fundamentals-6-documentation

Introduction

This examination may stress you. Learn about the stress, crisis interventions, communication, and documentation in this 100-item Fundamentals of Nursing Exam. Challenge yourself with this exam to be more prepared for your NCLEX and NLE exams.

Topics

Topics or concepts included in this exam are:

  • Stress and response to stress
  • Crisis Intervention
  • Communication
  • Documentation
  • Learning

Guidelines

  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales (if any) are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.

Questions

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Fundamentals of Nursing Exam 6: Stress, Documentation, Crisis Interventions (100 Items)

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Fundamentals of Nursing Exam 6: Stress, Documentation, Crisis Interventions (100 Items)

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

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

47. Ronny told Blake “I see dead people.” Blake responded, “You see dead people?” This exchange is an example of what therapeutic communication technique? 

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

48. Ronny told Blake, “Do you think I’m crazy?” Blake responded, “Do you think you’re crazy?” Blake 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 Blake “I really think a lot about my ex-boyfriend recently.” Blake 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 Blake “I cannot sleep, I stay away all night.” Blake 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.” Blake responded “Really? That is hard to believe. How do you feel about it?” What technique did Blake 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 Blake “ 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. Mr. Poncho was caught by the 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. Poncho 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 Mr. Poncho 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 Blake, 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 Blake?

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 four (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 bedtime

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 ordered, 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. Martin 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

Answers and Rationale

Countercheck your answers to those below. Rationales are not given on this exam. If you have any disputes or clarifications, please direct them to the comments section.

1. Answer: B. Vasodilatation

Sympathetic activation to the heart results in coronary vasodilation and increased coronary flow due to increased metabolic activity (increased heart rate, contractility) despite direct vasoconstrictor effects of sympathetic activation on the coronaries. This is termed “functional sympatholysis.”

2. Answer: D. Blood pressure will increase

Blood pressure elevation secondary to hypoglycemia has been demonstrated in human experimentation through the activation of the sympathoadrenal system.

3. Answer: A. Increase heat, thereby produce abatement of phagocytosis

The inflammatory response is a defense mechanism that evolved in higher organisms to protect them from infection and injury. Its purpose is to localize and eliminate the injurious agent and to remove damaged tissue components so that the body can begin to heal. The response consists of changes in blood flow, an increase in permeability of blood vessels, and the migration of fluid, proteins, and white blood cells (leukocytes) from the circulation to the site of tissue damage. An inflammatory response that lasts only a few days is called acute inflammation, while a response of longer duration is referred to as chronic inflammation.

4. Answer: C. Immediate Vasoconstriction

Inflammation can be divided into several phases. The earliest, gross event of an inflammatory response is temporary vasoconstriction, i.e. narrowing of blood vessels caused by contraction of smooth muscle in the vessel walls, which can be seen as blanching (whitening) of the skin.

5. Answer: C. The affected part will lose its normal function

A fifth consequence of inflammation is the loss of function of the inflamed area, a feature noted by German pathologist Rudolf Virchow in the 19th century. Loss of function may result from pain that inhibits mobility or from severe swelling that prevents movement in the area.

6. Answer: C. Purulent

Purulent effluent refers to a thick yellow, gray or green drainage that comes out of a wound when infection invades the area. The fluid contains pathogenic microorganisms along with white cells, inflammatory cells and dead or dying bacteria. When the wound is infected, the volume of the purulent exudate increases.

7. Answer: A. Redness on the affected area

Vasodilation occurs first at the arteriole level, progressing to the capillary level, and brings about a net increase in the amount of blood present, causing the redness and heat of inflammation.

8. Answer: D. Monocytes

Monocytes and their macrophage and dendritic-cell progeny serve three main functions in the immune system. These are phagocytosis, antigen presentation, and cytokine production. Phagocytosis is the process of uptake of microbes and particles followed by digestion and destruction of this material. Monocytes can perform phagocytosis using intermediary (opsonising) proteins such as antibodies or complement that coat the pathogen, as well as by binding to the microbe directly via pattern-recognition receptors that recognize pathogens.

9. Answer: C. Eosinophil

It is known that eosinophils appear as an aftermath of anaphylaxis in sensitized tissues that are reexposed to specific antigens.

