1. Answer: A. Diagnose Illness
Health promotion activities involves the members in order to maximize their skills and knowledge. Its advantages to the members would include reduction of health care costs, reduce incidence of hospital admissions and offering layman forums wherein members can reach their optimal function.
2. Answer: B. Reduce risk factors
In health prevention, the risks are present but it can be reduced so that the tendency to get sick is also minimized. The rest of options were either part of health promotion activities or health maintenance.
3. Answer: B. Health Promotion
According to the World Health Organization, health promotion is the process of encouraging the people to heighten their control over and to improve their health status. It is geared towards a change of behaviour in order to attain optimal healthy functioning with the use of social and environmental interventions. However, this type of nursing goal often overlooked in hospitals.
4. Answer: D. Self-control
Self-control is also a part of the motivation to change behaviour or status. The other options were part of the major characteristics of normal health maintenance.
5. Answer: B. Access to social and economic resources
Health maintenance can be achieved when the economic resources are within reach. Health maintenance entails finances and relationships that must be made in order to see the change within the health-seeking behaviour of the individual.
6. Answer: B. Poverty
Poverty is the greatest threat to access to health programs. Increased incidence of preventable diseases, premature death and illnesses are linked to poverty which is a worldwide problem today.
7. Answer: A. Immunization
Primary disease prevention involves activities that would stop something in order to prevent worsening problem on the health. These activities involve regular exercise, stress management, nutrition class and immunization.
8. Answer: C. To prevent disability and render intervention in the earlier stage
9. Answer: C. Tertiary Disease Prevention
Tertiary Disease Prevention involves activities that can reduce the likelihood of having the similar disease state through rehabilitation and assistance to reach the optimal health status.
10 .Answer: C. Tertiary Disease Prevention
Tertiary Disease Prevention may not promise that a person can return to its normal state. At some point this type of prevention may give comfort and palliative type of care such as in terminal cases in a form of hospices.
Situation. For No. 11 – 12. A survey must be done in order to know the factors of increase incidence of needle-stick injuries among nursing personnel in the hospital.
11. Answer: A. Review related topics
Since this is a survey type of study, a nurse researcher must first review related topics in order to provide a deeper knowledge of the subject of the study. Collecting data using tool can be the next step and getting a permission to the hospital director will be next step when the study has been approved.
12. Answer: B. Readability of the findings
The findings must be understood so that purpose of the study can be complete. Other options were inconsistent to the feasibility of the study.
13. Answer: D. Community health survey
On the first day, a Community Health Nurse must be able to see the whole view of the community through a community health survey. This involves mapping the whole community in order to know the access roads and how many house will the nurse serve. In this type of ocular survey, the nurse may have an initial assessment of the whole community.
14. Answer: D. Home visit
Since you are situated in a community, a home visit is the best tool in assessing the community. This is an activity wherein the nurse goes on foot in order to visit each houses, place a survey on each house and provide an observation on the health status and living arrangement of the people.
15. Answer: C. Community conference
Conducting community conference can involve a lot of effort in the nurse’s part in order to get to know the people as a whole. Selecting a few clients can compromise the reliability of the facts taken. Observation can also do not supply the needed answers to questions since you really need to interact with the community.
16. Answer: B. Orientation Phase
In the orientation phase, a community health nurse must state the length of their stay in the community in order to provide the client a space to adjust with their presence and absence after the community immersion.
17. Answer: C. Care of families
With a premise, family is the basic unit of the society, the community health nursing is geared towards caring this small unit because this is the major driving force of the overall health status of the whole country.
18. Answer: A. Treatment of Illness
Treatment of Illness does not belong to the group. Community health is part of the paramedical or medical approach that is concerned on the present health situation of the whole community.
19. Answer: B. Assess the patient
Using the Nursing Process, assessment is the initial step upon meeting the patient. In this manner, you will be able to plan and perform nursing procedures using the nursing diagnosis that has been formulated.
