You are on page 1of 7

MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Peñablanca Cagayan

COLLEGE OF NURSING

NCM 105: CARE OF CLIENTS WITH MALADAPTIVE BEHAVIORS


SEMIFINAL EXAMINATION
TEST I INSTRUCTIONS:
This test questionnaire contains 100 questions.
This exam is for 2 hours only. You must pass your answer sheet when the time allotted has elapsed. Answer sheets that will be passed after the
allotted time will NOT BE ACCEPTED.
Shade only (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
Do not put any unnecessary markings on the answer sheet. Doing so will invalidate your answers.
Keep the answer sheets neat and clean. DO NOT MUTILATE

START HERE 
1. Nursing is considered a practice discipline. What should the nurse be aware is the main difference between this and a research/theory
discipline?
a. Nursing uses theory and research to help understand its focus.
b. Nursing is not considered a practice discipline, and therefore does not utilize research.
c. Nonpractice disciplines do not utilize theory in development of their focus.
d. Nonpractice disciplines have a central focus of performance of a professional role.
2. Based on the concept that health is a highly individual perception, which of the following individuals would consider himself/herself healthy?
a. A senior citizen who has high blood pressure and refuses to leave home
b. An honors college student who has multiple sclerosis and uses a wheelchair for mobility
c. A college student who is seen in the student clinic for minor complaints at least once a week
d. A homeless person who walks several miles each day looking for food
3. Which of the following descriptions best fits the eudaemonistic model of health?
a. Health is defined in terms of the individual's ability to fulfill societal roles
b. Health is a process of adaptation.
c. Health is identified by the absence of disease or injury
d. Health is the realization of a person's potential
4. An otherwise healthy 59-year-old client is hospitalized with multiple fractures of the lower extremities after an automobile accident. Where would
this client be placed on Dunn's high-level wellness grid?
a. Protected poor health in a favorable environment
b. Poor health in an unfavorable environment
c. Emergent high-level wellness in an unfavorable environment
d. High-level wellness in a favorable environment
5. Acute illness is characterized by:
a. Severe symptoms of relatively short duration
b. Physical limitations and discomfort that gradually increase over time
c. Occasional remissions
d. An extended duration
6. When the client states that "my head hurts and my vision is blurry," what type and source of data is this?
a. Primary and objective c. Secondary and objective
b. Primary and subjective d. Secondary and subjective
7. When the nurse asks the client, "Why did you come to the clinic today?" what kind of assessment is being performed?
a. Initial assessment c. Problem-focused assessment
b. Emergency assessment d. Time-lapsed reassessment
8. The nurse asks a client, "What happened to your leg?" This is an example of:
a. A neutral question c. A closed question
b. A leading question d. An open-ended question
9. Which of the following positions assumed by the nurse and the client facilitates an easy exchange of information?
a. The client is in bed and the nurse stands at the foot of the bed
b. Seated; the nurse places the chairs at right angles to one another, about a foot apart
c. The client is in bed and the nurse stands at the side of the bed
d. The client is in bed and the nurse sits on a chair at a 45-degree angle to the bed
10. Which of the following nursing diagnoses uses the PES format?
a. Fluid Volume Deficit related to prolonged vomiting
b. Risk for Impaired Skin Integrity as manifested by poor skin turgor and old age
c. Ineffective Airway Clearance related to infectious process as manifested by excessive mucous and retained secretions
d. Ineffective Airway Clearance as manifested by secretions in the bronchi presence of allergies, and airway spasm
11. A client who has been unable to void for 12 hours tells the nurse, "I just urinated in the bathroom without any problem." Which of the following
nursing orders should be implemented next?
a. Assess character and quantity of urine.
b. Check for bladder distention.
c. Offer urinal q 4 h.
d. No further interventions are needed.
12. Why is a client with fever predisposed to pressure ulcers?
a. Pain perception is diminished.
b. Medications given to relieve fever cause edema.
c. The client may be too weak to change position.
d. Increased metabolism causes increased oxygen needs that cannot be met
SITUATION: A number of client in your unit are at risk of developing pressure sores. As a precaution, the supervisor emphasizes the nurse’s
responsibility in ensuring proper care of clients with problem of immobility.
13. While changing linen of Aling Mila, a comatose client, the nursing aide reports that she noticed a reddened area in the left buttock of the client.
Upon inspection, you noted that the area blanches and is the size of a peso coin. Your MOST appropriate immediate nursing approach would
be to:
a. measure the size of the reddened area for proper documentation
b. instruct the nursing aide to finish bed making using dry fresh linen
c. endorse a schedule for turning and positioning the client round the clock
d. position the client on her right side
14. To decrease the occurrence of pressure sores on Aling Mila the nursing team’s goal is to reduce pressure points. The MOST appropriate
nursing intervention would be to:
a. elevate the head part of the bed as little as possible c. use a “donut” cushion while client is seated
b. massage over the bony prominences d. place the client on a side lying position

