D. Dinner should be the heaviest meal of the day

55. Among the following people, who requires the greatest caloric intake?

A. An individual in a long state of gluconeogenesis
B. An individual in a long state of glycogenolysis
C. A pregnant individual
D. An adolescent with a BMI of 25

56. Which nutrient deficiency is associated with the development of Pellagra, Dermatitis and Diarrhea?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6

57. Which Vitamin is not given in conjunction with the intake of LEVODOPA in cases of Parkinson’s Disease due to the fact that levodopa increases its level in the body?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6

58. A vitamin taken in conjunction with ISONIAZID to prevent peripheral neuritis

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6

59. The inflammation of the Lips, Palate and Tongue is associated in the deficiency of this vitamin

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin B6

60. Beri beri is caused by the deficiency of which Vitamin?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B3
D. Vitamin C

61. Which of the following is the best source of Vitamin E?

A. Green leafy vegetables
B. Vegetable oil
C. Fortified Milk
D. Fish liver oil

62. Among the following foods, which food should you emphasize giving on an Alcoholic client?

A. Pork liver and organ meats, Pork
B. Red meat, Eggs and Dairy products
C. Green leafy vegetables, Yellow vegetables, Cantaloupe and Dairy products
D. Chicken, Peanuts, Bananas, Wheat germs and yeasts

63. Which food group should you emphasize giving on a pregnant mother in first trimester to prevent neural tube defects?

A. Broccoli, Guava, Citrus fruits, Tomatoes
B. Butter, Sardines, Tuna, Salmon, Egg yolk
C. Wheat germ, Vegetable Oil, soybeans, corn, peanuts
D. Organ meats, Green leafy vegetables, Liver, Eggs

64. A client taking Coumadin is to be educated on his diet. As a nurse, which of the following food should you instruct the client to avoid?

A. Spinach, Green leafy vegetables, Cabbage, Liver
B. Salmon, Sardines, Tuna
C. Butter, Egg yolk, breakfast cereals
D. Banana, Yeast, Wheat germ, Chicken

65. Vitamin E plus this mineral works as one of the best anti oxidant in the body according to the latest research. They are combined with 5 Alpha reductase inhibitor to reduce the risk of acquiring prostate cancer

A. Zinc
B. Iron
C. Selenium
D. Vanadium

66. Incident of prostate cancer is found to have been reduced on a population exposed in tolerable amount of sunlight. Which vitamin is associated with this phenomenon?

A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D

67. Micronutrients are those nutrients needed by the body in a very minute amount. Which of the following vitamin is considered as a MICRONUTRIENT

A. Phosphorous
B. Iron
C. Calcium
D. Sodium

68. Deficiency of this mineral results in tetany, osteomalacia, osteoporosis and rickets.

A. Vitamin D
B. Iron
C. Calcium
D. Sodium

69. Among the following foods, which has the highest amount of potassium per area of their meat?

A. Cantaloupe
B. Avocado
C. Raisin
D. Banana

70. A client has HEMOSIDEROSIS. Which of the following drug would you expect to be given to the client?

A. Acetazolamide
B. Deferoxamine
C. Calcium EDTA
D. Activated charcoal

71. Which of the following provides the richest source of Iron per area of their meat?

A. Pork meat
B. Lean read meat
C. Pork liver
D. Green mongo

72. Which of the following is considered the best indicator of nutritional status of an individual?

A. Height
B. Weight
C. Arm muscle circumference
D. BMI

73. Jose Miguel, a 50 year old business man is 6’0 Tall and weights 179 lbs. As a nurse, you know that Jose Miguel is :

A. Overweight
B. Underweight
C. Normal
D. Obese

74. Jose Miguel is a little bit nauseous. Among the following beverages, Which could help relieve JM’s nausea?

A. Coke
B. Sprite
C. Mirinda
D. Orange Juice or Lemon Juice

75. Which of the following is the first sign of dehydration?

A. Tachycardia
B. Restlessness
C. Thirst
D. Poor skin turgor

76. What Specific gravity lab result is compatible with a dehydrated client?

A. 1.007
B. 1.020
C. 1.039
D. 1.029

77. Which hematocrit value is expected in a dehydrated male client?

A. 67%
B. 50%
C. 36%
D. 45%

78. Which of the following statement by a client with prolonged vomiting indicates the initial onset of hypokalemia?

A. My arm feels so weak
B. I felt my heart beat just right now
C. My face muscle is twitching
D. Nurse, help! My legs are cramping

79. Which of the following is not an anti-emetic?

A. Marinol
B. Dramamine
C. Benadryl
D. Alevaire

80. Which is not a clear liquid diet?

A. Hard candy
B. Gelatin
C. Coffee with Coffee mate
D. Bouillon

81. Which of the following is included in a full liquid diet?

A. Popsicles
B. Pureed vegetable meat
C. Pineapple juice with pulps
D. Mashed potato

82. Which food is included in a BLAND DIET?

A. Steamed broccoli
B. Creamed potato
C. Spinach in garlic
D. Sweet potato

83. Which of the following if done by the nurse, is correct during NGT Insertion?

A. Use an oil based lubricant
B. Measure the amount of the tube to be inserted from the Tip of the nose, to the earlobe, to the xiphoid process
C. Soak the NGT in a basin of ice water to facilitate easy insertion
D. Check the placement of the tube by introducing 10 cc of sterile water and auscultating for bubbling sound

84. Which of the following is the BEST method in assessing for the correct placement of the NGT?

A. X-Ray
B. Immerse tip of the tube in water to check for bubbles produced
C. Aspirating gastric content to check if the content is acidic
D. Instilling air in the NGT and listening for a gurgling sound at the epigastric area

85. A terminally ill cancer patient is scheduled for an NGT feeding today. How should you position the patient?

A. Semi fowlers in bed
B. Bring the client into a chair
C. Slightly elevated right side lying position
D. Supine in bed

86. A client is scheduled for NGT Feeding. Checking the residual volume, you determined that he has 40 cc residual from the last feeding. You reinstill the 40 cc of residual volume and added the 250 cc of feeding ordered by the doctor. You then instill 60 cc of water to clear the lumen and the tube. How much will you put in the client’s chart as input?

A. 250 cc
B. 290 cc
C. 350 cc
D. 310 cc

87. Which of the following if done by a nurse indicates deviation from the standards of NGT feeding?

A. Do not give the feeding and notify the doctor of residual of the last feeding is greater than or equal to 50 ml
B. Height of the feeding should be 12 inches about the tube point of insertion to allow slow introduction of feeding
C. Ask the client to position in supine position immediately after feeding to prevent dumping syndrome
D. Clamp the NGT before all of the water is instilled to prevent air entry in the stomach

88. What is the most common problem in TUBE FEEDING?

A. Diarrhea
B. Infection
C. Hyperglycemia
D. Vomiting

89. Which of the following is TRUE in colostomy feeding?

A. Hold the syringe 18 inches above the stoma and administer the feeding slowly
B. Pour 30 ml of water before and after feeding administration
C. Insert the ostomy feeding tube 1 inch towards the stoma
D. A Pink stoma means that circulation towards the stoma is all well

90. A client with TPN suddenly develops tremors, dizziness, weakness and diaphoresis. The client said “I feel weak” You saw that his TPN is already empty and another TPN is scheduled to replace the previous one but its provision is already 3 hours late. Which of the following is the probable complication being experienced by the client?

A. Hyperglycemia
B. Hypoglycemia
C. Infection
D. Fluid overload

91. To assess the adequacy of food intake, which of the following assessment parameters is best used?

A. Food likes and dislikes
B. Regularity of meal times
C. 3 day diet recall
D. Eating style and habits

92. The vomiting center is found in the

A. Medulla Oblongata
B. Pons
C. Hypothalamus
D. Cerebellum

93. The most threatening complication of vomiting in client’s with stroke is

A. Aspiration
B. Dehydration
C. Fluid and electrolyte imbalance
D. Malnutrition

94. Which among this food is the richest source of Iron?

A. Ampalaya
B. Broccoli
C. Mongo
D. Malunggay leaves

95. Which of the following is a good source of Vitamin A?

A. Egg yolk
B. Liver
C. Fish
D. Peanuts

96. The most important nursing action before gastrostomy feeding is

A. Check V/S
B. Assess for patency of the tube
C. Measure residual feeding
D. Check the placement of the tube

97. The primary advantage of gastrostomy feeding is

A. Ensures adequate nutrition
B. It prevents aspiration
C. Maintains Gastro esophageal sphincter integrity
D. Minimizes fluid-electrolyte imbalance

98. What is the BMI Of Budek, weighing 120 lbs and has a height of 5 feet 7 inches.

A. 20
B. 19
C. 15
D. 25

99. Which finding is consistent with PERNICIOUS ANEMIA?

A. Strawberry tongue
B. Currant Jelly stool
C. Beefy red tongue
D. Pale [ HYPOCHROMIC ] RBC

100. The nurse is browsing the chart of the patient and notes a normal serum lipase level. Which of the following is a normal serum lipase value?