20. Answer: A. Perform Tourniquet Test
A tourniquet test or otherwise known as Rumpel-Leede Capillary Fragility Test must be performed upon assessment of petechial rash in order to determine the hemorrhagic tendency of the patient. It does not conclude that the patient may have Dengue but an initial tool in making differential diagnosis. Diagnosing and prescribing medications are not responsibilities of a nurse.
21. Answer: A.
A blood pressure cuff is applied and inflated to a point within the average of systolic and diastolic pressure.
22. Answer: B.
The test is positive if there are 20 or more petechiae per square inch. This can be done by drawing an imaginary square on the cuff area.
23. Answer: B. Allowing home deliveries
It is now not allowed to have home deliveries due to the increasing maternal and child mortality. The program focused on the prevention of maternal complications even when a trained hilot or midwife will perform the delivery at home.
24. Answer: C. Breech Presentation
Breech presentation would need ceasarian section delivery since it is dangerous for the mother and the unborn child. Rural health units are only catering normal spontaneous vaginal deliveries with following criteria: cephalic presentation, adequate pelvimetry, gravida 4.
25. Answer: D. Signs
This is an example of nonverbal communication wherein the examiner can see or observe the changes on the body. Symptoms are complaints made by the patient. The other options are types of verbal communication.
26. Answer: B. Respondeat superior
This action is a premise to this principle. A senior staff must be knowledgeable of the novice nurse’s action so that he or she will be able to defend his or her unit together with his or her subordinates.
27. Answer: D. Verbal Assault
This does not have a physical evidence unless the victim will speak for himself or herself. The other options provide an evidence of the injury after the act has been done.
28. Answer: D. Perspiration
When the patient perspires, you cannot account the total amount of fluid being lost from the body. The skin is so vast for insensible fluid loss.
29. Answer: B. Apathy
This does not belong to the group. Apathy means being not concerned or emotionally attached to things or events. Amnesia is loss of memory, apraxia is inability to determine function or purpose of object. Agnosia is inability to recognize familiar objects.
30. Answer: D. Fat embolism
Fat embolism is caused by trauma on the long bones or burns. The most common cause of fat embolism would be fractures. This syndrome would manifest in a form of shortness of breath until delirium and even coma.
31. Answer: D. Medical or Surgical missions
Foreign nurses can practice the nursing profession during medical and surgical mission only. They could not be allowed to practice as nurse educator in a state college since it is a government owned school.
32.Answer: C. Operating room technician
An operating room technician is in charge of the linens, the materials being needed as well as even the transport of patients. He is considered as not sterile.
33. Answer: B. Deep pain
Deep pain in a fracture, particularly in tibia or forearm fracture is a characteristic feature of compartment syndrome.
34. Answer: A. Localized abscess
Localized abscess can be a predisposing factor of increase intracranial pressure. The other options does not belong on the known predisposing factor of increased intracranial pressure.
35. Answer: A. Assess for consciousness
the initial nursing action would be focused on the establishment of the patient’s current state of consciousness. When the patient appears to be drowsy, this means that the incident may happen in a few minutes or hours only. The conscious state would be useful for further assessments and procedures.
36. Answer: B. Preventing increase intracranial pressure
In craniotomy, increased intracranial pressure is a common problem after the surgery. Nurses must be able to detect it through the blood pressure, as well as on the status of the patient.
37. Answer: A. Dehydrated
In Diabetic patients, a sign of dehydration can be elevated blood sugar levels. The complaint of dryness of throat and mouth is also a good sign of dehydration.
38. Answer: C. 150 drops per minute
A microset has a drip factor of 60cc per minute. Using this type of drip factor will also require to infuse 150 drops per minute in order to reach the required fluid replacement every hour.
39. Answer: C. Arterial Blood Gas
Arterial blood gas is taken during the increase of blood glucose in order to check for signs of Diabetic Ketoacidosis. The pH level of the blood is noted at this time.