15. In a nurse’s meeting in the ward, the senior nurse discusses prevention of pressure sores. She identifies practices that are most likely to cause
shearing injury to the skin and should therefore be avoided. Of the following practices, which one causes the LEAST harm to the client?
a. failure to use a draw/lift sheet when moving the client upward
b. failure to lower the head part of the bed before moving the client upward
c. positioning an immobilized client without help from staff
d. dragging the heels of the client in bed as he is being positioned
SITUATION - Primary prevention involves health promotion as protection against disease. Activities of this type generally apply to the healthy
individuals before any disease or dysfunction occurs.
16. Nurses play a big role in the primary level of prevention. Examples of nurse activities showing primary prevention are the following EXCEPT:
a. referrals to client support groups like those for cancer patients
b. teaching parents of toddlers about prevention of poisoning and accidents at home
c. family planning classes to newly weds
d. giving immunizations to children
17. Secondary prevention includes health maintenance activities which involves the following EXCEPT:
a. nursing care to maintain skin integrity of a diabetic client
b. giving medications and treatments to discharged clients
c. proper positioning of clients with disability in the home setting
d. smoking cessation program
18. When teaching your clients about nutrition, you include the following food as rich sources of good cholesterol, EXCEPT:
a. fish b. beef c. soya d. olive oil
19. A community based hospital offers acute care in addition to adult outpatient services, exercise and yoga classes for young and old. This
Hospital provide which type of services?
a. tertiary and illness prevention c. secondary and tertiary
b. primary and tertiary d. primary and secondary
20. Mr. Tan, 48 years old is attending a smoking cessation program to be held at the nearby high school conducted by the school nurse. This
program is classified as:
a. diagnosis and treatment b. health restoration c. a. Flush the catheter with normal saline solution
rehabilitation d. health promotion b. elevate extremity to facilitate drainage by gravity