10. Answer: A. Neutrophils

Activated neutrophils are capable of presenting antigens via MHCII, thereby stimulating T-cell activation and proliferation.

11. Answer: C. Pavementation

Pavementation or the sticking of white blood cells to the linings of the finest blood vessels (capillaries) when inflammation occurs is the first process that occurs in the inflammatory response after injury.

12. Answer: D. I don’t know the answer, perhaps I can tell you after I find it out later

13. Answer: C. Third intention

Healing by third intention is a method of closing a grossly contaminated wound in which the wound is left open until contamination has been markedly reduced and inflammation has subsided and then is closed by first intention. Also called delayed primary closure.

14. Answer: A. First intention

Healing by first intention aka. primary wound healing or primary closure describes a wound closed by approximation of wound margins or by placement of a graft or flap, or wounds created and closed in the operating room.

15. Answer: B. Second intention

Healing by second intention aka. secondary wound healing or spontaneous healing Describes a wound left open and allowed to close by epithelialization and contraction.

16. Answer: B. High protein, High calorie with Vitamin A and C rich foods

Even if you do not currently have any aches or pains, adding these foods into your diet can help prepare your body for healing if you should happen to get hurt.

17. Answer: A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues

This type of mechanical debridement is done by placing a wet (or moist) gauze dressing on your wound and allowing it to dry, wound drainage and dead tissue can be removed when you take off the old dressing.

18. Answer: C. Compression of the local nerve endings by the edema fluids

Chemicals that stimulate nerve endings are released, making the area much more sensitive and the inflamed area is likely to be painful, especially when touched.

19. Answer: B. 1,3,4

20. Answer: D. Smoke cigarette around 3:00 A.M

The phrase “NPO After Midnight” is one of the most common in medicine. It is present not only in physician’s pre-operative orders, but repeated by nurses, ward secretaries and dietary workers. The goal of “NPO after midnight” was to ensure an empty stomach for the morning procedure.

21. Answer: B. Decrease Urine output

22. Answer: A. Directed towards helping an individual both physically and emotionally

Therapeutic nurse-patient communication helps nurses to build positive relationships with patients by showing warmth, respect, and empathy. It also increases confidence of the nurse by enabling nurses to ask for support, open up for feedbacks, and overcome anxiety. Therefore allows nurses to provide the best possible care for patients. Effective nurse-healthcare provider communications assure optimal patient-centered care.

23. Answer: B. Peplau

Peplau published her Theory of Interpersonal Relations in 1952, and in 1968, interpersonal techniques became the crux of psychiatric nursing. The nursing model identifies four sequential phases in the interpersonal relationship: orientation, identification, exploitation, and resolution.

24. Answer: A. Pre Orientation

Pre-orientation phase begins when the nurse is assigned to the patient. It includes all that the nurse thinks and does before interacting with the patient such as when the nurse review the client’s medical records.

25. Answer: B. Orientation

Orientation Phase begins when the nurse and the patient meet for the patient. In this phase, parameters of the relationship is done. Explanation of roles is also done during this phase which includes the responsibilities and expectation of the patient and nurse, with the expectations of both parties of what they can and can’t do. It is during the orientation phase when the nurse begins to know the patient.

26. Answer: C. Working

The working phase is highly individualized. it is more structured than the orientation phase- meaning most of the therapeutic work is done during this phase.

27. Answer: B. Positive regard

Unconditional positive regard often described as acceptance is the third core condition and this involves taking a non-judgemental attitude towards the client accepting and respecting them for who and what they are.

28. Answer: B. Positive regard

Refer to #27

29. Answer: A. It is a nervous energy

Stress is a normal physical response to events that make you feel threatened or upset your balance in some way. A nervous energy is more part of anxiety.

30. Answer: D. Martina is in Crisis

Martina is in Crisis. She feels sad and down during this tough time. She can have intense negative feelings for weeks, months or more.

31. Answer: D. The source of dread or uneasiness is from a recognized entity

Anxiety is a general term for several disorders that cause nervousness, fear, apprehension, and worrying. These disorders affect how we feel and behave, and they can manifest real physical symptoms. Mild anxiety is vague and unsettling, while severe anxiety can be extremely debilitating, having a serious impact on daily life.

