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FUNDA Q & A

Concepts of Man and His Basic Human Needs


1.) The theory on man as a Bio psychosocial and Spiritual being by Sister Callista Roy conceptualizes the
following EXCEPT:
A.) Man, as a biologic being is like all other men
B.) Man, as a psychologic being is like no other man
C.) Man, as a social being is like some other men
D.) Man, is a spiritual being only when he professes that he believes in God
Ans: D>According to the theory on Man as Bio psychosocial and Spiritual Being, all men are spiritual by
nature. This is because of the will and intellect; virtues of faith, hope, and charity, and the belief of
existence of supreme power who guides mans faith and destiny
2.) Which of the following is NOT a characteristic of an open system?
A.) It is self-sufficient and is totally isolated from other systems
B.) It exchanges matter, energy or information with the environment
C.) It allows sustaining elements to enter the system to nourish it
D.) It is easily affected by changes in other systems
Ans: A>an open system needs to exchange matter, energy and information. It is interrelated and
interdependent with other systems
3.) Which aspect of mans nature is demonstrated by making a choice therapeutic regimen reluctantly?
A.) Limited and unlimited nature
B.) Mature nature with core of immaturity
C.) A creature of indecisiveness
D.) Rational and logical, yet irrational at times
Ans: C> Man is a creature of indecisiveness. He is always at the crossroad of choosing
4.) Body image is:
A.) The way a person appears and his style of grooming
B.) The way the person looks at a certain age
C.) The way a person pictures/perceives his appearance and function and how he compares himself
with others.
D.) A body with complete parts and functions
Ans: C>Body image is the way a person perceives his appearance and function
5.) The nursing diagnosis Body Image Disturbance is most likely to be written for which of the following
persons?
A.) A patient with above the knee amputation
B.) A patient with second degree burns
C.) A quadriplegic patient
D.) A person entering the health care system after moving from wellness to illness
Ans: D>A person entering a health care system most likely would experience alteration in body image
6.) The nurse should assess the activity tolerance of the patient with which of the following conditions?
A.) Diabetes mellitus
B.) Diarrhea
C.) Anemia
D.) Kidney stones
Ans: C>Activity intolerance is an appropriate nursing diagnosis for a client with anemia. IN anemia, there
is low oxygen-carrying capacity of the blood, so the client experiences weakness and fatigue
7.) According to Maslows hierarchy of needs, which of the following is a basic physiologic need after
oxygen?
A.) Water
B.) Freedom from infection
C.) Love and belongingness
D.) Self-esteem
Ans: A>Water is next to oxygen in the hierarchy of physiologic needs for survival
8.) Mrs. Sy, diagnosed with cancer of the breast, is scheduled to undergo chemotherapy. How should
the nurse deals with the topic of hair loss with client?
A.) A.)Discuss about hair loss as it occurs
B.) B.)Provide reading material about chemotherapy
C.) C.)Acknowledge that hair loss may be a difficult side effect and explore the patients feeling
about this
D.) Give the patient information about headscarf, hats or wigs
Ans: C>Focusing on the feelings of the client regarding hair loss is therapeutic. Discussing about wigs,
headscarf, and hats will be dealt with later
9.) The following are characteristics of basic human needs EXCEPT:
A.) Priorities are uniform to all individuals
B.) Needs may be met in different ways
C.) Needs are interrelated
D.) Needs may be deferred
Ans: A>Priorities vary from individual to individual, according to stage of growth and development, life
situations and other factors
10.) Which of the following needs is considered by the nurse when she implements reverse isolation for
the client with leukemia?
A.) Physiologic need
B.) Safety and security
C.) Love and belongingness
D.) Self esteem
Ans: B>The client with leukemia has low resistance to infections. Protecting him from infection by
implementing reverse or protective isolation technique meets his need for safety and security
11.) Who among the following clients should be attended first by the nurse?
A) The client with cough and colds
A.) B.) The client with pain on the chest
B.) The client with fever due to infection
C.) The client who is for discharge
Ans: B>the client with pain on the chest should be attended first by the nurse because he needs to be
assessed and managed immediately before severe problem occurs. The clients with signs and symptoms
of infections may be dealt with after those without infections to prevent contamination. The client for
discharge would require longer nursing time for health teachings, and may be dealt with later Concepts
of Health and Illness
12.) The following are concepts of health:
1. Health is a state of complete physical, mental, and social wellbeing and not merely the absence
of disease or infirmity
2. Health is the ability to maintain balance
3. Health is the ability to maintain the internal environment
4. Health is the 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
Ans D1-WHO concept of health2-Walter Cannons concept of health onhomeostasis3-Claude Bernards
concept of health on internalmilieu4- Neumanns concept of health on integration of parts and subparts
of an individual
13.) The theorist who advocates that health is the ability to maintain dynamic equilibrium is:
A.) Claude Bernard
B.) Walter Cannon
C.) Hans Selye
D.) Martha Rogers
ANS: B> Walter Cannon advocates that health is the ability to maintain dynamic
equilibrium(homeostasis)
14.) The Health-Illness Continuum Theory describes which of the following:
1.) The effect of environment to well-being and illness
2.) High level wellness is achieved if a person is able to function independently
3.) Precursor of illness may be hereditary, environmental and behavioral factors
4.) The relationship between agent, host and environment
A.) 1,2,3,4
B.) 1,3,4
C.) 1,2,3
D.) 2,3,4
ANS: C> 1,2,3 Dunns Health-illness Continuum Theory describes the following:1.) The effect of
environment to well-being and illness 2.) High level wellness is achieved if a person is able to function
independently 3.) Precursor of illness may be hereditary, environmental and behavioral factors
15.) Which of the following statements is not true is high-level wellness?
A.) It is applicable only to healthy individuals
B.) It is the ability to perform activities of daily living
C.) It connotes maximizing ones potentialities
D.) It is the ability to perform self-care
ANS: A> The statement which is NOT TRUE in high level wellness is that, it is applicable only to healthy
individuals. High level wellness is applicable to both the well and the ill, as long as one maximizes his
potentialities and functions independently
16.) Mrs. De Guzman had been diagnosed to have hypertension since 15 years ago. Since then, she had
maintained low sodium diet, to control her blood pressure. This practice is viewed as:
A.) Her superstitious belief
B.) Her cultural belief
C.) Her personal
D.) Her health belief
ANS: D> Health belief of an individual influences his/her preventive health behavior. Health beliefs
maybe influenced by individual perceptions, modifying factors, perceived benefits of preventive actions
and perceived barriers to preventive actions
17.) The Role Performance Model of health views that:
A.) Health is the absence of signs and symptoms of disease
B.) Health is successful adaptation
C.) Health is the ability to perform ones work or job
D.) Health is realization of ones potential
ANS: C> The Role Performance Model of health by Smith views that health is the ability to perform
ones societal roles such as ones work or job
18.) Mr. Salvador practices excessive alcohol intake. This is considered as which type of precursor to
illness?
A.) Behavioral factor
B.) Environmental factor
C.) Hereditary factor
D.) Genetic factor
ANS: A> Taking alcohol excessively is a behavioral precursor of illness. Other behavioral factors that may
lead to illness are as follows: cigarette smoking, poor diet, sedentary lifestyle, poor hygiene, inadequate
rest and sleep, excessive worry and tension, etc.
19.) A person who may or may not be affected by disease is:
A.) Agent
B.) Carrier
C.) Victim
D.) Host
ANS: D> A host is an individual who may or may not be affected by disease
20.) Health promotion activities are directed to achieve the following:
1. Increasing level of wellness
2. Improving quality of life
3. Relying on health care personnel to maintain health
4. Promoting healthful lifestyle
A.) 1,2,4
B.) 2,3,4
C.) 1,2,3
D.) 1,2,3,4
ANS: A> 1,2,4 Health promotion activities are directed to achieve the following:1.) Increasing level of
wellness 2.) Improving quality of life 3.) Promoting healthful lifestyle Furthermore, health promotion
involves the principles of self-responsibility for ones health
21.) Which of the following behaviors is not expected when a client assumes the sick role?