A. 10 U/L
B. 100 U/L
C. 200 U/L
D. 350 U/L

Funda 3 Answer Key

FUNDAMENTALS OF NURSING TEST III


Content Outline

1. Physical response to stress
2. Psychological response to stress
3. Spiritual response to stress
4. Stress management
5. Crisis and Crisis intervention
6. Communication
7. Recording
8. Documentation
9. Learning

1. The coronary vessels, unlike any other blood vessels in the body, respond to sympathetic stimulation by

A. Vasoconstriction
B. Vasodilatation
C. Decreases force of contractility
D. Decreases cardiac output

2. What stress response can you expect from a patient with blood sugar of 50 mg / dl?

A. Body will try to decrease the glucose level
B. There will be a halt in release of sex hormones
C. Client will appear restless
D. Blood pressure will increase

3. All of the following are purpose of inflammation except

A. Increase heat, thereby produce abatement of phagocytosis
B. Localized tissue injury by increasing capillary permeability
C. Protect the issue from injury by producing pain
D. Prepare for tissue repair

4. The initial response of tissue after injury is

A. Immediate Vasodilation
B. Transient Vasoconstriction
C. Immediate Vasoconstriction
D. Transient Vasodilation

5. The last expected process in the stages of inflammation is characterized by

A. There will be sudden redness of the affected part
B. Heat will increase on the affected part
C. The affected part will loss its normal function
D. Exudates will flow from the injured site

6. What kind of exudates is expected when there is an antibody-antigen reaction as a result of microorganism infection?

A. Serous
B. Serosanguinous
C. Purulent
D. Sanguinous

7. The first manifestation of inflammation is

A. Redness on the affected area
B. Swelling of the affected area
C. Pain, which causes guarding of the area
D. Increase heat due to transient vasodilation

8. The client has a chronic tissue injury. Upon examining the client’s antibody for a particular cellular response, Which of the following WBC component is responsible for phagocytosis in chronic tissue injury?

A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes

9. Which of the following WBC component proliferates in cases of Anaphylaxis?

A. Neutrophils
B. Basophils
C. Eosinophil
D. Monocytes

10. Icheanne, ask you, her Nurse, about WBC Components. She got an injury yesterday after she twisted her ankle accidentally at her gymnastic class. She asked you, which WBC Component is responsible for proliferation at the injured site immediately following an injury. You answer:

A. Neutrophils
B. Basophils
C. Eosinophils
D. Monocytes

11. Icheanne then asked you, what is the first process that occurs in the inflammatory response after injury, You tell her:

A. Phagocytosis
B. Emigration
C. Pavementation
D. Chemotaxis

12. Icheanne asked you again, What is that term that describes the magnetic attraction of injured tissue to bring phagocytes to the site of injury?

A. Icheanne, you better sleep now, you asked a lot of questions
B. It is Diapedesis
C. We call that Emigration
D. I don’t know the answer, perhaps I can tell you after I find it out later

13. This type of healing occurs when there is a delayed surgical closure of infected wound

A. First intention
B. Second intention
C. Third intention
D. Fourth intention

14. Type of healing when scars are minimal due to careful surgical incision and good healing

A. First intention
B. Second intention
C. Third intention
D. Fourth intention

15. Imelda, was slashed and hacked by an unknown suspects. She suffered massive tissue loss and laceration on her arms and elbow in an attempt to evade the criminal. As a nurse, you know that the type of healing that will most likely occur to Miss Imelda is

A. First intention
B. Second intention
C. Third intention
D. Fourth intention

16. Imelda is in the recovery stage after the incident. As a nurse, you know that the diet that will be prescribed to Miss Imelda is

A. Low calorie, High protein with Vitamin A and C rich foods
B. High protein, High calorie with Vitamin A and C rich foods
C. High calorie, Low protein with Vitamin A and C rich foods
D. Low calorie, Low protein with Vitamin A and C rich foods

17. Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is

A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues
B. It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
C. It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent contamination
D. It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet dressing to stimulate healing of the wound in a wet medium

18. The primary cause of pain in inflammation is

A. Release of pain mediators
B. Injury to the nerve endings
C. Compression of the local nerve endings by the edema fluids
D. Circulation is lessen, Supply of oxygen is insufficient

19. The client is in stress because he was told by the physician he needs to undergo surgery for removal of tumor in his bladder. Which of the following are effects of sympatho-adreno-medullary response by the client?

1. Constipation
2. Urinary frequency
3. Hyperglycemia
4. Increased blood pressure

A. 3,4
B. 1,3,4
C.1,2,4
D.1,4

20. The client is on NPO post midnight. Which of the following, if done by the client, is sufficient to cancel the operation in the morning?

A. Eat a full meal at 10:00 P.M
B. Drink fluids at 11:50 P.M
C. Brush his teeth the morning before operation
D. Smoke cigarette around 3:00 A.M

21. The client place on NPO for preparation of the blood test. Adreno-cortical response is activated and which of the following below is an expected response?

A. Low BP
B. Decrease Urine output
C. Warm, flushed, dry skin
D. Low serum sodium levels

22. Which of the following is true about therapeutic relationship?

A. Directed towards helping an individual both physically and emotionally
B. Bases on friendship and mutual trust
C. Goals are set by the solely nurse
D. Maintained even after the client doesn’t need anymore of the Nurse’s help

23. According to her, A nurse patient relationship is composed of 4 stages : Orientation, Identification, Exploitation and Resolution

A. Roy
B. Peplau
C. Rogers
D. Travelbee

24. In what phase of Nurse patient relationship does a nurse review the client’s medical records thereby learning as much as possible about the client?

A. Pre Orientation
B. Orientation
C. Working
D. Termination

25. Nurse Aida has seen her patient, Roger for the first time. She establish a contract about the frequency of meeting and introduce to Roger the expected termination. She started taking baseline assessment and set interventions and outcomes. On what phase of NPR Does Nurse Aida and Roger belong?

A. Pre Orientation
B. Orientation
C. Working
D. Termination

26. Roger has been seen agitated, shouting and running. As Nurse Aida approaches, he shouts and swear, calling Aida names. Nurse Aida told Roger “That is an unacceptable behavior Roger, Stop and go to your room now.” The situation is most likely in what phase of NPR?

A. Pre Orientation
B. Orientation
C. Working
D. Termination

27. Nurse Aida, in spite of the incident, still consider Roger as worthwhile simply because he is a human being. What major ingredient of a therapeutic communication is Nurse Aida using?

A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness

28. Nurse Irma saw Roger and told Nurse Aida “ Oh look at that psychotic patient “ Nurse Aida should intervene and correct Nurse Irma because her statement shows that she is lacking?

A. Empathy
B. Positive regard
C. Comfortable sense of self
D. Self awareness

29. Which of the following statement is not true about stress?

A. It is a nervous energy
B. It is an essential aspect of existence
C. It has been always a part of human experience
D. It is something each person has to cope

30. Martina, a Tennis champ was devastated after many new competitors outpaced her in the Wimbledon event.
She became depressed and always seen crying. Martina is clearly on what kind of situation?

A. Martina is just stressed out
B. Martina is Anxious
C. Martina is in the exhaustion stage of GAS
D. Martina is in Crisis

31. Which of the following statement is not true with regards to anxiety?

A. It has physiologic component
B. It has psychologic component
C. The source of dread or uneasiness is from an unrecognized entity
D. The source of dread or uneasiness is from a recognized entity

32. Lorraine, a 27 year old executive was brought to the ER for an unknown reason. She is starting to speak but her speech is disorganized and cannot be understood. On what level of anxiety does this features belongs?

A. Mild
B. Moderate
C. Severe
D. Panic

33. Elton, 21 year old nursing student is taking the board examination. She is sweating profusely, has decreased awareness of his environment and is purely focused on the exam questions characterized by his selective attentiveness. What anxiety level is Elton exemplifying?

A. Mild
B. Moderate
C. Severe
D. Panic

34. You noticed the patient chart : ANXIETY +3 What will you expect to see in this client?

A. An optimal time for learning, Hearing and perception is greatly increased
B. Dilated pupils
C. Unable to communicate
D. Palliative Coping Mechanism

35. When should the nurse starts giving XANAX?

A. When anxiety is +1
B. When the client starts to have a narrow perceptual field and selective inattentiveness
C. When problem solving is not possible
D. When the client is immobile and disorganized

36. Which of the following behavior is not a sign or a symptom of Anxiety?

A. Frequent hand movement
B. Somatization
C. The client asks a question
D. The client is acting out

37. Which of the following intervention is inappropriate for client’s with anxiety?

A. Offer choices
B. Provide a quiet and calm environment
C. Provide detailed explanation on each and every procedures and equipments
D. Bring anxiety down to a controllable level

38. Which of the following statement, if made by the nurse, is considered not therapeutic?

A. “How did you deal with your anxiety before?”
B. “It must be awful to feel anxious.”
C. “How does it feel to be anxious?”
D. “What makes you feel anxious?”

39. Marissa Salva, Uses Benson’s relaxation. How is it done?

A. Systematically tensing muscle groups from top to bottom for 5 seconds, and then releasing them
B. Concentrating on breathing without tensing the muscle, Letting go and repeating a word or sound after each exhalation
C. Using a strong positive, feeling-rich statement about a desired change
D. Exercise combined with meditation to foster relaxation and mental alacrity

40. What type of relaxation technique does Lyza uses if a machine is showing her pulse rate, temperature and muscle tension which she can visualize and assess?

A. Biofeedback
B. Massage
C. Autogenic training
D. Visualization and Imagery

41. This is also known as Self-suggestion or Self-hypnosis

A. Biofeedback
B. Meditation
C. Autogenic training
D. Visualization and Imagery

42. Which among these drugs is NOT an anxiolytic?

A. Valium
B. Ativan
C. Milltown
D. Luvox

43. Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with God’s expectation. He fears that in the course of his illness, God will be punitive and not be supportive. What kind of spiritual crisis is Kenneth experiencing?

1. Spiritual Pain
2. Spiritual Anxiety
3. Spiritual Guilt
4. Spiritual Despair

A. 1,2
B. 2,3
C. 3,4
D. 1,4

44. Grace, believes that her relationship with God is broken. She tried to go to church to ask forgiveness everyday to remedy her feelings. What kind of spiritual distress is Grace experiencing?