32. Answer: D. Panic

Panic is the highest level of anxiety and is associated with dread, terror and a sense of impending doom. You may not be able to communicate, function or concentrate because you are unable to think rationally. You may start uncontrollably pacing and become increasingly active without absolute purpose.

33. Answer: B. Moderate

At this level, you lose the broader picture and focus only on the cause of the anxiety. You may not be able to pay attention like usual, and even though your perceptual field is narrowed, you are still able to solve a problem. Mild and moderate levels of anxiety are considered normal.

34. Answer: B. Dilated pupils

35. Answer: B. When the client starts to have a narrow perceptual field and selective inattentiveness

36. Answer: C. The client asks a question

37. Answer: A. Offer choices

38. Answer: D. “What makes you feel anxious?”

39. Answer: B. Concentrating on breathing without tensing the muscle, Letting go and repeating a word or sound after each exhalation

The Relaxation Response is essentially the opposite reaction to the “fight or flight” response. According to Dr. Benson, using the Relaxation Response is beneficial as it counteracts the physiological effects of stress and the fight or flight response.

40. Answer: A. Biofeedback

Biofeedback is a technique you can use to learn to control your body’s functions, such as your heart rate. With biofeedback, you’re connected to electrical sensors that help you receive information (feedback) about your body (bio). This feedback helps you focus on making subtle changes in your body, such as relaxing certain muscles, to achieve the results you want, such as reducing pain.

In essence, biofeedback gives you the power to use your thoughts to control your body, often to help with a health condition or physical performance. Biofeedback is often used as a relaxation technique.

41. Answer: C. Autogenic training

Autogenic Therapy (AT) is a powerful mind and body technique involving simple relaxation and body awareness exercises. These reduce the intensity of the body’s stress response, and replace it with a calmer physiological state in which self-healing naturally begins to occur.

42. Answer: D. Luvox

Luvox (fluvoxamine) is a selective serotonin reuptake inhibitor (SSRI) antidepressant. Fluvoxamine affects chemicals in the brain that may become unbalanced and cause obsessive-compulsive symptoms. It is frequently used along with benzodiazepine anxiolytics in clinics.

43: Answer: B. 2,3

Spiritual anxiety is the expression of fear of God’s wrath and punishment; fear that God might not take care of one, either immediately or in the future; and/or worry that God is displeased with one’s behavior. Spiritual guilt is an expression suggesting that one has failed to do the things which he should have done in life and/or done things which were not pleasing to God; articulation of concerns about the “kind” of life one has lived. Spiritual pain is the expression of discomfort of suffering relative to one’s relationship with God, verbalization of feelings of having a void or lack of spiritual fulfillment, and/or a lack of peace in terms of one’s relationship to one’s creator. And spiritual despair is the expression suggesting that there is no hope of ever having a relationship with God or of pleasing Him and/or a feeling that God no longer can or does care for one.

44. Answer: B. Spiritual Alienation

Spiritual alienation is the expressions of loneliness or the feeling that God seems very far away and remote from one’s everyday life, verbalization that one has to depend upon one’s self in times of trial or need, and/or a negative attitude toward receiving any comfort or help from God.

45. Answer: B. Spiritual Loss

Spiritual loss is the expression of feelings of having temporarily lost or terminated the love of God, fear that one’s relationship with God has been threatened, and/or a feeling of emptiness with regard to spiritual things.

46. Answer: C. Making observation

Making observation is a therapeutic observation that is verbalizing what is observed or perceived.

47. Answer: B. Restating

Restating lets client know whether an expressed statement has or has not been understood.

48. Answer: A. Reflecting

Reflecting directs questions or feelings back to client so that they may be recognized and accepted.

49. Answer: A. Reflecting

Reflecting is directing back to the patient questions, feelings, and ideas.

50. Answer: B. Restating

Restating is repeating the main idea expressed.

51. Answer: C. Voicing Doubt

Voicing doubt is expressing uncertainty as to the reality of client’s perception.

52. Answer: C. “Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a patient here”

This is an example of presenting reality. It is clarifying misconceptions that client may be expressing.

53. Answer: D. “Why are you so anxious? Please tell me more about your feelings Erik”

Requesting an explanation is an ineffective behavior and response.

54. Answer: C. Displacement

Displacement is the redirecting of thoughts feelings and impulses directed at one person or object, but taken out upon another person or object. People often use displacement when they cannot express their feelings in a safe manner to the person they are directed at.