A.) The client seeks for sick leave
B.) The client consults a physician because of headache and perceived fever
C.) The client takes medications as prescribed by the physician
D.) The client ignores his dizziness, with the hope that it will be relieved spontaneously
ANS: D> Ignoring signs and symptoms of a disease is not a sick role behavior. Sick role emphasizes that
the person: is not held responsible for his condition ; is excused from social roles; is obliged to get well
as soon as possible; is obliged to seek for competent help, i.e. seeking advice of health professionals for
validation of real illness, explanation of symptoms and reassurance or prediction of outcome Health and
Illness- Asepsis and Infection Control
22.) Which of the following situations may cause droplet transmission of microorganisms?
A.) Facing a clients who is coughing and sneezing within a distance of 3 feet
B.) Eating contaminated shell fish
C.) Puncture from intravenous needle removed from a client with hepatitis B
D.) Exposure to flood water
Ans: A> Facing client who is coughing and sneezing most likely would cause droplet transmission of
microorganisms
23.) Which of the following is most effective practice by caregivers and family, when caring for a client
with low resistance to infection due to cancer.
A.) Allow two visitors only, at a time
B.) Wash hands frequently
C.) Wear masks in the clients room at all times
D.) Meticulous cleaning of the clients room
ANS: B> Hand washing is the most effective practice to prevent transfer of microorganisms24.) The
primary why the faucet is considered as contaminated is:
A.) It is located in unsterile area
B.) B.) Many people are using it
C.) C.) It is frequently used
D.) D.) It is opened by dirty hands
ANS: D> The faucet is considered contaminated primarily because it is opened by dirty hands
25.) The nurse enters the room of the client on airborne precautions due to tuberculosis. Which of the
following are appropriate actions by the nurse?
1. She wears the mask, covering the nose and mouth
2. She washes her hands before and after removing gloves, after suctioning the clients secretions
3. She removes gloves and mask before leaving the clients room
4. She discards contaminated suction catheter tip in a trash can found in the clients room
A.) 1 and 2
B.) 1 and 3
C.) 1,2 and 3
D.) 1,2,3, and 4
ANS: D> 1,2,3, and 4 the mask should cover the nose and mouth snugly. The hands should be washed
before and after removing gloves. Gloves and mask should be removed before leaving the clients room,
to contain the microorganism within the clients unit. Contaminated articles like suction catheter should
be discarded in a trashcan found in the clients room to prevent contamination of the outside
environment.
26.) A 14-yar old male is to be admitted to the unit due to high fever related to influenza. With whom
among the following clients should be placed together in the room?
A.) The 12-year old male client who had undergone appendectomy
B.) The 12-year old female with flu
C.) The 12-year old boy with flu
D.) The 12- year old boy with leukemia
ANS: C> Clients infected with the same type of microorganism may cohabitate. The gender and the age
of the clients should also be considered. Clients of the same gender and approximately of the same age
group will stay together well
27.) After caring for a client with extensive body burns, the nurse performs which of the following
actions when removing protective wear?
A.) Remove, mask, gown, gloves, cap and shoe cover
B.) Remove gloves, mask, gown, cap and shoe cover
C.) Remove gown, mask, gloves, cap and shoe cover
D.) Remove cap and shoe cover, mask, gloves, gown
ANS: B> To remove protective wear, peel off gloves first, then the mask, gown cap and shoe cover. This
is to prevent contamination of skin by the contaminated gloves
28.) When discarding used needle and syringes, which of the following is appropriate nursing action?
A.) Remove needle from the syringe and discard them in separate containers
B.) Recap needle, then discard the needle still attached to the syringe into a container
C.) Discard the uncapped needle and syringe into a container
D.) Break the needle, then discard syringe into a container
ANS: C Discard the uncapped needle and syringe into a leak-proof, puncture-proof container. This is to
prevent needle puncture of self. Universal precaution: NEVER RECAP NEEDLE
29.) When performing surgical hand scrub, which of the following nursing actions ensure prevention of
contamination?
1. Keep fingernails short, clean, without nail polish
2. Open faucet with knee or foot control
3. Keep hands above elbows when washing and rinsing
4. Wear cap, mask, and shoe cover after hand scrub
A.) 1,3,4
B.) 1,2,3
C.) 1,2,4
D.) 2,3,4
ANS: B> 1,2 and 3- Surgical hand scrub involves the following actions: Keep fingernails short, clean,
without nail polish, open faucets with knee or foot control; keep hands above elbows when washing and
rinsing. Cap, mask, shoe cover should be worn before hand scrub, to prevent contamination of the
scrubbed hand
30.) When removing gloves, which of the following is inappropriate nursing action?
A.) Wash gloved hands first
B.) Peel off gloves inside out
C.) Use glove-to-glove, skin-to-skin technique
D.) Remove mask and gown before removing gloves
ANS: D> When removing gloves, it is inappropriate to remove mask and gown first before gloves.
Appropriate nursing actions are: wash gloved hands first, peel off gloves inside out; use glove-to-glove,
skin-to-skin techniques. Remove gloves first, followed by the mask, gown, cap, and shoe cover
31.) When pouring sterile solution, the nurse performs which of the following actions correctly?
A.) Hold bottle 6 inches above receptacle on the sterile field
B.) Remove cap of bottle and place it with the underside lid down on a flat surface
C.) Return excess solution from sterile receptacle to the bottle
D.) Place the bottle of sterile solution within the sterile field
ANS: A> When pouring sterile solution, hold bottle 6inches above receptacle on the sterile field. Cap of
the bottle should be placed with underside lip up, on a flat surface. Excess solution should not be
returned to the bottle because this is considered contaminated. The bottle of the sterile solution should
be placed outside the sterile field because the outside part of the bottle is no sterile. Remember, sterile
field/object should come in contact with sterile objects only, to maintain sterility. STRESS,
ADAPTATION,HOMEOSTASIS
32.) Which of the following does not characterize stress?
A.) Stress is a nervous energy
B.) A single stress does not cause a disease
C.) Stress in inherent to life
D.) Stress may be protective but at times problematic
ANS: A> this is an incorrect statement because stress is not a nervous strategy; it is a psychophysiologic
response
33.) Adaptive responses of man to stressors are characterized by the following:
5. They are attempts to maintain equilibrium
6. They are fairly uniform in all individuals
7. They are limitless
8. They are always adequate to overcome stressors
A.) 1 and 2
B.) 1 and 3
C.) 1 and 4
D.) 2 and 4
ANS: B> 1 and 3 adaptive responses are attempts to maintain equilibrium and they are not limitless
34.) The first manifestation of inflammation is:
A.) Heat
B.) Redness
C.) Swelling
D.) Pain
ANS: B> The first manifestation of inflammation is redness. This is due to increased blood flow to the
area affected
35.) The primary cause of pain at the site of inflammation is:
A.) Release of bradykinin
B.) Injury to nerve endings
C.) Compression of local nerve endings by edema fluids
D.) Impaired circulations
ANS: C> The primary cause of pain at the site of inflammation is the compression of local nerve endings
by edema fluids
36.) The client is in stress because he was told by the physician that he needs to undergo surgery for
removal of tumor in his stomach. Which of the following are effects of activation of the sympatho-
adreno-medullary response in the client?
1. Constipation
2. Urinary frequency
3. Hypoglycemia
4. Increased BP
A.) 1 and 2
B.) 1 and 3
C.) 2 and 3
D.) 1 and 4
ANS: D>1 and 4- Effects of SAMR are due to release of norepinephrine and epinephrine. These include
constipation and increase BP
37.) The client is on NPO since midnight, as preparation for blood test. Adreno-cortical response is
activated. Which of the following is an expected response?
A.) Low BP
B.) Decrease urine output
C.) Warm, flushed, dry skin
D.) Low serum Na levels
ANS: B> Adreno-cortical response involves release of aldosterone that leads to retention of sodium and
water. This results to decreased urine output
38.) The client fell from the stairs, and had twisted her ankle. The injury caused inflammation of the
ankle. The nursing interventions for the inflamed ankle would least likely include which of the following?
E.) Elevate the ankle with pillow support
F.) Apply warm compress over the ankle for the first seventy-two hours
G.) Apply compression bandage over the ankle
H.) Administer anti-inflammatory drug as ordered by the M.D.
ANS: B> Application of warm compress over an inflamed body part for the first 72hours of injury is not
included in the nursing interventions for inflammation. Cold compress is preferably applied during the
first 72hours to cause vasoconstriction and prevent/reduce swelling.