A. Spiritual Pan
B. Spiritual Alienation
C. Spiritual Guilt
D. Spiritual Despair

45. Remedios felt “EMPTY” She felt that she has already lost God’s favor and love because of her sins. This is a type of what spiritual crisis?

A. Spiritual Anger
B. Spiritual Loss
C. Spiritual Despair
D. Spiritual Anxiety

46. Budek is working with a schizophrenic patient. He noticed that the client is agitated, pacing back and forth, restless and experiencing Anxiety +3. Budek said “You appear restless” What therapeutic technique did Budek used?

A. Offering general leads
B. Seeking clarification
C. Making observation
D. Encouraging description of perception

47. Rommel told Budek “ I SEE DEAD PEOPLE “ Budek responded “You see dead people?” This Is an example of therapeutic communication technique?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

48. Rommel told Budek, “Do you think Im crazy?” Budek responded, “Do you think your crazy?” Budek uses what example of therapeutic communication?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

49. Myra, 21 year old nursing student has difficulty sleeping. She told Nurse Budek “I really think a lot about my x boyfriend recently” Budek told Myra “And that causes you difficulty sleeping?” Which therapeutic technique is used in this situation?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

50. Myra told Budek “I cannot sleep, I stay away all night” Budek told her “You have difficulty sleeping” This is what type of therapeutic communication technique?

A. Reflecting
B. Restating
C. Exploring
D. Seeking clarification

51. Myra said “I saw my dead grandmother here at my bedside a while ago” Budek responded “Really? That is hard to believe, How do you feel about it?” What technique did Budek used?

A. Disproving
B. Disagreeing
C. Voicing Doubt
D. Presenting Reality

52. Which of the following is a therapeutic communication in response to “I am a GOD, bow before me Or ill summon the dreaded thunder to burn you and purge you to pieces!”

A. “You are not a GOD, you are Professor Tadle and you are a PE Teacher, not a Nurse. I am Glen, Your nurse.”
B. “Oh hail GOD Tadle, everyone bow or face his wrath!”
C. “Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a patient here”
D. “How can you be a GOD Mr. Tadle? Can you tell me more about it?”

53. Erik John Senna, Told Nurse Budek “ I don’t want to that, I don’t want that thing.. that’s too painful!” Which of the following response is NON THERAPEUTIC

A. “ This must be difficult for you, But I need to inject you this for your own good”
B. “ You sound afraid”
C. “Are you telling me you don’t want this injection?”
D. “Why are you so anxious? Please tell me more about your feelings Erik”

54. Legrande De Salvaje Y Cobrador La Jueteng, was caught by the bacolod police because of his illegal activities. When he got home after paying for the bail, He shouted at his son. What defense mechanism did Mr. La Jueteng used?

A. Restitution
B. Projection
C. Displacement
D. Undoing

55. Later that day, he bought his son ice cream and food. What defense mechanism is Legrande unconsciously doing?

A. Restitution
B. Conversion
C. Redoing
D. Reaction formation

56. Crisis is a sudden event in ones life that disturbs a person’s homeostasis. Which of the following is NOT TRUE in crisis?

A. The person experiences heightened feeling of stress
B. Inability to function in the usual organized manner
C. Lasts for 4 months
D. Indicates unpleasant emotional feelings

57. Which of the following is a characteristic of crisis?

A. Lasts for an unlimited period of time
B. There is a triggering event
C. Situation is not dangerous to the person
D. Person totality is not involved

58. Levito Devin, The Italian prime minister, is due to retire next week. He feels depressed due to the enormous loss of influence, power, fame and fortune. What type of crisis is Devin experiencing?

A. Situational
B. Maturational
C. Social
D. Phenomenal

59. Estrada, The Philippine president, has been unexpectedly impeached and was out of office before the end of his term. He is in what type of crisis?

A. Situational
B. Maturational
C. Social
D. Phenomenal

60. The tsunami in Thailand and Indonesia took thousands of people and change million lives. The people affected by the Tsunami are saddened and do not know how to start all over again. What type of crisis is this?

A. Situational
B. Maturational
C. Social
D. Phenomenal

61. Which of the following is the BEST goal for crisis intervention?

A. Bring back the client in the pre crisis state
B. Make sure that the client becomes better
C. Achieve independence
D. Provide alternate coping mechanism

62. What is the best intervention when the client has just experienced the crisis and still at the first phase of the crisis?

A. Behavior therapy
B. Gestalt therapy
C. Cognitive therapy
D. Milieu Therapy

63. Therapeutic nurse client relationship is describes as follows

1. Based on friendship and mutual interest
2. It is a professional relationship
3. It is focused on helping the patient solve problems and achieve health-related goals
4. Maintained only as long as the patient requires professional help

A. 1,2,3
B. 1,2,4
C. 2,3,4
D. 1,3,4

64. The client is scheduled to have surgical removal of the tumor on her left breast. Which of the following manifestation indicates that she is experiencing Mild Anxiety?

A. She has increased awareness of her environmental details
B. She focused on selected aspect of her illness
C. She experiences incongruence of action, thoughts and feelings
D. She experiences random motor activities

65. Which of the following nursing intervention would least likely be effective when dealing with a client with aggressive behavior?

A. Approach him in a calm manner
B. Provide opportunities to express feelings
C. Maintain eye contact with the client
D. Isolate the client from others

66. Whitney, a patient of nurse Budek, verbalizes… “I have nothing, nothing… nothing! Don't make me close one more door, I don't wanna hurt anymore!” Which of the following is the most appropriate response by Budek?

A. Why are you singing?
B. What makes you say that?
C. Ofcourse you are everything!
D. What is that you said?

67. Whitney verbalizes that she is anxious that the diagnostic test might reveal laryngeal cancer. Which of the following is the most appropriate nursing intervention?

A. Tell the client not to worry until the results are in
B. Ask the client to express feelings and concern
C. Reassure the client everything will be alright
D. Advice the client to divert his attention by watching television and reading newspapers

68. Considered as the most accurate expression of person’s thought and feelings

A. Verbal communication
B. Non verbal communication
C. Written communication
D. Oral communication

69. Represents inner feeling that a person do not like talking about.

A. Overt communication
B. Covert communication
C. Verbal communication
D. Non verbal communication

70. Which of the following is NOT a characteristic of an effective Nurse-Client relationship?

A. Focused on the patient
B. Based on mutual trust
C. Conveys acceptance
D. Discourages emotional bond

71. A type of record wherein , each person or department makes notation in separate records. A nurse will use the nursing notes, The doctor will use the Physician’s order sheet etc. Data is arranged according to information source.

A. POMR
B. POR
C. Traditional
D. Resource oriented

72. Type of recording that integrates all data about the problem, gathered by members of the health team.

A. POMR
B. Traditional
C. Resource oriented
D. Source oriented

73. These are data that are monitored by using graphic charts or graphs that indicated the progression or fluctuation of client’s Temperature and Blood pressure.

A. Progress notes
B. Kardex
C. Flow chart
D. Flow sheet

74. Provides a concise method of organizing and recording data about the client. It is a series of flip cards kept in portable file used in change of shift reports.

A. Kardex
B. Progress Notes
C. SOAPIE
D. Change of shift report

75. You are about to write an information on the Kardex. There are 4 available writing instruments to use. Which of the following should you use?

A. Mongol #2
B. Permanent Ink
C. A felt or fountain pen
D. Pilot Pentel Pen marker

76. The client has an allergy to Iodine based dye. Where should you put this vital information in the client’s chart?

A. In the first page of the client’s chart
B. At the last page of the client’s chart
C. At the front metal plate of the chart
D. In the Kardex

77. Which of the following is NOT TRUE about the Kardex

A. It provides readily available information
B. It is a tool of end of shift reports
C. The primary basis of endorsement
D. Where Allergies information are written

78. Which of the following, if seen on the Nurses notes, violates characteristic of good recording?

A. The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate of 120 and Respiratory rate of 22
B. Ate 50% of food served
C. Refused administration of betaxolol
D. Visited and seen By Dr. Santiago

79. The physician ordered : Mannerix a.c , what does a.c means?

A. As desired
B. Before meals
C. After meals
D. Before bed time

80. The physician ordered, Maalox, 2 hours p.c, what does p.c means?
A. As desired
B. Before meals
C. After meals
D. Before bed time

81. The physician ordered, Maxitrol, Od. What does Od means?

A. Left eye
B. Right eye
C. Both eye
D. Once a day

82. The physician orderd, Magnesium Hydroxide cc Aluminum Hydroxide. What does cc means?

A. without
B. with
C. one half
D. With one half dose

83. Physician ordered, Paracetamol tablet ss. What does ss means?

A. without
B. with
C. one half
D. With one half dose

84. Which of the following indicates that learning has been achieved?

A. Matuts starts exercising every morning and eating a balance diet after you taught her mag HL tayo program
B. Donya Delilah has been able to repeat the steps of insulin administration after you taught it to her
C. Marsha said “ I understand “ after you a health teaching about family planning
D. John rated 100% on your given quiz about smoking and alcoholism

85. In his theory of learning as a BEHAVIORISM, he stated that transfer of knowledge occurs if a new situation closely resembles an old one.

A. Bloom
B. Lewin
C. Thorndike
D. Skinner

86. Which of the following is TRUE with regards to learning?

A. Start from complex to simple
B. Goals should be hard to achieve so patient can strive to attain unrealistic goals
C. Visual learning is the best for every individual
D. Do not teach a client when he is in pain

87. According to Bloom, there are 3 domains in learning. Which of these domains is responsible for the ability of Donya Delilah to inject insulin?