55. Answer: A. Restitution

Restitution is the mechanism of relieving the mind of a load of guilt by making up or reparation (paying up with interest).

56. Answer: C. Lasts for 4 months

57: Answer: B. There is a triggering event

Crisis is any event that is, or is expected to lead to, an unstable and dangerous situation affecting an individual, group, community, or whole society.

58. Answer: B. Maturational

Maturational crisis a life crisis in which usual coping mechanisms are inadequate in dealing with a stress common to a particular stage in the life cycle or with stress caused by a transition from one stage to another.

59. Answer: A. Situational

Situational crisis is an unexpected crisis that arises suddenly in response to an external event or a conflict concerning a specific circumstance.

60. Answer: C. Social

Social Crisis is the crisis which hampers the social life of an individual. It can include recession, World War, terrorism etc., these are the major factor which is responsible for social crisis.

61. Answer: D. Provide alternate coping mechanism

One of the goals for crisis intervention is that the victim and the counselor begin to collaboratively generate and explore alternatives for coping. Although this situation will be unlike any other experience before, the counselor should assist the individual in looking at what has worked in the past for other situations; this is typically the most difficult to achieve in crisis counseling.

62. Answer D. Milieu Therapy

The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s hospital experience are considered therapeutic.

63. Answer: C. 2,3,4

A therapeutic nurse-client relationship is established for the benefit of the client. It includes nurses working with the client to create goals directed at improving their health status. Goals are centered on the client’s values, beliefs and needs. A partnership is formed between nurse and client. The nurse empowers patient and families to get involved in their health. This relationship has three phases, a beginning (first time contact/introduction), a middle (develop a relationship to deliver care) and an end (the patient is no longer dependant on the nurse).

64. Answer: A. She has increased awareness of her environmental details

Mild anxiety is anxiety that is manageable without any additional techniques. Mild anxiety tends to be when you have irritating symptoms that don’t seem to go away, but otherwise don’t control you.

65. Answer: B. Provide opportunities to express feelings

Providing opportunities for the client to express his or her feelings will likely trigger his or her aggressiveness more.

66. Answer: D. What is that you said?

Clarification should be sought at each step of the way. The patient is usually quite aware when he is not being understood. Eventually he may cease trying to communicate. Peplau states that it is always possible to ask: What is that you said?

67. Answer: B. Ask the client to express feelings and concern

Asking the client to verbalize what she or he perceives may relieve the tension the client is feeling and he or she might be less likely to take action on ideas that are harmful or frightening.

68. Answer: B. Non verbal communication

Non verbal communication is considered as the most accurate expression of person’s thought and feelings. Nonverbal communication represents two-thirds of all communication.

69. Answer: B. Covert communication

“Overt” means “done or shown openly or plainly apparent” in the Oxford English dictionary. This can refer to all sorts of actions which are done in plain sight or with clear manifestations. “Covert,” on the other hand, means the exact opposite of overt – not openly acknowledged or displayed.

70. Answer: D. Discourages emotional bond

Emotional support is important in order for a nurse-client relationship to be effective. It is giving and receiving reassurance and encouragement done through understanding.

71. Answer: D. Resource oriented

72. Answer: A. POMR

Problem-oriented medical record (POMR) is a method of recording data about the health status of a patient in a problem-solving system. The POMR preserves the data in an easily accessible way that encourages ongoing assessment and revision of the health care plan by all members of the health care team.

73. Answer: D. Flow sheet

Flowsheet (in a patient record) is a graphic summary of several changing factors, especially the patient’s vital signs or weight and the treatments and medications given.

74. Answer: A. Kardex

The Kardex is a trademark for a card-filing system that allows quick reference to the particular needs of each patient for certain aspects of nursing care.

75. Answer: A. Mongol #2

Kardexes are a huge risk factor for med errors that is why they are written in pencil. They are not legal documents and are discarded when the patient is transferred out. And they are only as good as the nurse responsible for checking the orders

76. Answer: C. At the front metal plate of the chart

77. Answer: C. The primary basis of endorsement

Refer to #75.