39.) Which of the following events characterize the GAS stage of Alarm?
A.) Fight-or-flight response is activated
B.) The person regains homeostasis
C.) Adaptive mechanisms fail
D.) Levels of resistance are increased
ANS: A> During the GAS stage of Alarm, fight-or-flight response is activated
40.) The client is a 57 year old male who works as a traffic officer. He is exposed to sunlight from
morning until afternoon. Which of the following is considered as a physiologic adaptive mode of the
client?
A.) He learns to interpret different traffic signs
B.) He sees to it that he wears his uniform as dignified as a policeman does
C.) He develops dark skin
D.) He learns the skill of giving traffic directions to drivers and pedestrian
ANS: C> Development of dark skin due to prolonged exposure to sunlight, is an example of physiologic
adaptive mode
41.) The first protective cells launched at the site of tissue injury are the:
A.) Basophils
B.) Eosinophils
C.) Monocytes
D.) Neutrophils
ANS: D> Neutrophils are the first protective cells launched at the site of injury to perform phagocytosis
Therapeutic Communication
42.) Therapeutic nurse-patient relationship is described as follows:1. It is based on friendship and
mutual interest2. It is a professional relationship3. It is focused on helping the patient solve problems
and achieve health-related goals4. It is 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
ANS: C> 2,3,4- Nurse-patient relationship is professional relationship, it is a helping relationship; it is
maintained only as long as the patient requires professional help. It is not based on friendship and
mutual interest.
43.) During the working phase of therapeutic relationship, the nurse performs the following activities
EXCEPT:
A.) Reviews the clients medical record
B.) Establishes a contract with the client regarding expectations and responsibilities
C.) Decides with the client on mutually agreed upon goals
D.) Discusses with the client on time frame of the relationship
ANS: A> Reviewing the clients medical record is inactivity done during the pre-interaction phase of the
therapeutic nurse-patient relationship. All the other choices are performed during the working phase
44.) The client has been scheduled to undergo surgery for removal of tumor in her right breast. Which of
the following manifestations indicate that she is experiencing mild anxiety?
A.) She has increased awareness of the environment details
B.) She focuses on selected aspect of her illness
C.) She experiences incongruence of thoughts, feelings and actions
D.) She experiences random motor activity
ANS: A> Increased awareness of the environment details is a manifestation of mild anxiety
45.) Which of the following nursing interventions would least likely be effective when dealing with a
client with aggressive behavior?
A.) Approach in calm, direct manner
B.) Provide opportunities to express feelings
C.) Maintain eye contact with the client
D.) Isolate the client from other clients
ANS: D> Isolating the client who manifests aggressive behavior would be ineffective intervention. This
may further agitate him. Providing outlets, like physical activities will be more effective, to divert the
clients energy
46.) The client express fear that God will not be supportive and might be punitive. He is experiencing
which of the following responses?
A.) Spiritual pain
B.) Spiritual anger
C.) Spiritual anxiety
D.) Spiritual loss
ANS: C>Spiritual anxiety is expression of fear that God will not be supportive and might be punitive
47.) The client verbalizes, Im nothing. Which of the following is the most appropriate response by the
nurse?
A.) Are you suggesting that you feel worthless?
B.) Of course, youre everything.
C.) Thats not true.
D.) You should not feel that way.
ANS: A Attempts to translate into feelings is a therapeutic technique of communication. Using denial (B),
disagreeing (C), and advising (D), arenon-therapeutic techniques of communication.
48.) The client verbalizes that he is very anxious that the diagnostic tests he had undergone might reveal
he has cancer. Which of the following is most appropriate nursing intervention?
A.) Tell the client not to worry unnecessarily, until the results are in.
B.) Ask the client to express feelings and concerns with regards to outcome of the tests
C.) Reassure the client that everything will Beal right
D.) Advise the client to divert his attention by watching television or reading newspaper
ANS: B> Exploring the clients feelings and encouraging evaluation encourage verbalization by the client
and therefore promote therapeutic nurse-client relationship. Reassuring (A and C), advising (D),are non-
therapeutic techniques of communication
49.) Which of the following statements clearly defines therapeutic communication?
A.) Therapeutic communication is an interactional process which is primarily directed by the nurse
B.) Therapeutic communication is conveys feelings of warmth, acceptance and empathy from the
nurse to a patient in a 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 the assessment component of the nursing process
ANS; C> Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying
patient needs and developing mutual goals.
50.) Which of the following concepts is most important in establishing therapeutic nurse-patient
relationship?
A.) The nurse must fully understand the patients feelings, perceptions and reactions before goals
can be established
B.) The nurse must be a role model for health-fostering behaviors
C.) The nurse must recognize that the patient may manifest maladaptive behavior during illness
D.) The nurse needs to understand that the patient may test her before he can accept and trust her
ANS: D> In establishing therapeutic nurse-patient relationship, the nurse needs to understand that the
patient may test her before he can accept and trust her
51.) Which communication skill is most effective in dealing with covert communication?
A.) validation
B.) Listening
C.) Evaluation
D.) Clarification
ANS: A> Validation is required for covert communication. Only the patient can describe what he wants
to convey through covert communication.
52.) Which of the following are qualities of 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
ANS: D> 1,2,3 4- Good recording is characterized by brevity, completeness and chronology,
appropriateness and accuracy.
53.) All of the following chart entries are correct EXCEPT:
A.) Complained of chest pain
B.) Chest pain relieved after administration of NTG sublingually
C.) Able to ambulate to the bathroom without assistance
D.) Vital signs 120/84 82, 18
ANS: D> Recording of vital signs should beT,PR,RR,BP. So the recording of vital signs letter D is incorrect.
The rest are correct chart entries.
54.) The accepted method for signing a nurses note is:
A.) J.C./R.N.
B.) Juan Cruz, Clinical Instructor
C.) Juan Cruz
D.) Juan D. Cruz, R.N.
ANS: D> The accepted method of signing a nurses notes is writing ones full name n script and affixing
R.N. to signify ones status as a registered nurse
55.) Which of the following teachings methods is most appropriate for teaching a diabetic client oneself-
injection of insulin?
A.) Detailed explanations
B.) Demonstration
C.) Use of pamphlets
D.) Filmstrip
ANS: B> Demonstration is the best teaching strategy for psychomotor skills like self-injection of insulin.
56.) the most important characteristic of effective nurse-patient relationship is that:
A.) It is growth-facilitating
B.) It is based on mutual understanding
C.) It fosters hope and confidence
D.) It involves primarily emotional bond
ANS: A> The most important characteristic of effective nurse-patient relationship is that, it is growth-
facilitating for the nurse and the patient
57.) Which of the following statements is most likely to promote a clients compliance in performing
post-operative deep breathing, coughing and turning exercises?
A.) You will be given adequate medication is these exercises will cause you pain.
B.) Deep breathing, coughing and turning exercises will promote good breathing, body circulation.
This will prevent complications.
C.) These exercises will promote maximum respiratory ventilation, prevent thrombophlebitis and
atelectasis.
D.) Your cooperation during these exercises will determine the rate of your recovery.
ANS: B> Giving information is a therapeutic technique of communication, like giving explanation on the
benefits that a client will experience from deep breathing, coughing and turning exercises during the
postop period
58.) When using printed material to teach diabetic patient about foot care, the nurse should:
A.) Read the material to the patient
B.) Allow the patient to read the material
C.) Give the material to a family member to read the patient
D.) Read the material to evaluate its clarity, accuracy and effectiveness
ANS: D> Reading materials to be distributed to clients should be evaluated by the nurse, for clarity,
accuracy and effectiveness
59.) The patient asks the nurse, Do you think, I have the cancer? The most appropriate response of
the nurse is:
A.) I will refer you to your doctor.
B.) If I were you, I will not worry unnecessarily
C.) You sound concerned about what the doctor may find.
D.) You will undergo different tests before cancer can be diagnosed.
ANS: C> Focusing on clients feeling is therapeutic
60.) The patient is scheduled for proctosigmoidoscopy. She says she is nervous. The most appropriate
response to be made byte nurse is:
A.) You need not worry. You have the best doctor in the hospital.
B.) I dont blame you for feeling that way. If I were in your position, I would feel the same.
C.) Why do you feel that way? Dont you trust God?
D.) You sound really upset. Would you like to stand talk about it?