SITUATION: While in the ward, you are assigned to clients with problems related to the gastrointestinal tract.
21. The nurse is preparing Mr. Lim for cleansing enema. When administering enema the maximum height at which the enema can should be held
from the level of the bed is:
a. 14 inches b. 10 inches c. 16 inches d. 12 inches
22. While administering the enema, Mr. Lim complains of abdominal cramps. Which of the following would be the MOST appropriate action of the
nurse?
a. clamp the tubing a few minutes till the cramps subside then continue c. stop the procedure and refer to the attending physician
b. pull the rectal tube slowly till the cramps subside d. lower the enema can to slow down the inflow of the enema
solution
SITUATION- Proper Nutrition and elimination are important to health and the nurse has an important role to play in assisting people from various age
groups obtain proper information
23. Roman, 36 years old is diagnosed with peptic ulcer and asks you what food is best to add to his diet so as not to exacerbate his symptoms.
Your BEST response would be for him to take
a. leafy green vegetable dishes c. mocha, café latte and other similar drinks
b. citrus fruit juices or shakes d. milk regularly 3-4 times daily
24. You are assigned to Mrs. Dulay, a client with an order for cleansing enema. While doing the procedure, the client groans and complains of
abdominal cramping. Your MOST appropriate initial nursing action would be to:
a. reduce the flow of the fluid by clamping the enema tubing c.lower the height of the enema container
b. instruct the client to relax, inhale and exhale slowly d. push the rectal tube further in by 2 inches
25. An elderly client you are taking care of has fecal incontinence for 3 days now. He is able to tolerate food but has no control of his bowel
movement. He has soft watery stools and uses adult diapers. While caring for his client you will watch out closely for risk of:
a. increased abdominal cramping c. malnutrition and weight loss
b. perineal and anal skin breakdown d. falls when he tries to go the bathroom
26. Dennis, 5 years old, is brought to the hospital for severe diarrhea. You are aware that a major problem that may develop that will adversely
affect Dennis would be:
a. severe abdominal cramping
b. excessive passing of flatus
c. severe fluid electrolyte imbalance
d. irritation of the anal sphincter
27. the regulating centers for fluid and food intake are located in the:
a. thalamus c. medulla oblongata
b. hypothalamus d. pons
28. The enzyme that initiates digestion of starch in the mouth is:
a. amylase b. sucrose c. maltase d. lactase
29. Kwashiorkor is a condition characterized by:
a. caloric deficiency c. protein deficiency
b. vitamin deficiency d. mineral deficiency
30. Which of the following interventions would BEST relieve anorexia
a. provide small frequent feeding
b. remove unsightly articles from the patient’s unit
c. provide three full meals a day
d. provide good hygienic measures
31. The following are good sources of calcium EXCEPT
a. Cheese b. Milk c. Soy products d. carbonated drinks
32. Which of the following is a good source of Vitamin A?
a. Eggs b. Liver c. Fish d. peanuts
33. The following may be given to relieve nausea and vomiting except:
a dry toast b. milk c. coca cola beverages d. ice chips
34. The most threatening complication of vomiting is:
a. aspiration b. dehydration c. fever d. malnutition
35. The vomiting center is found in the:
a. cerebellum b. hypothalamus c. medulla oblongata d. cerebrum
36. Prolonged deficiency in Vitamin B12 may lead to:
a. beri beri b. pernicious anemia c. pellagra d. peripheral neuritis
37. The vitamin necessary for the absorption of calcium is:
a. Vitamin D b. Vitamin C c. Vitamin A d. Vitamin B
38. Vitamin K is necessary for:
a. bone and teeth formation
b. integrity of skin and mucous membrane
c. blood coagulation
d. formulation of RBC
39. Constipation is best described as:
a. irregular passage of stool
b. passage of stool every other day
c. passage of hard, dry stool
d. passage of liquid feces
40. The accumulation of hardened, putty-like fecal mass at the rectum is:
a. obstipation b. constipation c. tymphanites d. fecal impaction
41. The most important nursing intervention to correct skin dryness is:
A. Avoid bathing the patient until the condition is remedied, and notify the physician
B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
C. Consult the dietitian about increasing the patient’s fat intake, and take necessary measures to prevent infection
D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved
areas
42. When bathing a patient’s extremities, the nurse should use long, firm strokes from the distal to the proximal areas. This technique:
A. Provides an opportunity for skin assessment
B. Avoids undue strain on the nurse
C. Increases venous blood return
D. Causes vasoconstriction and increases circulation