A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

88. Which domains of learning is responsible for making John and Marsha understand the different kinds of family planning methods?

A. Cognitive
B. Affective
C. Psychomotor
D. Motivative

89. Which of the following statement clearly defines therapeutic communication?

A. Therapeutic communication is an interaction process which is primarily directed by the nurse
B. It conveys feeling of warmth, acceptance and empathy from the nurse to a patient in relaxed atmosphere
C. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals
D. Therapeutic communication is an assessment component of the nursing process

90. Which of the following concept is most important in establishing a therapeutic nurse patient relationship?

A. The nurse must fully understand the patient’s feelings, perception and reactions before goals can be established
B. The nurse must be a role model for health fostering behavior
C. The nurse must recognize that the patient may manifest maladaptive behavior after illness
D. The nurse should understand that patients might test her before trust is established

91. Which of the following communication skill is most effective in dealing with covert communication?

A. Validation
B. Listening
C. Evaluation
D. Clarification

92. Which of the following are qualities of a good recording?

1. Brevity
2. Completeness and chronology
3. Appropriateness
4. Accuracy

A. 1,2
B. 3,4
C. 1,2,3
D. 1,2,3,4

93. All of the following chart entries are correct except

A. V/S 36.8 C,80,16,120/80
B. Complained of chest pain
C. Seems agitated
D. Able to ambulate without assistance

94. Which of the following teaching method is effective in client who needs to be educated about self injection of insulin?

A. Detailed explanation
B. Demonstration
C. Use of pamphlets
D. Film showing

95. What is the most important characteristic of a nurse patient relationship?

A. It is growth facilitating
B. Based on mutual understanding
C. Fosters hope and confidence
D. Involves primarily emotional bond

96. Which of the following nursing intervention is needed before teaching a client post spleenectomy deep breathing and coughing exercises?

A. Tell the patient that deep breathing and coughing exercises is needed to promote good breathing, circulation and prevent complication
B. Tell the client that deep breathing and coughing exercises is needed to prevent Thrombophlebitis, hydrostatic pneumonia and atelectasis
C. Medicate client for pain
D. Tell client that cooperation is vital to improve recovery

97. The client has an allergy with penicillin. What is the best way to communicate this information?

A. Place an allergy alert in the Kardex
B. Notify the attending physician
C. Write it on the patient’s chart
D. Take note when giving medications

98. An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client’s pain?

A. Perform physical assessment
B. Have the client rate his pain on the smiley pain rating scale
C. Active listening on what the patient says
D. Observe the client’s behavior

99. Therapeutic communication begins with?

A. Knowing your client
B. Knowing yourself
C. Showing empathy
D. Encoding

100. The PCS gave new guidelines including leaflets to educate cancer patients. As a nurse, When using materials like this, what is your responsibility?

A. Read it for the patient
B. Give it for the patient to read himself
C. Let the family member read the material for the patient
D. Read it yourself then, Have the client read the material

Funda 2 Answer Key with Rationale

FUNDAMENTALS OF NURSING TEST II

CONTENT OUTLINE

1. Illness
2. Infection and Asepsis
3. Basic concept of Stress and Adaptation


1. When the General adaptation syndrome is activated, FLIGHT OR FIGHT response sets in. Sympathetic nervous system releases norepinephrine while the adrenal medulla secretes epinephrine. Which of the following is true with regards to that statement?

A. Pupils will constrict
B. Client will be lethargic
C. Lungs will bronchodilate
D. Gastric motility will increase

* To better understand the concept : The autonomic nervous system is composed of SYMPATHETIC and PARASYMPATHETIC Nervous system. It is called AUTONOMIC Because it is Involuntary and stimuli based. You cannot tell your heart to kindly beat for 60 per minute, Nor, Tell your blood vessels, Please constrict, because you need to wear skirt today and your varicosities are bulging. Sympathetic Nervous system is the FIGHT or FLIGHT mechanism. When people FIGHT or RUN, we tend to stimulate the ANS and dominate over SNS. Just Imagine a person FIGHTING and RUNNING to get the idea on the signs of SNS Domination. Imagine a resting and digesting person to get a picture of PNS Domination. A person RUNNING or FIGHTING Needs to bronchodilate, because the oxygen need is increased due to higher demand of the body. Pupils will DILATE to be able to see the enemy clearly. Client will be fully alert to dodge attacks and leap through obstacles during running. The client's gastric motility will DECREASE Because you cannot afford to urinate or defecate during fighting nor running.

2. Which of the following response is not expected to a person whose GAS is activated and the FIGHT OR FLIGHT response sets in?

A. The client will not urinate due to relaxation of the detrusor muscle
B. The client will be restless and alert
C. Clients BP will increase, there will be vasodilation
D. There will be increase glycogenolysis, Pancrease will decrease insulin secretion

* If vasodilation will occur, The BP will not increase but decrease. It is true that Blood pressure increases during SNS Stimulation due to the fact that we need more BLOOD to circulate during the FIGHT or FLIGHT Response because the oxygen demand has increased, but this is facilitated by vasoconstriction and not vasodilation. A,B and D are all correct. The liver will increase glycogenolysis or glycogen store utilization due to a heightened demand for energy. Pancrease will decrease insulin secretion because almost every aspect of digestion that is controlled by Parasympathetic nervous system is inhibited when the SNS dominates.

3. State in which a person’s physical, emotional, intellectual and social development or spiritual functioning is diminished or impaired compared with a previous experience.

A. Illness
B. Disease
C. Health
D. Wellness

* Disease is a PROVEN FACT based on a medical theory, standards, diagnosis and clinical feature while ILLNESS Is a subjective state of not feeling well based on subjective appraisal, previous experience, peer advice etc.

4. This is the first stage of illness wherein, the person starts to believe that something is wrong. Also known as the transition phase from wellness to illness.

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

* A favorite board question are Stages of Illness. When a person starts to believe something is wrong, that person is experiencing signs and symptoms of an illness. The patient will then ASSUME that he is sick. This is called assumption of the sick role where the patient accepts he is Ill and try to give up some activities. Since the client only ASSUMES his illness, he will try to ask someone to validate if what he is experiencing is a disease, This is now called as MEDICAL CARE CONTACT. The client seeks professional advice for validation, reassurance, clarification and explanation of the symptoms he is experiencing. client will then start his dependent patient role of receiving care from the health care providers. The last stage of Illness is the RECOVERY stage where the patient gives up the sick role and assumes the previous normal gunctions.

5. In this stage of illness, the person accepts or rejects a professionals suggestion. The person also becomes passive and may regress to an earlier stage.

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

* In the dependent patient role stage, Client needs professionals for help. They have a choice either to accept or reject the professional's decisions but patients are usually passive and accepting. Regression tends to occur more in this period.

6. In this stage of illness, The person learns to accept the illness.

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

* Acceptance of illness occurs in the Assumption of sick role phase of illness.

7. In this stage, the person tries to find answers for his illness. He wants his illness to be validated, his symptoms explained and the outcome reassured or predicted

A. Symptom Experience
B. Assumption of sick role
C. Medical care contact
D. Dependent patient role

* At this stage, The patient seeks for validation of his symptom experience. He wants to find out if what he feels are normal or not normal. He wants someone to explain why is he feeling these signs and symptoms and wants to know the probable outcome of this experience.

8. The following are true with regards to aspect of the sick role except

A. One should be held responsible for his condition
B. One is excused from his societal role
C. One is obliged to get well as soon as possible
D. One is obliged to seek competent help

* The nurse should not judge the patient and not view the patient as the cause or someone responsible for his illness. A sick client is excused from his societal roles, Oblige to get well as soon as possible and Obliged to seek competent help.

9. Refers to conditions that increases vulnerability of individual or group to illness or accident

A. Predisposing factor
B. Etiology
C. Risk factor
D. Modifiable Risks

10. Refers to the degree of resistance the potential host has against a certain pathogen

A. Susceptibility
B. Immunity
C. Virulence
D. Etiology

* Immunity is the ABSOLUTE Resistance to a pathogen considering that person has an INTACT IMMUNITY while susceptibility is the DEGREE of resistance. Degree of resistance means how well would the individual combat the pathogens and repel infection or invasion of these disease causing organisms. A susceptible person is someone who has a very low degree of resistance to combat pathogens. An Immune person is someone that can easily repel specific pathogens. However, Remember that even if a person is IMMUNE [ Vaccination ] Immunity can always be impaired in cases of chemotherapy, HIV, Burns, etc.

11. A group of symptoms that sums up or constitute a disease

A. Syndrome
B. Symptoms
C. Signs
D. Etiology

* Symptoms are individual manifestation of a certain disease. For example, In Tourette syndrome, patient will manifest TICS, but this alone is not enough to diagnose the patient as other diseases has the same tic manifestation. Syndrome means COLLECTION of these symptoms that occurs together to characterize a certain disease. Tics with coprolalia, echolalia, palilalia, choreas or other movement disorders are characteristics of TOURETTE SYNDROME.

12. A woman undergoing radiation therapy developed redness and burning of the skin around the best. This is best classified as what type of disease?

A. Neoplastic
B. Traumatic
C. Nosocomial
D. Iatrogenic

* Iatrogenic diseases refers to those that resulted from treatment of a certain disease. For example, A child frequently exposed to the X-RAY Machine develops redness and partial thickness burns over the chest area. Neoplastic are malignant diseases cause by proliferation of abnormally growing cells. Traumatic are brought about by injuries like Motor vehicular accidents. Nosocomial are infections that acquired INSIDE the hospital. Example is UTI Because of catheterization, This is commonly caused by E.Coli.