ANS: D> Focusing on clients feeling is therapeutic
61.) Which of the following behavior should the nurse recognize when caring for elderly patients?
A.) Most elderly resent being cared for by people not related to them
B.) Many elderly patients need support in maintaining their independence
C.) Elderly patients refuse to change old habits
D.) Most elderly are unable to learn new skills
ANS: B> Maintaining independence among elderly is essential to maintain their ego integrity
62.) The nurse can best evaluate that the patients learning by:
A.) His ability to repeat what was taught
B.) A desired change in his behavior
C.) Verbal acknowledgements that he understands
D.) His ability to get a good score from a questionnaire
ANS: B> The best evidence that learning has taken place is an observable desired change in the clients
behavior
63.) Therapeutic communication begins with:
A.) Giving initial care
B.) Showing empathy
C.) Interacting with patient
D.) Knowing your patient
ANS: D> Therapeutic communication begins with knowing the client
64.) Which of the following responses is appropriate when a patient requests to be discharged at once?
A.) I will notify the supervisor about your request.
B.) You can only be discharged after the doctor has given a medical clearance.
C.) I will notify your doctor, so I can inform him about your request.
D.) I understand your request but please sign this special form.
ANS: C> Discharge from the hospital requires physicians order. Reassuring the client that his desire to
go home will be conveyed to the M.D.is therapeutic
65.) From your admission interview of a patient, you obtained a history of allergies. You can best
communicate this information by:
A.) Placing allergy alert in kardex
B.) Writing in the patients chart
C.) Informing his attending physician
D.) Observation of the patients behavior
ANS: C> Informing the attending physician about the clients allergies is the best way to communicate
the information. Merely placing the information in the kardex, writing in the patients chart, will not
ensure that the physician will be properly informed about the patients allergy
66.) Which of the following techniques can be most helpful in assessing the degree of distress and
discomfort of a newly admitted patient?
A.) Review the nurses notes
B.) Performing physical assessment
C.) Active listening on what the patient says
D.) Observation of the patients behavior
ANS: C> Active listening on what the patient says will be most helpful in assessing the degree of distress
and discomfort her is expressing. Only the patient will be able to describe his distress and discomfort,
because these are subjective data.
67.) Which of the following factors will least likely facilitate learning of a patient?
A.) Motivation to learn
B.) Active participation in the learning activity
C.) Influencing the client to change his health beliefs
D.) Positively worded corrections
ANS: C> Influencing the client to change his health beliefs will least likely facilitate his learning. Learning
takes place more easily if the new leaning is closely related to previous learning like health beliefs.
68.) Which of the following principles must be given consideration by the nurse when giving patient
teaching to an elderly client/
A.) Use audio-visual aids to facilitate learning
B.) Provide opportunity for independence tolerant
C.) Provide lecture for at least 2 hours
D.) Proceed from complex to simple material
ANS: B> An elderly client learns best if he is given opportunity for independence to learn. Audio-visual
aids may be ineffective among elderly because of possible visual and hearing impairment. Elderly have
short attention span, so providing lecture for at least 2 hours is ineffective. Proceeding from simple to
complex material facilitates learning; not complex to simple material. Stages of Growth and
Development: Adulthood
69.) The development task of the young adult according to Erikson is:
A.) Identity vs. Role confusion
B.) Intimacy vs. Isolation
C.) Generativity vs. Stagnation
D.) Ego Integrity vs. Despair
Ans: B
70.) The following are characteristics of a middleaged adult EXCEPT:
A.) There is a sense of stability and consolidation
B.) The person becomes more oriented and career-oriented
C.) The person is more family oriented and career-oriented
D.) The person is more concerned with adhering to laws that protect the welfare and rights of
others.
Ans: C
71.) The aging process which is characterized by severe mental deterioration is:
A.) Senility
B.) Senescence
C.) Gerontology
D.) Geriatrics
Ans: A
72.) The rate of Living Theory of Aging conceptualizes that:
A.) Changes in replication of DNA RNA are the causes of aging
B.) Aging is caused by a change in the immune system
C.) The body is like a machine, parts wear out and the machine breaks down
D.) The faster one lives, the sooner one ages and dies
Ans: D
73.) The Disengagement Theory of aging believes that:
A.) Human beings are mortal and must eventually leave their place and role in society
B.) One must constantly struggle to remain functional
C.) Persons will remain the same unless external and internal factors stimulate change
D.) NOTA
Ans: A
74.) Which of the following is inappropriate nursing action for the elderly when providing hygienic
practices and skin care?
A.) Provide daily bath
B.) Use mild, super fatted soap
C.) Use body lotion
D.) Change position frequently
Ans: A
75.) The following are appropriate nursing actions for the elderly with hearing impairment EXCEPT:
A.) Speak clearly, in well-enunciated words
B.) Use normal tone of voice
C.) Repeat instructions as needed
D.) Increase loudness of voice when speaking
Ans: D
76.) Which of the following colors is difficult to be distinguished by an elderly?
A.) Red
B.) Green
C.) Purple
D.) Blue
Ans: C
77.) Which of the following enhances drug toxicity among elderly?
A.) Less acute vision
B.) Decreased renal function
C.) Altered memory
D.) Diminished sense of taste
Ans: B
78.) Which of the following should be include in the nursing care plan of an elderly?
A.) Provide health teachings in several brief sessions
B.) Provide recreational activities like needle works
C.) Make decisions for the client
D.) Use audio-visual aids when providing health teachings
Ans: A
79.) Which of the following may be a primary reason why an elderly finds it difficult to comply with low
sodium diet?
A.) The patient had been used to taking salty foods in his younger years
B.) The patient experiences diminished sense of taste
C.) The patient has decreased absorption in the GI tract
D.) The patient experiences decreased peristalsis
Ans: B
80.) The following are true in the human sexuality of the elderly EXCEPT:
A.) There is minimal change in amount of sexual response
B.) There is cessation of sexual activity among elderly
C.) There is increased refractory periods in male
D.) There is reduced vaginal lubrication
Ans: B
81.) The following are characteristics of an elderly who has achieved ego integrity EXCEPT:
A.) Views life with sense of wholeness and satisfaction from past accomplishments
B.) Accepts death as completion of life
C.) Experiences serenity and shares wisdom
D.) He wishes to live life longer to correct past mistakes
Ans: D
82.) According to Kohlbergs theory on moral development, relationships are based on:
A.) Mutual trust
B.) Mutual satisfaction of needs
C.) Mutual approval of each other
D.) Mutual beliefs
Ans: A
83.) According to Havighursts theory on developmental tasks, the following are tasks of a65-year old
person EXCEPT:
A.) Adjusting to retirement and reduced income
B.) Adjusting to decreasing Physical strength and health
C.) Establishing an explicit affiliation with ones age group
D.) Adjusting to aging parents
Ans: D
84.) Which of the following will help maintain the self-esteem of an elderly client?
A.) Provide as much independence as possible, with consideration to safety
B.) Assist the client to accept the need for seeking help in making decisions and judgments
C.) Do hygiene measures for the elderly to promote sense of well-being
D.) Plan for routine activities of daily living to be followed by the client
Ans: A
85.) The following are appropriate nursing actions to prevent postural hypotension in an elderly patient
EXCEPT:
A.) Advise to get out of bed gradually
B.) Instruct to have a daily fluid intake of 3glasses a day
C.) Advise to avoid straining at stool
D.) Advise to avoid bending down and suddenly standing up again
Ans: B
86.) Which of the following is not appropriate nursing intervention for an elderly with osteoporosis?
A.) Include milk and dairy products in diet
B.) Take large amounts of protein-rich and salty foods
C.) Have regular exercise
D.) Wear rubber-soled, low heeled shoes that grip well
Ans: B
87.) The following are nursing interventions to minimize confusion among elderly?
A.) Use touch to convey concern
B.) Have clocks or calendars in the environment
C.) Keep a routine of activities of daily living
D.) All of theses
Ans: D
88.) The following nursing interventions are appropriate in the prevention of pressure sores among
bedridden elderly patient EXCEPT:
A.) Massage bony prominences
B.) Apply alcohol on the skin
C.) Apply cornstarch over the bed linens
D.) Elevate head of bed at 45 to 90 degree angle
Ans: B
89.) Florence Nightingale conceptualizes that nursing is:
A.) The act of utilizing the environment of the patient to assist him in his recovery
B.) Assisting the individual, sick or well, in the performance of those activities contributing to
health, preventing illness and rehabilitating the sick or disabled
C.) A humanistic science dedicated to compassionate concern with maintaining and promoting
health, preventing illness and rehabilitating the sick or disabled
D.) A unique profession in that it is concerned with all the variables affecting an individuals
response to stressors.