43. Vivid dreaming occurs in which stage of sleep?
A. Stage I non-REM
B. Rapid eye movement (REM) stage
C. Stage II non-REM
D. Delta stage
44. The natural sedative in meat and milk products (especially warm milk) that can help induce sleep is:
A. Flurazepam
B. Temazepam
C. Tryptophan
D. Methotrimeprazine
45. Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:
A. Have the patient take a 30- to 60-minute nap in the afternoon
B. Turn on the television in the patient’s room
C. Provide quiet music and interesting reading material
D. Massage the patient’s back with long strokes
46. For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds?
A. Cover the mattress with a sheepskin.
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels.
D. Apply petrolatum barrier creams.
47. A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection?
A. Fever
B. Intact skin
C. Inflammation
D. Lethargy
48. A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are
initiated. Which rule must be observed to follow contact precautions?
A. A clean gown and gloves must be worn when in contact with the client.
B. Everyone who enters the room must wear a N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard waste.
D. Place the client in a room with a client with an upper respiratory infection.
49. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?
a. The bladder distends and its capacity increases
b. Older adults ignore the need to void
c. Urine becomes more concentrated
d. The amount of urine retained after voiding increases
50. During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
a. Perineal skin irritation
b. Fluid intake of less than 1,500 mL/d
c. History of antihistamine intake
d. Hx of UTI
e. A fecal impaction
51. During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes
incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate?
a. stress urinary incontinence
b. reflex urinary incontinence
c. functional urinary incontinence
d. urge urinary incontinence
52. Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply.
a. Voids each time there is an urge
b. Practices slow, deep breathing until the urge decreases
c. Uses adult diapers, for “just in case”
d. Drinks citrus juices and carbonated beverages
e. Performs pelvic muscle exercises
53. A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation?
a. Coughing
b. Mobility deficits
c. Prostate enlargement
d. Urinary tract infection
54. A nurse in a provider’s office is assessing a client who reports losing control of urine when ever she coughs, laughs, or sneezes. The client
relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to
control or eliminate the clients incontinence? Select all that apply.
a. Limit total daily fluid intake
b. Decrease or avoid caffeine
c. Increase the intake of calcium supplements
d. Avoid the intake of alcohol
e. Use Crede maneuver
55. Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?
A. Constipation
B. Diarrhea
C. Incontinence
D. Hemorrhoids
56. Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?
A. “I need to drink one and a half to 2 quarts of liquid each day.”
B. “I need to take a laxative such as milk of magnesia or if I don’t have a BM every day.”
C. “If my bowel pattern changes on its own, I should call you.”
D. “Eating my meals at regular times is likely to result in regular bowel movements.”
57. A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema?
A. Oil retention
B. Return flow
C. High large volume
D. Low, small volume
58. The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports
feeling “bloated” the nurse consult with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?
A. Soapsuds
B. Retention
C. Return flow
D. Oil retention
59. A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of
the following foods should the nurse recommend?
A. Macaroni and cheese
B. Fresh food and whole wheat toast
C. Rice pudding and ripe bananas
D. Roast chicken and white rice
60. A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following
findings? Select all that apply.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema
61. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following are
appropriate steps for the nurse to take? Select all that apply.
A. Warm the enema solution prior to installation.
B. Position the client on the left side with the right leg flexed forward.
C. Lubricate the rectal tube or nozzle.
D. Slowly insert the rectal tube about 2 inches.
E. Hang the enema container 24 inches above the clients anus
62. While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
A. Have a client hold his breath briefly.
B. Discontinue the fluid installation.
C. Remind the client that cramping is common at this time.
D. Lower the enema fluid container.
63. A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s
condition?
A. Hypoxia
B. Hypoxemia
C. Dyspnea
D. Cyanosis
64. To prevent postoperative complications, Nurse Kim assists the client with coughing and deep breathing exercises. This is best accomplished by