13. The classification of CANCER according to its etiology Is best described as

1. Nosocomial
2. Idiopathic
3. Neoplastic
4. Traumatic
5. Congenital
6. Degenrative

A. 5 and 2
B. 2 and 3
C. 3 and 4
D. 3 and 5

* Aside from being NEOPLASTIC, Cancer is considered as IDIOPATHIC because the cause is UNKNOWN.

14. Term to describe the reactiviation and recurrence of pronounced symptoms of a disease

A. Remission
B. Emission
C. Exacerbation
D. Sub acute

15. A type of illness characterized by periods of remission and exacerbation

A. Chronic
B. Acute
C. Sub acute
D. Sub chronic

* A good example is Multiple sclerosis that characterized by periods of remissions and exacerbation and it is a CHRONIC Disease. An acute and sub acute diseases occurs too short to manifest remissions. Chronic diseases persists longer than 6 months that is why remissions and exacerbation are observable.

16. Diseases that results from changes in the normal structure, from recognizable anatomical changes in an organ or body tissue is termed as

A. Functional
B. Occupational
C. Inorganic
D. Organic

* As the word implies, ORGANIC Diseases are those that causes a CHANGE in the structure of the organs and systems. Inorganic diseases is synonymous with FUNCTIONAL diseases wherein, There is no evident structural, anatomical or physical change in the structure of the organ or system but function is altered due to other causes, which is usually due to abnormal response of the organ to stressors. Therefore, ORGANIC BRAIN SYNDROME are anatomic and physiologic change in the BRAIN that is NON PROGRESSIVE BUT IRREVERSIBLE caused by alteration in structure of the brain and it's supporting structure which manifests different sign and symptoms of neurological, physiologic and psychologic alterations. Mental disorders manifesting symptoms of psychoses without any evident organic or structural damage are termed as INORGANIC PSYCHOSES while alteration in the organ structures that causes symptoms of bizaare pyschotic behavior is termed as ORGANIC PSYCHOSES.

17. It is the science of organism as affected by factors in their environment. It deals with the relationship between disease and geographical environment.

A. Epidemiology
B. Ecology
C. Statistics
D. Geography

* Ecology is the science that deals with the ECOSYSTEM and its effects on living things in the biosphere. It deals with diseases in relationship with the environment. Epidimiology is simply the Study of diseases and its occurence and distribution in man for the purpose of controlling and preventing diseases. This was asked during the previous boards.

18. This is the study of the patterns of health and disease. Its occurrence and distribution in man, for the purpose of control and prevention of disease.

A. Epidemiology
B. Ecology
C. Statistics
D. Geography

* Refer to number 17.

19. Refers to diseases that produced no anatomic changes but as a result from abnormal response to a stimuli.

A. Functional
B. Occupational
C. Inorganic
D. Organic

* Refer to number 16.

20. In what level of prevention according to Leavell and Clark does the nurse support the client in obtaining OPTIMAL HEALTH STATUS after a disease or injury?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

* Perhaps one of the easiest concept but asked frequently in the NLE. Primary refers to preventions that aims in preventing the disease. Examples are healthy lifestyle, good nutrition, knowledge seeking behaviors etc. Secondary prevention are those that deals with early diagnostics, case finding and treatments. Examples are monthly breast self exam, Chest X-RAY, Antibiotic treatment to cure infection, Iron therapy to treat anemia etc. Tertiary prevention aims on maintaining optimum level of functioning during or after the impact of a disease that threatens to alter the normal body functioning. Examples are prosthetis fitting for an amputated leg after an accident, Self monitoring of glucose among diabetics, TPA Therapy after stroke etc.

The confusing part is between the treatment in secondary and treatment in tertiary. To best differentiate the two, A client with ANEMIA that is being treated with ferrous sulfate is considered being in the SECONDARY PREVENTION because ANEMIA once treated, will move the client on PRE ILLNESS STATE again. However, In cases of ASPIRING Therapy in cases of stroke, ASPIRING no longer cure the patient or PUT HIM IN THE PRE ILLNESS STATE. ASA therapy is done in order to prevent coagulation of the blood that can lead to thrombus formation and a another possible stroke. You might wonder why I spelled ASPIRIN as ASPIRING, Its side effect is OTOTOXICITY [ CN VIII ] that leads to TINNITUS or ringing of the ears.

21. In what level of prevention does the nurse encourage optimal health and increases person’s susceptibility to illness?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

* The nurse never increases the person's susceptibility to illness but rather, LESSEN the person's susceptibility to illness.

22. Also known as HEALTH MAINTENANCE prevention.

A. Primary
B. Secondary
C. Tertiary
D. None of the above

* Secondary prevention is also known as HEALTH MAINTENANCE Prevention. Here, The person feels signs and symptoms and seeks Diagnosis and treatment in order to prevent deblitating complications. Even if the person feels healthy, We are required to MAINTAIN our health by monthly check ups, Physical examinations, Diagnostics etc.

23. PPD In occupational health nursing is what type of prevention?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

* PPD or PERSONAL PROTECTIVE DEVICES are worn by the workes in a hazardous environment to protect them from injuries and hazards. This is considered as a PRIMARY prevention because the nurse prevents occurence of diseases and injuries.

24. BCG in community health nursing is what type of prevention?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

25. A regular pap smear for woman every 3 years after establishing normal pap smear for 3 consecutive years Is advocated. What level of prevention does this belongs?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

26. Self monitoring of blood glucose for diabetic clients is on what level of prevention?

A. Primary
B. Secondary
C. Tertiary
D. None of the above

27. Which is the best way to disseminate information to the public?

A. Newspaper
B. School bulletins
C. Community bill boards
D. Radio and Television

* An actual board question, The best way to disseminate information to the public is by TELEVISION followed by RADIO. This is how the DOH establish its IEC Programs other than publising posters, leaflets and brochures. An emerging new way to disseminate is through the internet.

28. Who conceptualized health as integration of parts and subparts of an individual?

A. Newman
B. Neuman
C. Watson
D. Rogers

* The supra and subsystems are theories of Martha Rogers but the parts and subparts are Betty Neuman's. She stated that HEALTH is a state where in all parts and subparts of an individual are in harmony with the whole system. Margarex Newman defined health as an EXPANDING CONSCIOUSNESS. Her name is Margaret not Margarex, I just used that to help you remember her theory of health.

29. The following are concept of health:

1. Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity.
2. Health is the ability to maintain balance
3. Health is the ability to maintain internal milieu
4. Health is integration of all parts and subparts of an individual

A. 1,2,3
B. 1,3,4
C. 2,3,4
D. 1,2,3,4

* All of the following are correct statement about health. The first one is the definition by WHO, The second one is from Walter Cannon's homeostasis theory. Third one is from Claude Bernard's concept of Health as Internal Milieu and the last one is Neuman's Theory.

30. The theorist the advocated that health is the ability to maintain dynamic equilibrium is

A. Bernard
B. Selye
C. Cannon
D. Rogers

* Walter Cannon advocated health as HOMEOSTASIS or the ability to maintain dynamic equilibrium. Hans Selye postulated Concepts about Stress and Adaptation. Bernard defined health as the ability to maintain internal milieu and Rogers defined Health as Wellness that is influenced by individual's culture.

31. Excessive alcohol intake is what type of risk factor?

A. Genetics
B. Age
C. Environment
D. Lifestyle

32. Osteoporosis and degenerative diseases like Osteoarthritis belongs to what type of risk factor?

A. Genetics
B. Age
C. Environment
D. Lifestyle

33. Also known as STERILE TECHNIQUE

A. Surgical Asepsis
B. Medical Asepsis
C. Sepsis
D. Asepsis

* Surgical Asepsis is also known as STERILE TECHNIQUE while Medical Asepsis is synonymous with CLEAN TECHNIQUE.

34. This is a person or animal, who is without signs of illness but harbors pathogen within his body and can be transferred to another

A. Host
B. Agent
C. Environment
D. Carrier

35. Refers to a person or animal, known or believed to have been exposed to a disease.

A. Carrier
B. Contact
C. Agent
D. Host

36. A substance usually intended for use on inanimate objects, that destroys pathogens but not the spores.

A. Sterilization
B. Disinfectant
C. Antiseptic
D. Autoclave

* Disinfectants are used on inanimate objects while Antiseptics are intended for use on persons and other living things. Both can kill and inhibit growth of microorganism but cannot kill their spores. That is when autoclaving or steam under pressure gets in, Autoclaving can kill almost ALL type of microoganism including their spores.

37. This is a process of removing pathogens but not their spores

A. Sterilization
B. Auto claving
C. Disinfection
D. Medical asepsis

* Both A and B are capable on killing spores. Autoclaving is a form of Sterilization. Medical Asepsis is a PRACTICE designed to minimize or reduce the transfer of pathogens, also known as your CLEAN TECHNIQUE. Disinfection is the PROCESS of removing pathogens but not their spores.

38. The third period of infectious processes characterized by development of specific signs and symptoms

A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period

* In incubation period, The disease has been introduced to the body but no sign and symptom appear because the pathogen is not yet strong enough to cause it and may still need to multiply. The second period is called prodromal period. This is when the appearance of non specific signs and symptoms sets in, This is when the sign and symptoms starts to appear. Illness period is characterized by the appearance of specific signs and symptoms or refer tp as time with the greatest symptom experience. Acme is the PEAK of illness intensity while the convalescent period is characterized by the abatement of the disease process or it's gradual disappearance.

39. A child with measles developed fever and general weakness after being exposed to another child with rubella. In what stage of infectious process does this child belongs?