Ans:A
90.) Which of the following nursing theorists conceptualizes that all persons strive to achieve self-care?
A.) Sister Callista Roy
B.) Dorothea Orem
C.) Dorothy Johnson
D.) Jean Watson
Ans: B
91.) Which of the following nursing theorists introduced Transcultural Nursing Model?
A.) Imogene King
B.) Dorothea Orem
C.) Dorothy Johnson
D.) Madeleine Leininger
Ans: D
92.) The most important communication skill to be developed by the nurse manager except.
A.) Performing bedside nursing
B.) Assertiveness
C.) Questioning
D.) Attentive Listening
Ans: D
93.) Which of the following moral theories is based on respect for other humans and belief that
relationships are based on mutual trust?
A.) Eriksons Theory
B.) Kolbergs Theory
C.) Freuds Theory
D.) Schulman and Meklers Theory
Ans: B
94.) The caregiver role of the nurse emphasizes:
A.) Implementing nursing care measures
B.) Providing direct nursing care
C.) Recognition of needs of clients
D.) Observation of the clients responses to illness
Ans: C
95.) The nurse takes the patients advocate role when she;
A.) Defends the rights of the patient
B.) Intercedes on behalf of the patient
C.) Refers the patient to other services
D.) Works with the significant others
Ans: A
96.) The manager role of the nurse is best demonstrated when she:
A.) Plans nursing care with the patient
B.) B.) Intercedes on behalf of the patient
C.) C.) Refers the patient to other services
D.) D.) Works with the significant of others
E.) Ans: B
97.) All of the following are primary responsibilities of the nurse manager EXCEPT
A.) Performing bedside nursing
B.) B.) Coordinating and delegating patient care
C.) C.) Setting standards of performance
D.) D.) Designating staff schedules
Ans: A
98.) The four concepts common to nursing that appear in each of the current conceptual models
A.) Person, Nursing, Environment, Medicine
B.) Person, Health, Nursing, Support System
C.) Person, Environment, Health, Nursing
D.) Person, Environment, Psychology, Nursing
Ans:C
99.) Which of the following is not a subjective data?
A.) Dizziness
B.) Chest pain
C.) Anxiety
D.) Bluish discoloration
Ans: D
100.) the following are specific activities during evaluation EXCEPT:
A.) Collecting data
B.) Performing nursing interventions
C.) Measuring goal attainment
D.) Revising or modifying the care plan
Ans: B
















Funda Part 2--Nursing Process
1.) Which of the following is incorrect statementof nursing diagnosis?
A.) High risk for ineffective airway clearancerelated to pneumonia
B.) High risk for injury related to dizziness
C.) Constipation related to decreased activityand fluids as manifested by small, hard, formedstool every
three days
D.) Anxiety related to insufficient knowledgeregarding surgical experienceANS: A> is incorrect statement
of nursing diagnosis(refer to NANDA, appendix A). B,C and D arecorrect statement of nursing diagnosis.
2.) Which of the following would NOT be a basisfor establishing priorities in client care?
A.) Actual problems take precedence over potential concerns
B.) Attend to equipment and contraptions first,such as IV fluids, urinary catheter, drainagetubes, before
the client
C.) Airway should always be given highestpriority
D.) Clients with unstable condition should begiven priority over those with stable conditions.ANS: B>
Attend to client first before equipment. A, Cand D are basis for establishing priorities inclient care
3.) Which of the following is an incorrectstatement of outcome procedure?
A.) Ambulates 30 feet with cane beforedischarge
B.) Discusses fears and concerns regarding thesurgical procedure during preoperative teaching
C.) Demonstrates proper coughing techniqueafter the teaching session
D.) Reestablishes normal pattern of bowelelimination
ANS: D> Outcome criteria should be specific,measurable, attainable, realistic and time-bound.A, B and C
are correct statements of outcomecriteria--Assessing Health
4.) The primary factor responsible for body heatproduction is:
A.) Metabolism
B.) Release of thyroxine
C.) Thyroxine output
D.) Muscle activity
ANS: A> The primary factor responsible for bodyproduction is metabolism
5.) The heat-regulating center is found in the:A.) Medulla oblongataB.) ThalamusC.) HypothalamusD.)
PonsANS: C> The heat-regulating center is found in thehypothalamus
6.) A process of heat loss which involves thetransfer of heat from one surface to another is:A.)
RadiationB.) ConductionC.) ConvectionD.) EvaporationANS: B> Conduction is the process of heat loss
whichinvolves the transfer of heat from one surface toanother
7.) The following statements are true about bodytemperature EXCEPT:A.) Core body temperature
measures thetemperature of deep tissuesB.) Highest body temperature is usually reachedbetween 8:00
P.M. to 12:00 M.N.C.) Elderly people are at risk of hypothermia dueto decreased thermoregulatory
controls anddecreased subcutaneous fatsD.) Sympathetic response stimulation decreasesbody heat
productionANS: D> Is incorrect statement about body temperature.Sympathetic nervous system
releasesnorepinephrine which increases metabolic rate,thereby increases body heat production.
8.) The client with fever had been observed toexperience elevated temperature for few days,followed
by 1 to 2 days of normal range of temperature. The type of fever he isexperiencing is:A.) Intermittent
fever B.) Relapsing fever C.) Remittent fever D.) Constant fever ANS: B> Relapsing fever is on-and-off
fever
9.) Which of the following is NOT an appropriatenursing action when taking oral temperature?A.) Wash
the thermometer from the bulb to thestem before useB.) Place the thermometer under the
tonguedirected towards the sideC.) Take oral temperature for 2-3 minutesD.) Take oral temperature
using a thermometer with pear-shaped bulbANS: D> Is not appropriate nursing action when takingoral
temperature. Thermometer with pear-shaped or rounded bulb is used for rectaltemperature-taking
10.) The following are contraindications to oraltemperature taking EXCEPT:A.) DyspneaB.) DiarrheaC.)
Nasal-packingD.) Nausea and vomitingANS: B> Diarrhea is not a contraindication for oraltemperature-
taking
11.) Which of the following nursing actions isinappropriate when taking the rectaltemperature?
A.) Assist client to assume lateral position
B.) Lubricate thermometer with water-solublelubricant before use
C.) Hold the thermometer in place for 2 minutes
D.) Instruct to strain during insertion of thethermometer
ANS: D
> Instructing client to strain during insertion of rectal thermometer is inappropriate. This maycause
trauma to the anus.
12.) The following are correct nursing actionswhen taking the radial pulse EXCEPT:A.) Put the palms
downwardB.) Use the thumb to palpate the arteryC.) Use two to three fingertips to palpate thepulse at
the inner wristD.) Assess the pulse rate, rhythm, volume andbilateral equalityANS: B> Using the thumb
when palpating pulse isincorrect nursing action. The thumb has strongpulsation and the nurse might be
counting her own pulse, instead of the clients pulse
13.) The difference between the systolicpressure and the diastolic pressure is:A.) Apical rateB.) Cardiac
rateC.) Pulse deficitD.) Pulse pressureANS: D> Pulse pressure is the difference betweensystolic pressure
and diastolic pressure.
14.) When measuring the blood pressure, thefollowing are nursing considerations EXCEPT:A.) Ensure
that the client is restedB.) Use appropriate size of BP cuff C.) Initiate and deflate BP cuff 2-3 mm
Hg/secD.) Read upper meniscus of mercuryANS: D> Reading the upper meniscus of mercury willyield
inaccurate BP reading. BP reading is doneby noting the level of the lower meniscus of themercury.
15.) The process involved in the exchange of gases in the lungs is:A.) DiffusionB.) OsmosisC.) Hydrostatic
pressureD.) Oncotic pressureANS: A> Diffusion is exchange of gases from an area of higher pressure to
an area of lower pressure.
16.) The primary respiratory center is:A.) Medulla oblongataB.) PonsC.) Carotid and aortic bodiesD.)