implementing which of the following?
a. Coughing exercises one hour before meals and deep breathing one hour after meals.
b. Forceful coughing as many times as tolerated.
c. Huff coughing every two hours or as needed.
d. Diaphragmatic and pursed lip breathing 5 to 10 times, four times a day
65. Nurse Aleli is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care?
a. Percussion and postural drainage should be done before lunch.
b. The order should be coughing, percussion, positioning, and then suctioning.
c. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.
d. Percussion and postural drainage should always be preceded by three minutes of 100% oxygen.
66. A nurse is teaching a client with pancreatitis about following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes
which food on the item list?
A. Chocolate milk.
B. Broccoli.
C. Apple.
D. Salmon.
67. The nurse is giving dietary instructions on a client who is on a vegan diet. The nurse provides dietary teaching focus on foods high in which
vitamin that may be lacking in a vegan diet?
A. Vitamin A.
B. Vitamin D.
C. Vitamin E.
D. Vitamin C.
68. A client who is recovering from a surgery has been ordered a change from a clear liquid diet to a full liquid diet. The nurse would offer which full
liquid item to the client?
A. Popsicle.
B. Carbonated beverages.
C. Gelatin.
D. Pudding.
69. A postoperative client has been placed on a clear-liquid diet. The nurse provides the client with which items that are allowed to be consumed on
this diet?
A. Vegetable juices.
B. Custard.
C. Sherbet.
D. Bouillon.
70. The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client
understands the dietary instructions if she selects which of the following from her menu?
A. Nuts and fish.
B. Oranges and dark green leafy vegetables.
C. Butter and margarine.
D. Sugar and candy.
71. The nurse is participating at a health fair at the local mall giving influenza vaccinations to senior citizens. What level of prevention is the nurse
practicing?
A. Primary Prevention
B. Secondary Prevention
C. Tertiary Prevention
D. Quaternary Prevention
72. A patient experienced a myocardial infarction four weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local
fitness center. In what level of prevention is the patient participating?
A. Primary Prevention
B. Secondary Prevention
C. Tertiary Prevention
D. Quaternary Prevention
73. When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal supplements, encourages family to bring in music
that the patient likes to help them to relax, and frequently prays with her patients if that is important to them. The nurse is practicing which
model?
A. Holistic
B. Health belief
C. Transtheoretical
D. Health promotion
74. Which are most susceptible to skin injury?
A. Very thin and very obese people.
B. Very thin and people with large muscle mass.
C. Very obese and diabetic people.
D. Smokers and alcoholics.
75. The nurse is aware that any description of health would include the concept that:
a. health is the absence of illness, and illness is the presence of chronic disease.
b. culture, education, and socioeconomic status influence one’s definition of health or illness.
c. illness is a biologic malfunction, and health is biologic soundness.
d. lifestyle factors are the major determinant of health or illness.
76. The nurse explains that an idiopathic disease is one that:
a. is caused by inherited characteristics.
b. develops suddenly, related to new viruses.
c. results from injury during labor or delivery.
d. has an unknown cause.
77. The nurse uses a diagram to demonstrate how Dunn’s theory of health and illness can be compared with a:
a. plant that grows from a seed, blossoms, wilts, and dies.
b. continuum, with peak wellness and death at opposite ends; the person moves back and forth in a dynamic state of change.
c. ladder; from birth to death the individual moves progressively downward a ladder to eventual death.
d. state of mind dependent on the individual perception of their own health or illness.
78. According to Maslow’s hierarchy, physiological needs are those that:
a. nurture intimacy. b. foster independence. c. encourage social interaction. d. are essential to human life.
79. The nurse encourages a patient to participate in health maintenance by maintaining an ideal body weight as a method of _____
a. primary b. secondary c. tertiary d. simple
80. A nurse clarifies that methods of tertiary prevention are designed for:
a. rehabilitation.
b. delay of the development of a disorder.
c. screening for early detection of disease.
d. using an established protocol of therapy for a specific disease.
Prepared by:

KAREN MAE S. ALCANTARA, MSN/ NINA P. PARACAD, MSN


Instructors

Recommending Approval:

REYNALDO M. ADDUCUL, RN, RM, MSN


Dean, College of Nursing and School of Midwifery

Approved by:

PRESENITA C. AGUON, Ph.D


Vice President for Academic Affairs