A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period

* To be able to categorize MEASLES in the Illness period, the specific signs of Fever, Koplik's Spot and Rashes must appear. In the situation above, Only general signs and symptoms appeared and the Specific signs and symptoms is yet to appear, therefore, the illness is still in the Prodromal period. Signs and symptoms of measles during the prodromal phase are Fever, fatigue, runny nose, cough and conjunctivitis. Koplik's spot heralds the Illness period and cough is the last symptom to disappear. All of this processes take place in 10 days that is why, Measles is also known as 10 day measles.

40. A 50 year old mailman carried a mail with anthrax powder in it. A minute after exposure, he still hasn’t developed any signs and symptoms of anthrax. In what stage of infectious process does this man belongs?

A. Incubation period
B. Prodromal period
C. Illness period
D. Convalescent period

* Anthrax can have an incubation period of hours to 7 days with an average of 48 hours. Since the question stated exposure, we can now assume that the mailman is in the incubation period.

41. Considered as the WEAKEST LINK in the chain of infection that nurses can manipulate to prevent spread of infection and diseases

A. Etiologic/Infectious agent
B. Portal of Entry
C. Susceptible host
D. Mode of transmission

* Mode of transmission is the weakest link in the chain of infection. It is easily manipulated by the Nurses using the tiers of prevention, either by instituting transmission based precautions, Universal precaution or Isolation techniques.

42. Which of the following is the exact order of the infection chain?

1. Susceptible host
2. Portal of entry
3. Portal of exit
4. Etiologic agent
5. Reservoir
6. Mode of transmission

A. 1,2,3,4,5,6
B. 5,4,2,3,6,1
C. 4,5,3,6,2,1
D. 6,5,4,3,2,1

* Chain of infection starts with the SOURCE : The etiologic agent itself. It will first proliferate on a RESERVOIR and will need a PORTAL OF EXIT to be able to TRANSMIT irslef using a PORTAL OF ENTRY to a SUSCEPTIBLE HOST. A simple way to understand the process is by looking at the lives of a young queen ant that is starting to build her colony. Imagine the QUEEN ANT as a SOURCE or the ETIOLOGIC AGENT. She first need to build a COLONY, OR the RESERVOIR where she will start to lay the first eggs to be able to produce her worker ants and soldier ants to be able to defend and sustain the new colony. They need to EXIT [PORTAL OF EXIT] their colony and crawl [MODE OF TRANSMISSION] in search of foods by ENTERING / INVADING [PORTAL OF ENTRY] our HOUSE [SUSCEPTIBLE HOST]. By imagining the Ant's life cycle, we can easily arrange the chain of infection.

43. Markee, A 15 year old high school student asked you. What is the mode of transmission of Lyme disease. You correctly answered him that Lyme disease is transmitted via

A. Direct contact transmission
B. Vehicle borne transmission
C. Air borne transmission
D. Vector borne transmission

* Lyme disease is caused by Borrelia Burdorferi and is transmitted by a TICK BITE.

44. The ability of the infectious agent to cause a disease primarily depends on all of the following except

A. Pathogenicity
B. Virulence
C. Invasiveness
D. Non Specificity

* To be able to cause a disease, A pathogen should have a TARGET ORGAN/S. The pathogen should be specific to these organs to cause an infection. Mycobacterium Avium is NON SPECIFIC to human organs and therefore, not infective to humans but deadly to birds. An immunocompromised individual, specially AIDS Patient, could be infected with these NON SPECIFIC diseases due to impaired immune system.

45. Contact transmission of infectious organism in the hospital is usually cause by

A. Urinary catheterization
B. Spread from patient to patient
C. Spread by cross contamination via hands of caregiver
D. Cause by unclean instruments used by doctors and nurses

* The hands of the caregiver like nurses, is the main cause of cross contamination in hospital setting. That is why HANDWASHING is the single most important procedure to prevent the occurence of cross contamination and nosocomial infection. D refers to Nosocomial infection and UTI is the most common noscomial infection in the hospital caused by urinary catheterization. E.Coli seems to be the major cause of this incident. B best fits Cross Contamination, It is the spread of microogranisms from patient o patient.

46. Transmission occurs when an infected person sneezes, coughs or laugh that is usually projected at a distance of 3 feet.

A. Droplet transmission
B. Airborne transmission
C. Vehicle transmission
D. Vector borne transmission

47. Considered as the first line of defense of the body against infection

A. Skin
B. WBC
C. Leukocytes
D. Immunization

* Remember that intact skin and mucus membrane is our first line of defense against infection.

48. All of the following contributes to host susceptibility except

A. Creed
B. Immunization
C. Current medication being taken
D. Color of the skin

* Creed, Faith or religious belief do not affect person's susceptibility to illness. Medication like corticosteroids could supress a person's immune system that will lead to increase susceptibility. Color of the skin could affect person's susceptibility to certain skin diseases. A dark skinned person has lower risk of skin cancer than a fair skinned person. Fair skinned person also has a higher risk for cholecystitis and cholelithiasis.

49. Graciel has been injected TT5, her last dosed for tetanus toxoid immunization. Graciel asked you, what type of immunity is TT Injections? You correctly answer her by saying Tetanus toxoid immunization is a/an

A. Natural active immunity
B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity

* TT1 ti TT2 are considered the primary dose, while TT3 to TT5 are the booster dose. A woman with completed immunization of DPT need not receive TT1 and TT2. Tetanus toxoid is the actual toxin produce by clostridium tetani but on its WEAK and INACTIVATED form. It is Artificial because it did not occur in the course of actual illness or infection, it is Active because what has been passed is an actual toxin and not a ready made immunoglobulin.

50. Agatha, was hacked and slashed by a psychotic man while she was crossing the railway. She suffered multiple injuries and was injected Tetanus toxoid Immunoglobulin. Agatha asked you, What immunity does TTIg provides? You best answered her by saying TTIg provides

A. Natural active immunity
B. Natural passive immunity
C. Artificial active immunity
D. Artificial passive immunity

* In this scenario, Agatha was already wounded and has injuries. Giving the toxin [TT Vaccine] itself would not help Agatha because it will take time before the immune system produce antitoxin. What agatha needs now is a ready made anti toxin in the form of ATS or TTIg. This is artificial, because the body of agatha did not produce it. It is passive because her immune system is not stimulated but rather, a ready made Immune globulin is given to immediately supress the invasion.

51. This is the single most important procedure that prevents cross contamination and infection

A. Cleaning
B. Disinfecting
C. Sterilizing
D. Handwashing

* When you see the word HANDWASHING as one of the options, 90% Chance it is the correct answer in the local board. Or should I say, 100% because I have yet to see question from 1988 to 2005 board questions that has option HANDWASHING on it but is not the correct answer.

52. This is considered as the most important aspect of handwashing

A. Time
B. Friction
C. Water
D. Soap

* The most important aspect of handwashing is FRICTION. The rest, will just enhance friction. The use of soap lowers the surface tension thereby increasing the effectiveness of friction. Water helps remove transient bacteria by working with soap to create the lather that reduces surface tension. Time is of essence but friction is the most essential aspect of handwashing.

53. In handwashing by medical asepsis, Hands are held ….

A. Above the elbow, The hands must always be above the waist
B. Above the elbow, The hands are cleaner than the elbow
C. Below the elbow, Medical asepsis do not require hands to be above the waist
D. Below the elbow, Hands are dirtier than the lower arms

* Hands are held BELOW the elbow in medical asepsis in contrast with surgical asepsis, wherein, nurses are required to keep the hands above the waist. The rationale is because in medical asepsis, Hands are considered dirtier than the elbow and therefore, to limit contamination of the lower arm, The hands should always be below the elbow.

54. The suggested time per hand on handwashing using the time method is

A. 5 to 10 seconds each hand
B. 10 to 15 seconds each hand
C. 15 to 30 seconds each hand
D. 30 to 60 seconds each hand

* Each hands requires atleast 15 to 30 seconds of handwashing to effectively remove transient microorganisms.

55. The minimum time in washing each hand should never be below

A. 5 seconds
B. 10 seconds
C. 15 seconds
D. 30 seconds

* According to Kozier, The minimum time required for watching each hands is 10 seconds and should not be lower than that. The recommended time, again, is 15 to 30 seconds.

56. How many ml of liquid soap is recommended for handwashing procedure?

A. 1-2 ml
B. 2-3 ml
C. 2-4 ml
D. 5-10 ml

* If a liquid soap is to be used, 1 tsp [ 5ml ] of liquid soap is recommended for handwashing procedure.

57. Which of the following is not true about sterilization, cleaning and disinfection?

A. Equipment with small lumen are easier to clean
B. Sterilization is the complete destruction of all viable microorganism including spores
C. Some organism are easily destroyed, while other, with coagulated protein requires longer time
D. The number of organism is directly proportional to the length of time required for sterilization

* Equipments with LARGE LUMEN are easier to clean than those with small lumen. B C and D are all correct.

58. Karlita asked you, How long should she boil her glass baby bottle in water? You correctly answered her by saying

A. The minimum time for boiling articles is 5 minutes
B. Boil the glass baby bottler and other articles for atleast 10 minutes
C. For boiling to be effective, a minimum of 15 minutes is required
D. It doesn’t matter how long you boil the articles, as long as the water reached 100 degree Celsius

* Boiling is the most common and least expensive method of sterilization used in home. For it to be effective, you should boil articles for atleast 15 minutes.