ProprioceptorsANS: A> The primary respiratory center is the medullaoblongata. It contains the
centralchemoreceptors that are stimulated by highlevels of carbon dioxide in the blood
17.) Which of the following primarily affects BP?A.) AgeB.) StressC.) Gender D.) ObesityANS: B> Stress is
the primary factor that affects BP,because of release of norepinephrine by thesympathetic nervous
system.
18.) The following are social data about a clientEXCEPT:A.) Patients lifestyleB.) Religious practicesC.)
Family home situationD.) Usual health statusANS: A> Patients lifestyle is not a social data
19.) The systematic manner of collecting dataabout the client by listening to body sounds withthe use of
stethoscope is:A.) InspectionB.) PalpationC.) PercussionD.) AuscultationANS: D> Auscultation is listening
to body sounds withthe use of stethoscope
20.) The following are appropriate nursingactions when performing physical healthexamination to a
client EXCEPT:A.) Ensure privacy of the client throughout theprocedureB.) Prepare the needed articles
and equipmentbefore the procedureC.) Assess the abdomen following thissequence: right lower
quadrantsD.) When assessing the chest, it is best to placethe client in side lyingANS: D> This is incorrect
nursing action. The bestposition when assessing the chest is sitting or upright position. This allows
assessment of theanterior and posterior chest
21.) Which of the following is inappropriatenursing action when collecting clean-catchmidstream urine
specimen for routine urinalysis?A.) Collect early morning, first voided specimenB.) Do perineal care
before collection of specimenC.) Collect 5-10 mls of urineD.) Discard the first flow of urineANS: C> This is
inappropriate nursing action. For routine urinalysis, 3-50 mls of urine specimen isrequired to yield
accurate results
22.) Which of the following nursing actions isincorrect when performing Benedicts test?A.) Collect 24-
hour urine specimenB.) Ensure that Benedicts solution remainsunchanged after heating itC.) Add 8-10
drops of urineD.) Interpret that the urine is negative for glucose when the color remains blueANS: A>
This is incorrect nursing action. Whenperforming Benedicts test, collect second-voided urine specimen
23.) Heat and acetic acid test is done todetermineA.) Presence of albumin in the urineB.) Presence of
glucose in the urineC.) Presence of ketones in the urineD.) Presence of RBC in the urineANS: A> Heat and
acetic acid test is done to determinepresence of albumin in the urine.
24.) Which of the following is correct nursingaction when collecting urine specimen from aclient with
indwelling urethral catheter?
A.) Collect urine specimen from the urinarydrainage ba
B.) Detach the catheter from the connecting tube
C.) Use sterile needle and syringe to aspirateurine specimen from the drainage port
D.) Flush the catheter with sterile NSS beforecollection of urine specimen
ANS: C> When collecting urine specimen from a clientwith indwelling urethral catheter, collect
urinespecimen by using sterile needle and syringe toaspirate urine specimen from the drainage port.
25.) The following are independent nursinginterventions for a febrile client EXCEPT:A.) Administer
paracetamol 500 mg. tab every 4hours PRN for temperature 38.5 CB.) Increase fluid intakeC.) Promote
bed restD.) Keep the clients clothing clean and dryANS: A> Administration of antipyretic to a febrile
clientis dependent nursing intervention, (notindependent nursing intervention)------Basic Human Needs:
Oxygenation----
26.) The common opening between therespiratory and digestive system is:A.) PharynxB.) LarynxC.)
TracheaD.) BronchusANS: A> The common opening between the respiratoryand digestive system is the
pharynx
27.) The right lung has:A.) 2 lobesB.) 3 lobesC.) 4 lobesD.) 5 lobesANS: B> The right lung has 3 lobes
28.) The amount of air that remains in the lungsafter forceful exhalation is:A.) Functional residual
capacityB.) Residual volumeC.) Tidal volumeD.) Minute volumeANS: B> The amount of air that remains
in the lungsafter forceful exhalation is residual volume
29.) Cheyne-Stokes breathing is:A.) Slow, shallow respirations which result toinadequate alveolar
ventilationB.) Difficulty of breathing in reclining positionC.) Marked rhythmic waxing and waning of
respirations from very deep to very shallowbreathing and temporary apneaD.) Shallow breaths
interrupted by apneaANS: C> Cheyne-stokes breathing is marked waxingand waning of respirations from
very deep tovery shallow breathing and temporary apnea
30.) The best position to promote maximum lungexpansion is:A.) SupineB.) RetractionsC.) Noisy
breathingD.) Semi fowlersANS: D> The best position to promote maximum lungexpansion is Semi-
Fowlers
31.) The characteristic manifestation of airwayobstruction is:A.) BradypneaB.) RetractionsC.) Noisy
breathingD.) TachypneaANS: C> The characteristic manifestation of airwayobstruction is noisy breathing.
32.) The following are appropriate nursinginterventions to promote normal respiratoryfunction
EXCEPT:A.) Adequate fluid intakeB.) Minimize cigarette smokingC.) Deep breathing and coughing
exercisesD.) Frequent change of position amongbedridden clientsANS: B> This is inappropriate nursing
intervention topromote respiratory function. Appropriate isavoid or quit cigarette smoking, not just
tominimize it
33.) The initial manifestations of hypoxemia areA.) Restlessness, tachycardiaB.) Dizziness, faintnessC.)
Headache, blurring of visionD.) Dyspnea, retractionsANS: A> The initial manifestations of hypoxemia
arerestlessness and tachycardia
34.) The following are appropriate nursingactions when performing percussion, vibrationand postural
drainage, EXCEPT:A.) Verify doctors order B.) Perform the procedure before meals and atbedtimeC.)
provide good oral hygiene after theprocedureD.) Each position during postural drainageshould be
assumed for 30 minutesANS: D> This is inappropriate nursing action duringchest physiotherapy.
Appropriate is to assumeeach position during postural drainage for 10 to15 minutes
35.) Which of the following nursing actions isinappropriate when providing steam inhalationtherapy?A.)
Check doctors order B.) Cover the eyes with moist washclothC.) Place the spout 3-4 inches away from
thepatients noseD.) Place the patient in semi-fowlers positionANS: C> This inappropriate nursing action
whenproviding steam inhalation therapy. Appropriateis to place the spout at least 12 inches from
thepatients nose.
36.) To be effective, steam inhalation should berendered for at least:A.) 5-10 minutesB.) 15-20
minutesC.) 30-45 minutesD.) 60-70 minutesANS: B> To be effective, steam inhalation should berendered
for at least 15-20 minutes



37.) The correct pressure of the wall suction unitwhen suctioning an adult patient is:A.) 95-110 mm
HgB.) 100-120 mm HgC.) 50-95 mm HgD.) 10-15 mm HgANS: B> The correct pressure of the wall suction
unitwhen suctioning an adult patient is 100-120 mmHg
38.) Which of the following is inappropriatenursing action when performing
oropharyngealsuctioning?A.) Place the client in semi-fowlers or lateralpositionB.) Measure length of
catheter from the tip of thenose to the earlobe.C.) Lubricate suction catheter with alcoholD.) Apply
suction during withdrawal of thesuction catheter tip:ANS: C> When performing oropharyngeal
suctioning, itis inappropriate to lubricate catheter withalcohol. Alcohol may irritate mucous
membraneof airways. Appropriate is, use sterile water or sterile NSS.
39.) The maximum time for applying suction is:A.) 5-10 secondsB.) 10-15 secondsC.) 15-20 secondsD.)
20-30 secondsANS: B> The maximum time for applying suction is 10to 15 seconds. This is to prevent
hypoxia
40.) To evaluate effectiveness of suctioning, thenurse should primarily:A.) Auscultate the chest for clear
breath soundsB.) Assess the respiratory rateC.) Check the skin color D.) palpate the pulse rateANS: A> To
evaluate effectiveness of suctioning, thenurse should primarily auscultate the chest for clear breath
sounds
41.) The oxygen administration device preferredfor patients with COPD is:A.) Nasal cannulaB.) Oxygen
tentC.) Venturi maskD.) Oxygen hoodANS: C> Venturi mask is the preferred device for oxygen therapy
among clients with COPD.