78. Answer: A. The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate of 120 and Respiratory rate of 22

Shortcuts would be safe to use on records when commenting on blood pressure, temperature, pulse rate, and respiratory rate respectively. Do not use an abbreviation unless you are sure that it is commonly understood and in general use.

79. Answer: B. Before meals

80. Answer: C. After meals

81. Answer: D. Once a day

82. Answer: B. with

83. Answer: C. one half

84. Answer: A. Martin starts exercising every morning and eating a balance diet after you taught her mag HL tayo program

Learning has been achieved by the patient if he or she applies and acts upon the teachings of the health care provider or the nurse. Verbalizing such learning does not guarantee an effective nurse teaching.

85. Answer: C. Thorndike

After several experiments on animals and learning development, Thorndike posited that learning was actually merely a change in behavior as a result of a consequence. Furthermore, if an action brought a reward, it was stamped into the mind and available for recall later. These two suppositions together came to be known as the Law of Effect, and now inform much of what we know about operant conditioning and behaviorism.

86. Answer: D. Do not teach a client when he is in pain

Pain tells us something is wrong. Pain does not suggest that the patient is ready to listen and perceive properly the teaching that the nurse may impart.

87. Answer: C. Psychomotor

Bloom’s Taxonomy model is in three parts, or ‘overlapping domains’. Again, Bloom used rather academic language, but the meanings are simple to understand: The learner should benefit from development of knowledge and intellect (Cognitive Domain); attitude and beliefs (Affective Domain); and the ability to put physical and bodily skills into effect – to act (Psychomotor Domain).

88. Answer: A. Cognitive

Refer to #87.

89. Answer: C. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals

Therapeutic communication is a process in which the nurse consciously influences a client or helps the client to a better understanding through verbal or nonverbal communication. Therapeutic communication involves the use of specific strategies that encourage the patient to express feelings and ideas and that convey acceptance and respect.

The goal of therapeutic communication is to increase self-worth or decrease psychological distress by collecting information to determine the illness, assessing and modifying the behavior, and providing health education.

90. Answer: D. The nurse should understand that patients might test her before trust is established

A therapeutic nurse-patient relationship is defined as a helping relationship that’s based on mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the gratification of your patient’s physical, emotional, and spiritual needs through your knowledge and skill.

91. Answer: A. Validation

92. Answer: D. 1,2,3,4

Documentation in nursing is also an integral part of providing quality and safe care to patients. Qualities of a good recording include Brevity, Completeness and chronology, Appropriateness and Accuracy.

93. Answer: C. Seems agitated

Being accurate is very important. For example, do not use vague terms such as “good urine output.” How many cc’s are “good?” Chart the specific amount and be accurate on things that you see and observe.

94. Answer: B. Demonstration

In teaching through demonstration, patients are set up to potentially conceptualize material more effectively.

95. Answer: A. It is growth facilitating

You can help your patient achieve harmony in mind, body, and spirit when engaging in a therapeutic relationship based on effective communication that incorporates caring behaviors. It’s a win-win situation in which you and your patient can experience growth by sharing “the moment” with each other.

96. Answer: A. Tell the patient that deep breathing and coughing exercises is needed to promote good breathing, circulation and prevent complication

Deep breathing and coughing will decrease your risk for a lung infection. Take a deep breath and hold it for as long as you can. Let the air out and then cough strongly. Deep breaths help open your airway. You may be given an incentive spirometer to help you take deep breaths. Put the plastic piece in your mouth and take a slow, deep breath. Then let the air out and cough. Repeat these steps 10 times every hour.

97. Answer: B. Notify the attending physician

98. Answer: C. Active listening on what the patient says

Assessment of the patient experiencing pain is the cornerstone to optimal pain management. However, the quality and utility of any assessment tool is only as good as the clinician’s ability to thoroughly focus on the patient. This means listening empathically, believing and legitimizing the patient’s pain, and understanding, to the best of his or her capability, what the patient may be experiencing. A health care professional’s empathic understanding of the patient’s pain experience and accompanying symptoms confirms that there is genuine interest in the patient as a person. This can influence a positive pain management outcome.

99. Answer: B. Knowing yourself

It is important for the nurse to know herself to identify kinds of behavior of ideas that make her anxious and to seed help for her problems. Otherwise, she is likely to add new problems to those with which the patient is already struggling.

100. Answer: D. Read it yourself then, Have the client read the material

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