59. This type of disinfection is best done in sterilizing drugs, foods and other things that are required to be sterilized before taken in by the human body

A. Boiling Water
B. Gas sterilization
C. Steam under pressure
D. Radiation

* Imagine foods and drugs that are being sterilized by a boiling water, ethylene oxide gas and autoclave or steam under pressure, They will be inactivated by these methods. Ethylene oxide gas used in gas sterlization is TOXIC to humans. Boiling the food will alter its consistency and nutrients. Autoclaving the food is never performed. Radiation using microwave oven or Ionizing radiation penetrates to foods and drugs thus, sterilizing them.

60. A TB patient was discharged in the hospital. A UV Lamp was placed in the room where he stayed for a week. What type of disinfection is this?

A. Concurrent disinfection
B. Terminal disinfection
C. Regular disinfection
D. Routine disinfection

* Terminal disinfection refers to practices to remove pathogens that stayed in the belongings or immediate environemnt of an infected client who has been discharged. An example would be Killing airborne TB Bacilli using UV Light. Concurrent disinfection refers to ongoing efforts implented during the client's stay to remove or limit pathogens in his supplies, belongings, immediate environment in order to control the spread of the disease. An example is cleaning the bedside commode of a client with radium implant on her cervix with a bleach disinfectant after each voiding.

61. Which of the following is not true in implementing medical asepsis

A. Wash hand before and after patient contact
B. Keep soiled linens from touching the clothings
C. Shake the linens to remove dust
D. Practice good hygiene

* NEVER shake the linens. Once soiled, fold it inwards clean surface out. Shaking the linen will further spread pathogens that has been harbored by the fabric.

62. Which of the following is true about autoclaving or steam under pressure?

A. All kinds of microorganism and their spores are destroyed by autoclave machine
B. The autoclaved instruments can be used for 1 month considering the bags are still intact
C. The instruments are put into unlocked position, on their hinge, during the autoclave
D. Autoclaving different kinds of metals at one time is advisable

* Only C is correct. Metals with locks, like clamps and scissors should be UNLOCKED in order to minimize stiffening caused by autoclave to the hinges of these metals. NOT ALL microorganism are destroyed by autoclaving. There are recently discovered microorganism that is invulnarable to extreme heat. Autoclaved instruments are to be used within 2 weeks. Only the same type of metals should be autoclaved as this will alteration in plating of these metals.

63. Which of the following is true about masks?

A. Mask should only cover the nose
B. Mask functions better if they are wet with alcohol
C. Masks can provide durable protection even when worn for a long time and after each and every patient care
D. N95 Mask or particulate masks can filter organism as mall as 1 micromillimeter

* only D is correct. Mask should cover both nose and mouth. Masks will not function optimally when wet. Masks should be worn not greater than 4 hours, as it will lose effectiveness after 4 hours. N95 mask or particulate mask can filter organism as small as 1 micromillimeter.

64. Where should you put a wet adult diaper?

A. Green trashcan
B. Black trashcan
C. Orange trashcan
D. Yellow trashcan

* Infectious waste like blood and blood products, wet diapers and dressings are thrown in yellow trashcans.

65. Needles, scalpels, broken glass and lancets are considered as injurious wastes. As a nurse, it is correct to put them at disposal via a/an

A. Puncture proof container
B. Reused PET Bottles
C. Black trashcan
D. Yellow trashcan with a tag “INJURIOUS WASTES”

* Needles, scalpels and other sharps are to be disposed in a puncture proof container.

66. Miranda Priestly, An executive of RAMP magazine, was diagnosed with cancer of the cervix. You noticed that the radioactive internal implant protrudes to her vagina where supposedly, it should be in her cervix. What should be your initial action?

A. Using a long forceps, Push it back towards the cervix then call the physician
B. Wear gloves, remove it gently and place it on a lead container
C. Using a long forceps, Remove it and place it on a lead container
D. Call the physician, You are not allowed to touch, re insert or remove it

* A dislodged radioactive cervical implant in brachytherapy are to be picked by a LONG FORCEP and stored in a LEAD CONTAINER in order to prevent damage on the client's normal tissue. Calling the physician is the second most appropriate action among the choices. A nurse should never attempt to put it back nor, touch it with her bare hands.

67. After leech therapy, Where should you put the leeches?

A. In specially marked BIO HAZARD Containers
B. Yellow trashcan
C. Black trashcan
D. Leeches are brought back to the culture room, they are not thrown away for they are reusable

* Leeches, in leech therapy or LEECH PHLEBOTOMY are to be disposed on a BIO HAZARD container. They are never re used as this could cause transfer of infection. These leeches are hospital grown and not the usual leeches found in swamps.

68. Which of the following should the nurse AVOID doing in preventing spread of infection?

A. Recapping the needle before disposal to prevent injuries
B. Never pointing a needle towards a body part
C. Using only Standard precaution to AIDS Patients
D. Do not give fresh and uncooked fruits and vegetables to Mr. Gatchie, with Neutropenia

* Never recap needles. They are directly disposed in a puncture proof container after used. Recapping the needles could cause injury to the nurse and spread of infection. B C and D are all appropriate. Standard precaution is sufficient for an HIV patient. A client with neutropenia are not given fresh and uncooked fruits and vegetables for even the non infective organisms found in these foods could cause severe infection on an immunocompromised patients.

69. Where should you put Mr. Alejar, with Category II TB?

A. In a room with positive air pressure and atleast 3 air exchanges an hour
B. In a room with positive air pressure and atleast 6 air exchanges an hour
C. In a room with negative air pressure and atleast 3 air exchanges an hour
D. In a room with negative air pressure and atleast 6 air exchanges an hour

* TB patients should have a private room with negative air pressure and atleast 6 to 12 air exhanges per hour. Negative pressure room will prevent air inside the room from escaping. Air exchanges are necessary since the client's room do not allow air to get out of the room.

70. A client has been diagnosed with RUBELLA. What precaution is used for this patient?

A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

* Droplet precaution is sufficient on client's with RUBELLA or german measles.

71. A client has been diagnosed with MEASLES. What precaution is used for this patient?

A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

* Measles is highly communicable and more contagious than Rubella, It requires airborne precaution as it is spread by small particle droplets that remains suspended in air and disperesed by air movements.

72. A client has been diagnosed with IMPETIGO. What precaution is used for this patient?

A. Standard precaution
B. Airborne precaution
C. Droplet precaution
D. Contact precaution

* Impetigo causes blisters or sores in the skin. It is generally caused by GABS or Staph Aureaus. It is spread by skin to skin contact or by scratching the lesions and touching another person's skin.

73. The nurse is to insert an NG Tube when suddenly, she accidentally dip the end of the tube in the client’s glass containing distilled drinking water which is definitely not sterile. As a nurse, what should you do?

A. Don’t mind the incident, continue to insert the NG Tube
B. Obtain a new NG Tube for the client
C. Disinfect the NG Tube before reinserting it again
D. Ask your senior nurse what to do

* The digestive tract is not sterile, and therefore, simple errors like this would not cause harm to the patient. NGT tube need not be sterile, and so is colostomy and rectal tubes. Clean technique is sufficient during NGT and colostomy care.

74. All of the following are principle of SURGICAL ASEPSIS except

A. Microorganism travels to moist surfaces faster than with dry surfaces
B. When in doubt about the sterility of an object, consider it not sterile
C. Once the skin has been sterilized, considered it sterile
D. If you can reach the object by overreaching, just move around the sterile field to pick it rather than reaching for it

* Human skin is impossible to be sterilized. It contains normal flora of microorganism. A B and D are all correct.

75. Which of the following is true in SURGICAL ASEPSIS?

A. Autoclaved linens and gowns are considered sterile for about 4 months as long as the bagging is intact
B. Surgical technique is a sole effort of each nurse
C. Sterile conscience, is the best method to enhance sterile technique
D. If a scrubbed person leaves the area of the sterile field, He/she must do handwashing and gloving again, but the gown need not be changed.

* Sterile conscience, or the moral imperative of a nurse to be honest in practicing sterile technique, is the best method to enhance sterile technique. Autoclaved linens are considered sterile only within 2 weeks even if the bagging is intact. Surgical technique is a team effort of each nurse. If a scrubbed person leave the sterile field and area, he must do the process all over again.

76. In putting sterile gloves, Which should be gloved first?

A. The dominant hand
B. The non dominant hand
C. The left hand
D. No specific order, Its up to the nurse for her own convenience

* Gloves are put on the non dominant hands first and then, the dominant hand. The rationale is simply because humans tend to use the dominant hand first before the non dominant hand. Out of 10 humans that will put on their sterile gloves, 8 of them will put the gloves on their non dominant hands first.

77. As the scrubbed nurse, when should you apply the goggles, shoe cap and mask prior to the operation?

A. Immediately after entering the sterile field
B. After surgical hand scrub
C. Before surgical hand scrub
D. Before entering the sterile field

* The nurse should put his goggles, cap and mask prior to washing the hands. If he wash his hands prior to putting all these equipments, he must wash his hands again as these equipments are said to be UNSTERILE.

78. Which of the following should the nurse do when applying gloves prior to a surgical procedure?

A. Slipping gloved hand with all fingers when picking up the second glove
B. Grasping the first glove by inserting four fingers, with thumbs up underneath the cuff
C. Putting the gloves into the dominant hand first
D. Adjust only the fitting of the gloves after both gloves are on

* The nurse should only adjust fitting of the gloves when they are both on the hands. Not doing so will break the sterile technique. Only 4 gingers are slipped when picking up the second gloves. You cannot slip all of your fingers as the cuff is limited and the thumb would not be able to enter the cuff. The first glove is grasp by simply picking it up with the first 2 fingers and a thumb in a pinching motion. Gloves are put on the non dominant hands first.