42.) Which of the following is not to be includedin the nursing interventions for a client receivingoxygen
therapy?A.) Place a Non-smoking sign at the bedsideB.) Place the client in semi-fowlers positionC.)
Place sterile water into the oxygen humidifier D.) Lubricate nares with oil to prevent dryness of the
mucous membraneANS: D> It is inappropriate to lubricate nares with oilwhen the client is receiving
oxygen therapy. Oilignites when exposed to compressed oxygen
43.) When assessing respiration, the nursedescribes the following EXCEPT:A.) RhythmB). EffortC.)
RateD.) DepthANS: C> When assessing respirations, the nurse shouldcount the rate, not simply describe
it.
44.) The small hair-like projections that line thetracheobronchial tree, which sweep out debrisand
excessive mucous from the lungs arecalled:A.) CiliaB.) VibrissaeC.) MacrophagesD.) Goblet cellsANS: A>
Cilia are small hair-like projections that line thetracheobronchial tree
45.) The following are appropriate nursingdiagnoses for clients with oxygenation problems:A.)
Ineffective airway clearance related totracheobronchial secretionsB.) Ineffective breathing pattern
related todecreased energy and fatigueC.) Impaired gas exchange related to alteredoxygen-carrying
capacity of the bloodD.) All of theseANS: D> All of these (A,B, and C) are appropriatenursing diagnoses
for clients with oxygenationproblems.---Basic Human Needs: Nutrition----
46.) The regulating center for fluid and foodintake are located in their A.) ThalamusB.) HypothalamusC.)
Medulla oblongataD.) PonsANS: B> The regulating centers for food and fluid intakeare found in the
hypothalamus
47.) The enzyme that initiates digestion of starchin the mouth is:A.) AmylaseB.) SucraseC.) MaltaseD.)
LactaseANS: A> The enzyme that initiates digestion of starch inthe mouth is salivary amylase
48.) Which of the following structure preventsgastric reflux?A.) Pyloric sphincter B.) Internal sphincter
C.) Cardiac sphincter D.) Sphincter of OddiANS: C> The cardiac sphincter also known as lower esophageal
sphincter prevents gastric reflux
49.) Which of the following nutrients remains inthe stomach for the longest period?A.) FatsB.)
ProteinsC.) CarbohydratesD.) Water ANS; A> Fats remains in the stomach for 4 to 6 hours;carbohydrates
for 1 to 2 hours; protein 3 to 4hours


50.) The pancreatic enzyme which completesdigestion of fats isA.) AmylaseB.) LipaseC.) TrypsinD.)
RenninANS: B> Lipase is the pancreatic enzyme thatcompletes digestion of fats
51.) Kwashiorkor is a condition characterized by:A.) Calorie deficiencyB.) Vitamin DeficiencyC.) Protein
deficiencyD.) Mineral deficiencyANS: C> Kwashiorkor is protein deficiency
52.) Which of the following is most effectivenursing measures to relieve anorexia EXCEPT:A.) Provide
small, frequent feedingsB.) Remove unsightly articles from the patientsunitC.) Provide three full meals a
dayD.) Provide good hygienic measuresANS: A> Providing small frequent feedings is mosteffective
nursing measure to relieve anorexia
53.) The following factors increase calorierequirements EXCEPT:A.) Cold climateB.) Activity and
exerciseC.) Fever D.) sleepANS: D> Sleep reduces calorie requirement by 10 to15% . A,B,and C are
factors that increasecalorie requirement.
54.) The following are good sources of calciumEXCEPT:A.) CheeseB.) MilkC.) Soy productsD.) Carbonated
drinksANS: D> Carbonated drinks are not sources of calcium.A,B and C are good sources of calcium.
55.) Which of the following is the richest sourceof iron?A.) MongoB.) MilkC.) Malunggay leavesD.)
PechayANS: A> Among these choices, mongo (a legume) isthe richest source of iron. The richest source
of iron is liver, next is lean meat, then legumes,then green leafy vegetables
56.) Which of the following is a good source of vitamin A?A.) EggsB.) Liver C.) FishD.) PeanutsANS: B>
Liver is very good source of fat-solublevitamins (A,D,E,K)
57.) The following may be given to relievenausea and vomiting EXCEPT:A.) Dry toastB.) MilkC.) Cold cola
beverageD.) Ice chipsANS: B> Milk does not relieve nausea and vomiting.A,B,C may relieve nausea and
vomiting
58.) The most life threatening complication of vomiting is:A.) AspirationB.) DehydrationC.) Fever D.)
MalnutritionANS: A> The most life-threatening complication of vomiting is aspiration. It causes
airwayobstruction.
59.) The vomiting center is found in the ________.A.) CerebellumB.) HypothalamusC.) Medulla
OblongataD.) CerebrumANS: C> The vomiting center in the Medulla Oblongata
60.) The best indicator of nutritional status of theindividual is:A.) WeightB.) HeightC.) Arm muscle
circumferenceD.) Adequacy of hair ANS: A> The best indicator of nutritional status is theweight
61.) To assess the adequacy of food intake,which of the following assessment parameters isbest
used?A.) Food preferences and dislikesB.) Regularity of meal timesC.) 3-day diet recallD.) Eating style
and habitsANS: C> Dietary diary e.g. 3-day diet recall, is the bestassessment parameter for adequacy of
foodintake
62.) Prolonged deficiency of vitamin B12 leadsto:A.) beriberiB.) Pernicious anemiaC.) PellagraD.)
Peripheral neuritisANS: B> Prolonged Vit B12 deficiency results topernicious anemia
63.) The vitamin necessary for absorption of calcium is:A.) Vit DB.) Vit AC.) Vit CD.) Vit EANS: A> Vit D
promotes absorption of calcium
64.) Vit. K is necessary for:
A.) Bone and teeth formation
B.) Integrity of skin and mucous membrane
C.) Blood coagulation
D.) Formation of RBC
ANS: C> Vitamin K is necessary for blood clotting. Prolonged deficiency of this vitamin leads to bleeding
65.) The following are signs and symptoms of dehydration EXCEPT:
A.) Weight loss
B.) Decreased urine output
C.) Elevated body temperature
D.) Elevated BP
ANS: D> Elevated BP is not a sign of dehydration .A,B,C are signs and symptoms of dehydration.
66.) The client is experiencing hypokalemia. Which of the following should be included in his diet?
A.) Banana
B.) Milk
C.) Cheese
D.) Fish
ANS: A> Hypokalemia is low serum potassium level. Providing potassium-rich foods like banana and
other fresh fruits is effective nursing intervention for this condition
67.) During insertion of NGT, which position is best assumed by the client?
A.) Low-Fowlers
B.) Semi-Fowlers
C.) High-Fowlers
D.) Lateral
ANS: C> During insertion of NGT, the patient is best placed in high-Fowlers position with neck
hyperextended until the tube is in the oropharynx. Once the NGT is in the oropharynx, the client is
instructed to flex the neck and swallow, as the tube is advanced.
68.) The length of NGT to be inserted is correctly measured;
A.) From the tip of the nose to the umbilicus
B.) From the tip of the nose to the xiphoidprocess
C.) From the tip of the nose to the earlobe to the umbilicus
D.) From the tip of the nose to the earlobe to the xiphoid process.
ANS: D> The length of NGT to be inserted is measured from the tip of the nose, to the earlobe, to the
xiphoid process (N-E-X) which is approximately50cm
69.) When inserting NGT, the neck should:
A.) Flexed
B.) Hyperextend
C.) Tilted to the left
D.) In neutral position
ANS: B> When inserting NGT, the neck is initially hyperextended
70.) The most accurate method of assessing method of placement of NGT is:
A.) Aspiration
B.) Testing the pH of gastric aspiration
C.) X-ray study
D.) Introduction of air into NGT and auscultate at the epigastric area.
ANS: C> The most accurate method of assessing placement of NGT is through X-ray.
71.) Which of the following is inappropriate nursing action when administering NGT feeding?
A.) Assist the client in Fowlers position
B.) Introduce feeding slowly
C.) Place the feeding 24 inches above the point of insertion of NGT
D.) Instill 60mls of water into the NGT after feeding
ANS: C> During NGT feeding, the height of the feeding is 12 inches above the point of NGT insertion, not
24 inches. If the height of feeding is too high, this results to very rapid introduction of feeding. This may
trigger nausea and vomiting.