40. Answer: B. To check for presence of ketones in the urine
A urine ketone test is done for patients with heart problems, as well as diabetes. Since the blood sugar of the patient is more than 240 mg/dL, it is warranted to perform such test so that ketones might be seen if the body tries to compensate with lack of sugar or carbohydrates in the body.
41. Answer: A. Strictly monitor the intake and output
This is the correct nursing action when monitoring the hydration status of the patient. Restricting the fluids may pose a great danger in dehydration. Increasing oral fluid intake in this patient is not indicated, only sips of water are allowed. The route of hydration is through intravenous line. Starting an IV line with D5NSS will eventually increase the blood sugar level of the patient.
42. Answer: D. Altered Nutrition: Less than body requirements related to diabetes mellitus
This statement does not belong to the group since the related factor is a medical term. A related factor should include a medical diagnosis rather a pathophysiologic state or current factors only.
43. Answer: C. NOC
This medical jargon is not allowed in charting. The following three statements are well used throughout the documentation.
44. Answer: D. Sunken eyeballs
In an adult patient, the first three options would reveal the fluid status of the patient. Sunken eyeballs are used for pediatric patients only to assess the fluid status.
45. Answer: A. Respiratory Acidosis
This is an example of an acute respiratory acidosis. The pH level is less than 7.35; PaCO2 is more than 45 and the Bicarbonate level is normal (26).
46. Answer: B. His mother
His mother is the most liable person to perform the consent since she is of legal age and next to his kin. His wife is considered to be minor.
47. Answer: C. Smell
The part of the brain that is responsible for emotions is the hypothalamus . The temporal lobe is responsible for the interpretation of semantics in speech and vision. It is also the area wherein auditory functions are located.
48. Answer: C. Mannitol 20%
Mannitol 20% is ordered in order to reduce the intracranial pressure as evidenced by elevated blood pressure of the patient. Magnesium sulphate and other options are also indicated in order to decrease the blood pressure but with different predisposing factors.
49. Answer: C. “Hello Ms. Kathleen, I am Nora, your new nurse. How are you?”
This statement is the most appropriate opening line for the orientation phase. Introducing yourself as a nurse may convey authority in a none threatening way. Asking open ended questions can also encourage the patient to elaborate his or her feelings.
50. Answer: B. Invite other patients
Inviting other patients, which means male or female is not a proper nursing action since she may attack the male participants. Taking in mind her previous actions towards the male counterpart, it is better to include females only in the game. Avoiding challenging remarks and frustrations can also minimize her crying spells and violent actions.
51. Answer: C. delusion of persecution
This type of delusion describes that a person is like being attacked, harassed, or cheated.
52. Answer: B. Ideas of reference
Ideas of reference has a content of holding a feeling that other people not related to him or her is talking or rendering something for him or her personally.
53. Answer: B. Alcoholics anonymous
This type of group includes only people who want to change their behaviour towards alcohol. The nurse need not to be an alcoholic in order to enter this group. He or she is only there in order to make sure that everything is well facilitated and organized.
54. Answer: C. blocker
As a blocker, you are the one who controls the situation when the talking of the topic is leading towards worthless topics.
55. Answer: C. Pia is reading a cookbook and preparing the needed materials for the baking session that is about the begin in 30 minutes.
Culinary therapy involves the utilization of cooking and baking as a form a therapy to its members.
56. Answer: D. Sub average intellectual functioning
Mental retardation is defined as a condition with impairment of sub average intellectual functioning that originates during the developmental period.
57. Answer: C. Meditation
Bio-behaviour treatment means that the intervention is focused on the wellness of the body using behavioural techniques.
58. Answer: A. symptoms of self-destruction or impulses
Antipsychotic drugs ease the dissociative symptoms such as self-destructing behaviours.
59. Answer: B. Neurotic
This type of behaviour is influenced by phobia and compulsions. The excessing rubbing of hands with alcohol is an example of compulsive behaviour.
60. Answer: C. 4-6 weeks
A crisis can be described as a stressing event that would occur between several days up to 4 to 6 weeks.