79. Which gloves should you remove first?

A. The glove of the non dominant hand
B. The glove of the dominant hand
C. The glove of the left hand
D. Order in removing the gloves Is unnecessary

* Gloves are worn in the non dominant hand first, and is removed also from the non dominant hand first. Rationale is simply because in 10 people removing gloves, 8 of them will use the dominant hand first and remove the gloves of the non dominant hand.

80. Before a surgical procedure, Give the sequence on applying the protective items listed below

1. Eye wear or goggles
2. Cap
3. Mask
4. Gloves
5. Gown

A. 3,2,1,5,4
B. 3,2,1,4,5
C. 2,3,1,5,4
D. 2,3,1,4,5

* The nurse should use CaMEy Hand and Body Lotion in moisturizing his hand before surgical procedure and after handwashing. Ca stands for CAP, M stands for MASK, Ey stands for eye goggles. The nurse will do handwashing and then [HAND], Don the gloves first and wear the Gown [BODY]. I created this mnemonic and I advise you use it because you can never forget Camey hand and body lotion. [ Yes, I know it is spelled as CAMAY ]]

81. In removing protective devices, which should be the exact sequence?

1. Eye wear or goggles
2. Cap
3. Mask
4. Gloves
5. Gown

A. 4,3,5,1,2
B. 2,3,1,5,4
C. 5,4,3,2,1
D. 1,2,3,4,5

* When the nurse is about to remove his protective devices, The nurse will remove the GLOVES first followed by the MASK and GOWN then, other devices like cap, shoe cover, etc. This is to prevent contamination of hair, neck and face area.

82. In pouring a plain NSS into a receptacle located in a sterile field, how high should the nurse hold the bottle above the receptacle?

A. 1 inch
B. 3 inches
C. 6 inches
D. 10 inches

* Even if you do not know the answer to this question, you can answer it correctly by imagining. If you pour the NSS into a receptacle 1 to 3 inch above it, Chances are, The mouth of the NSS bottle would dip into the receptacle as you fill it, making it contaminated. If you pour the NSS bottle into a receptacle 10 inches above it, that is too high, chances are, as you pour the NSS, most will spill out because the force will be too much for the buoyant force to handle. It will also be difficult to pour something precisely into a receptacle as the height increases between the receptacle and the bottle. 6 inches is the correct answer. It is not to low nor too high.

83. The tip of the sterile forceps is considered sterile. It is used to manipulate the objects in the sterile field using the non sterile hands. How should the nurse hold a sterile forceps?

A. The tip should always be lower than the handle
B. The tip should always be above the handle
C. The handle and the tip should be at the same level
D. The handle should point downward and the tip, always upward

* A sterile forcep is usually dipped into a disinfectant or germicidal solution. Imagine, if the tip is HIGHER than the handle, the solution will go into the handle and into your hands and as you use the forcep, you will eventually lower its tip making the solution in your hand go BACK into the tip thus contaminating the sterile area of the forcep. To prevent this, the tip should always be lower than the handle. In situation questions like this, IMAGINATION is very important.

84. The nurse enters the room of the client on airborne precaution due to tuberculosis. Which of the following are appropriate actions by the nurse?

1. She wears mask, covering the nose and mouth
2. She washes her hands before and after removing gloves, after suctioning the client’s secretion
3. She removes gloves and hands before leaving the client’s room
4. She discards contaminated suction catheter tip in trashcan found in the clients room

A. 1,2
B. 1,2,3
C. 1,2,3,4
D. 1,3

* All soiled equipments use in an infectious client are disposed INSIDE the client's room to prevent contamination outside the client's room. The nurse is correct in using Mask the covers both nose and mouth. Hands are washed before and after removing the gloves and before and after you enter the client's room. Gloves and contaminated suction tip are thrown in trashcan found in the clients room.

85. When performing surgical hand scrub, which of the following nursing action is required to prevent contamination?

1. Keep fingernail short, clean and with nail polish
2. Open faucet with knee or foot control
3. Keep hands above the elbow when washing and rinsing
4. Wear cap, mask, shoe cover after you scrubbed

A. 1,2
B. 2,3
C. 1,2,3
D. 2,3,4

* Cap, mask and shoe cover are worn BEFORE scrubbing.

86. When removing gloves, which of the following is an inappropriate nursing action?

A. Wash gloved hand first
B. Peel off gloves inside out
C. Use glove to glove skin to skin technique
D. Remove mask and gown before removing gloves

* Gloves are the dirtiest protective item nurses are wearing and therefore, the first to be removed to prevent spread of microorganism as you remove the mask and gown.

87. Which of the following is TRUE in the concept of stress?

A. Stress is not always present in diseases and illnesses
B. Stress are only psychological and manifests psychological symptoms
C. All stressors evoke common adaptive response
D. Hemostasis refers to the dynamic state of equilibrium

* All stressors evoke common adaptive response. A psychologic fear like nightmare and a real fear or real perceive threat evokes common manifestation like tachycardia, tachypnea, sweating, increase muscle tension etc. ALL diseases and illness causes stress. Stress can be both REAL or IMAGINARY. Hemostasis refers to the ARREST of blood flowing abnormally through a damage vessel. Homeostasis is the one that refers to dynamic state of equilibrium according to Walter Cannon.

88. According to this theorist, in his modern stress theory, Stress is the non specific response of the body to any demand made upon it.

A. Hans Selye
B. Walter Cannon
C. Claude Bernard
D. Martha Rogers

* Hans Selye is the only theorist who proposed an intriguing theory about stress that has been widely used and accepted by professionals today. He conceptualized two types of human response to stress, The GAS or general adaptation syndrome which is characterized by stages of ALARM, RESISTANCE and EXHAUSTION. The Local adaptation syndrome controls stress through a particular body part. Example is when you have been wounded in your finger, it will produce PAIN to let you know that you should protect that particular damaged area, it will also produce inflammation to limit and control the spread of injury and facilitate healing process. Another example is when you are frequently lifting heavy objects, eventually, you arm, back and leg muscles hypertorphies to adapt to the stress of heavy lifting.

89. Which of the following is NOT TRUE with regards to the concept of Modern Stress Theory?

A. Stress is not a nervous energy
B. Man, whenever he encounters stresses, always adapts to it
C. Stress is not always something to be avoided
D. Stress does not always lead to distress

* Man, do not always adapt to stress. Sometimes, stress can lead to exhaustion and eventually, death. A,C and D are all correct.

90. Which of the following is TRUE with regards to the concept of Modern Stress Theory?

A. Stress is essential
B. Man does not encounter stress if he is asleep
C. A single stress can cause a disease
D. Stress always leads to distress

* Stress is ESSENTIAL. No man can live normally without stress. It is essential because it is evoked by the body's normal pattern of response and leads to a favorable adaptive mechanism that are utilized in the future when more stressors are encountered by the body. Man can encounter stress even while asleep, example is nightmare. Disease are multifactorial, No diseases are caused by a single stressors. Stress are sometimes favorable and are not always a cause for distress. An example of favorable stress is when a carpenter meets the demand and stress of everyday work. He then develops calluses on the hand to lessen the pressure of the hammer against the tissues of his hand. He also develop larger muscle and more dense bones in the arm, thus, a stress will lead to adaptations to decrease that particular stress.

91. Which of the following is TRUE in the stage of alarm of general adaptation syndrome?

A. Results from the prolonged exposure to stress
B. Levels or resistance is increased
C. Characterized by adaptation
D. Death can ensue

* Death can ensue as early as the stage of alarm. Exhaustion results to a prolonged exposure to stress. Resistance is when the levels of resistance increases and characterized by being able to adapt.

92. The stage of GAS where the adaptation mechanism begins

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

* Adaptation mechanisms begin in the stage of alarm. This is when the adaptive mechanism are mobilized. When someone shouts SUNOG!!! your heart will begin to beat faster, you vessels constricted and bp increased.

93. Stage of GAS Characterized by adaptation

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

94. Stage of GAS wherein, the Level of resistance are decreased

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

* Resistance are decreased in the stage of alarm. Resistance is absent in the stage of exhaustion. Resistance is increased in the stage of resistance.

95. Where in stages of GAS does a person moves back into HOMEOSTASIS?

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

96. Stage of GAS that results from prolonged exposure to stress. Here, death will ensue unless extra adaptive mechanisms are utilized

A. Stage of Alarm
B. Stage of Resistance
C. Stage of Homeostasis
D. Stage of Exhaustion

97. All but one is a characteristic of adaptive response

A. This is an attempt to maintain homeostasis
B. There is a totality of response
C. Adaptive response is immediately mobilized, doesn’t require time
D. Response varies from person to person

* Aside from having limits that leads to exhaustion. Adaptive response requires time for it to act. It requires energy, physical and psychological taxes that needs time for our body to mobilize and utilize.

98. Andy, a newly hired nurse, starts to learn the new technology and electronic devices at the hospital. Which of the following mode of adaptation is Andy experiencing?

A. Biologic/Physiologic adaptive mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

99. Andy is not yet fluent in French, but he works in Quebec where majority speaks French. He is starting to learn the language of the people. What type of adaptation is Andy experiencing?

A. Biologic/Physiologic adaptive mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

* Sociocultural adaptive modes include language, communication, dressing, acting and socializing in line with the social and cultural standard of the people around the adapting individual.

100. Andy made an error and his senior nurse issued a written warning. Andy arrived in his house mad and kicked the door hard to shut it off. What adaptation mode is this?

A. Biologic/Physiologic adaptive mode
B. Psychologic adaptive mode
C. Sociocultural adaptive mode
D. Technological adaptive mode

* Andy uses a defense mechanism called DISPLACEMENT. All DMs are categorized as PSYCHOLOGIC ADAPTIVE RESPONSE to stressors.