72.) The primary purpose of gastrostomy is:
A.) For feeding
B.) For drainage
C.) To prevent flatulence
D.) To prevent aspiration of gastric reflex
ANS: A> The primary purpose of gastrostomy is for feeding
73.) The most important nursing action before gastrostomy feeding is:
A.) Check VS
B.) Assess for patency of the tube
C.) Measure residual feeding
D.) Check for placement of the tube
ANS: B> The most important nursing action before gastrostomy feeding is to assess for patency of the
tube. This is done by instilling 15-30 mls of water into the tube.
74.) The primary advantage of gastrostomy feeding is:
A.) It ensures adequate nutrition
B.) It prevents aspiration
C.) It maintains integrity of gastro-esophageal sphincter
D.) It minimizes fluid-electrolyte imbalances
ANS: C> The primary advantage of gastrostomy feeding is, it maintains the integrity of gastro-esophageal
sphincter (cardiac sphincter) of the stomach
75.) Vitamin B3 (Niacin) deficiency leads to:
A.) Pellagra
B.) Beriberi
C.) Scurvy
D.) Rickets
ANS: A> Vitamin B3 (Niacin) deficiency leads to pellagra--Basic Human Needs: Bladder and Bowel
&Elimination
76.) Constipation is best described as:
A.) Irregular passage of stool
B.) Passage of stool every other day
C.) Passage of hard, dry stool
D.) Seepage of liquid feces
ANS: C> Constipation is passage of hard, dry stool
77.) The accumulation of hardened, putty-like fecal mass at the rectum is
A.) Obstipation
B.) Constipation
C.) Tympanities
D.) Fecal impaction
ANS: D> Fecal impaction is the accumulation of hardened, putty-like fecal mass at the rectum
78.) The following are appropriate nursing measures to relieve constipation EXCEPT:
A.) Include fruits and vegetables
B.) Have adequate activity and exercise
C.) Take laxatives at regular basis
D.) Answer immediately to the urge to defecate
ANS: C> Regular use of laxative is inappropriate nursing measures to relieve constipation
79.) Castor oil acts as a laxative by:
A.) Providing chemical stimulation of the intestinal mucosa
B.) Softening the stool
C.) Increasing the bulk of the stool
D.) Lubricating the stool
ANS: A> Castor oil provides chemical stimulation to the intestinal mucosa, to increase peristalsis and
promote defecation
80.) Which of the following foods should be avoided by the client prevent flatulence?
A.) Fruit juice
B.) Cabbage
C.) Meat
D.) Fish
ANS: B> To prevent flatulence, avoid gas-forming foods like cabbage
81.) Which of the following antidiarrheal medications absorb gas or toxic substances from the bowel?
A.) Demulcent
B.) Cabbage
C.) Meat
D.) Fish
ANS: B> Absorbent anti-diarrheal medications absorb gas or toxic substances from the bowel
82.) The most common-side effect of overuse of laxatives is:
A.) Diarrhea
B.) Nausea and vomiting
C.) Constipation
D.) Flatulence
ANS: C> The most common side-effect of overuse of laxative is rebound constipation
83.) Which of the following should be included in the diet of the patient with diarrhea?
A.) Banana
B.) Papaya
C.) Pineapple
D.) Avocado
Ans: A> Banana should be included in the diet of the client with diarrhea. It is rich in potassium and it
replaces potassium losses due to diarrhea
84.) Which of the following fluids may be given to a client with diarrhea?
A.) Milk
B.) Coffee
C.) Tea
D.) Gatorade
ANS: D> Gatorade may be given to a client with diarrhea because it is rich in potassium
85.) Which of the following laxative increases the bulk of the stool?
A.) Colace
B.) Metamucil
C.) Dulcolax
D.) Duphalac
ANS: B> Metamucil increases bulk of the stool and it provides adequate mechanical stimulation for
peristalsis
86.) The following are appropriate nursing measures to relieve diarrhea EXCEPT:
A.) Provide high-fiber diet
B.) Promote rest
C.) Include banana in the diet
D.) Avoid fatty or fried food
ANS: A> High fiber die stimulates peristalsis and therefore inappropriate for a client with diarrhea
87.) The following are solutions used as non-retention enema EXCEPT:
A.) Tap water
B.) Carminative enema
C.) Normal Saline Solution
D.) Fleet Enema
ANS: B> Carminative enema is used for retention enema. A,C, and D are solutions used as non-retention
enema
88.) The medication that relieves flatulence is:
A.) Imodium (Loperamide)
B.) Plasil (Metochlopramide)
C.) Prostigmin (Neostigmine)
D.) Colace ( Na Docussate)
ANS: C> Prostigmin is cholinergic, so it stimulates peristalsis. It is used to relieve flatulence
89.) The best position of the adult client during enema administration is:
A.) Left lateral
B.) Supine
C.) Right lateral
D.) Semi-Fowlers
ANS: A> Left lateral position is the best position for the adult client receiving enema. This position
facilitates the flow of the solution into the colon by gravity
90.) Which of the following is inappropriate nursing action during rectal tube insertion to relieve
flatulence?
A.) Insert rectal tube for 3-4 inches
B.) Use rectal tube size Fr.22-30
C.) Keep rectal tube in place for 45 minutes
D.) Insert well-lubricated rectal tube in rotating motion
ANS: C> Keeping the rectal tube in place for 45 minutes is inappropriate. Beyond 30 minutes rectal tube
causes irritation of the mucous membrane in the rectal area.
91.) The following are correct nursing actions when administering enema EXCEPT:
A.) Provide privacy
B.) Introduce solution slowly
C.) Alternate NSS with tap water and soap suds
D.) Increase the flow rate of the enema solution if abdominal cramps occur
ANS: D> Increasing flow rate of enema solution if abdominal cramps occur is inappropriate nursing
action. Temporarily stop flow of solution if abdominal cramps occur, until peristalsis relaxes.
92.) The functional unit of the kidneys is the:
A.) Glomerulus
B.) Bowmans capsule
C.) Nephron
D.) Tubules
ANS: C> The nephron is the unit of the kidney
93.) Which of the following initiates voiding?
A.) Valsalva maneuver
B.) Increased intra-abdominal pressure
C.) Sympathetic response stimulation
D.) Parasympathetic response stimulation
ANS: D> The PNS promotes contraction of the bladder and promotes relaxation of urethral sphincter.
Therefore, it initiates voiding.
94.) The following are normal characteristics of urine EXCEPT:
A.) Appears clear
B.) pH= 3.5
C.) Sp.Gr=1.020
D.) Amber
ANS: B> Urine pH of 3.5 if too low. This indicates acidosis. The normal pH of urine is slightly acidic, an
average of 6
95.) Frequent scanty urination is:
A.) Urgency
B.) hesitancy
C.) Pollakuria
D.) Polyuria
ANS: C> Pollakuria is frequent scanty urination
96.) The volume of urine in the bladder that triggers the urge of an adult patient to void is:
A.) 50-100mls
B.) 100-200 mls
C.) 250-450 mls
D.) 500-600 mlsA
NS: C> 250-450 mls of urine in the bladder makes an adult client feel the urge to void
97.) Which of the following is not as assessment finding in urinary retention?
A.) Flat sound over the supra-pubic area on percussion
B.) Smooth, firm ovoid mass at the suprapubicarea
C.) Protrusion arising out the pelvis
D.) Frequent passage of small amount of urine
ANS: A> Flat sound over the supra-pubic area on percussion does not indicate bladder distention.
Accumulation of urine in the bladder will produce dull sound
98.) Which of the following is most effective nursing measure to relieve urinary retention?
A.) Allow the patient to listen to the sound of running water
B.) Dangle fingers in warm water
C.) Provide privacy
D.) Pour warm water over perineum
ANS: C> providing privacy is the most effective nursing measure to relieve urinary retention.
99.) The best position for female during urinary catheterization is:
A.) Supine
B.) Dorsal recumbent
C.) Lateral
D.) Semi-Fowlers
ANS: B> Dorsal recumbent position is the best position during urethral catheter insertion in a female
client.
100.) The female urethral meatus is located:
A.) Above the clitoris
B.) Below the vaginal
C.) Between the clitoris and vaginal orifice
D.) Between the vaginal orifice and anus
ANS: C> The female urethral meatus is located between the