INTEGRATED COMPREHENSIVE TEST III

Situation: Miss Marquez is preparing her students for their duty in the psychiatric ward she then asks some
related concepts in order to cast their knowledge in psychiatric nursing.

1. A sign and symptom of psychiatric disorder characterized by the person thinking that thoughts that
belong to him are being aired to the outside world:

a. Thought insertion

b. Thought broadcasting

c. Nihilistic ideas

d. Ideas of reference

2. An excessive thought and speech associated with excessive and unnecessary details irrelevant of the
question. The person never returns to central point and never answers the original question:

a. Circumstantiality

b. Tangentiality

c. Loose association

d. Waxy flexibility

3. Injection of clever and humorous word in order to convey a different meaning:

a. Punning

b. Echolalia

c. Echopraxia

d. Clang association

4. The patient says a word with linkage or small sounds like rang, bang, sang in order to compensate for
communication deficits:

a. Clang association

b. Echolalia

c. Echopraxia

d. Punning

5. An emotional instability or rapidly changing thoughts and feeling tones form sadness to euphoria

a. Blunt effect

b. Labile effect

c. Ambivalence

d. Anhedonia

Situation: Julia, primigravida is brought to the labor room with the following IE findings: cervical dilation 8cm
fully effaced +1AOG: 39 – 40 weeks.

6. Which of the following observation requires the nurse to refer stat to the obstetricians?

a. Sudden gush of amniotic fluid from vagina

 b. FHT is 110 during uterine contractions but returns to 130 after 10 seconds following contraction

c. Frequent urination

d. Blood streak mucus in the vaginal discharge

7. What is the first stage of labor considered to be achieved?

a. Cervix is 10 cm dilated

b. Uterine contractions occur every 2-3 min interval

c. Presenting part is t station + 1

d. Cervix is fully effaced

8. Upon administration to a labor room, which of the following is not a routine procedure considering her
cervical dilation

a. Monitor vital signs and FHT

b. Cleansing enema

c. Mini prep. Of the perineal care

d. Keep on NPO

9. Which of the following signs indicate that delivery is near?

1. Julie verbalized her desire to defecate

2. Uterine contractions increased in frequency duration and intensity

3. The perineum is bulging

4. Bloody show is increased

a. 1,2,3

b. 1,2,4

c. 2,3,4

d. 1,2,3,4

Situation: Maria 48 years old is a known diabetic type 1, she has often consulted her internist for medication.
She asks you she can get well.

10. Among the topics you will include as priority in health teaching to maria is:

a. Good exercise daily

b. Prevention of complication

c. Nutrition and diet therapy

d. Daily foot care

11. One party time, you saw Maria eating a big piece of cake. As a concerned nurse you would tell her:

a. Maria stop eating the cake

b. Maria, remember that you are taking medicine for diabetes

c. Its okay maria its party time anyway

 d. Why are you hard headed Maria?

12. The next morning Maria said she did not feel well, you would say:

a. I told you so

b. Have your blood sugar checked in the laboratory

c. See your doctor once

d. Come let me assess your health status

13. Upon checking, Maria was having hyperglycemia, you tell Maria to:

a. Have a good rest

b. Drink plenty of water

c. See her doctor right away

d. Take her prescribed insulin

14. If Maria asks you what to take for medication, you would answer that she:

a. Must try other alternative

b. Has to follow doctor prescription

c. Could consult other doctors

d. Can’t take a herbal medicine

Situation: Mr. tan a 40 yr old with asthmatic attack is admitted in the medical ward.

15. With your assessment which of these symptoms would you expect to develop late?

a. Lips pursed in an effort exhale

b. Cyanosis

c. Nasal flaring

d. Use accessory muscles for breathing

16. Your finding in your assessment would include the following except:

a. Air hunger and presence of wheezing sound

b. Tachycardia warm and moist skin

c. Ability only to speak words without taking deep breath

d. Tachycardia cool and moist skin

17. The least of nursing care that you would do with him is to:

a. Keep the side rails up

b. Give bricanyl tablet to ease his breathing

c. Keep his back always dry

d. Force fluid to liquefy the secretions

18. The most comfortable position for him to assume during asthmatic attack is:
 a. Sitting

b. Fowlers

c. Orthopneic

d. Supine

19. Which has the less tendency to participate or trigger asthmatic attack

a. Molds, house dust

b. Air pollution

c. Cold weather

d. Changes in climate

Situation: miss Mila Ty a victim of the quezon city incident burn, she sustained 2nd and 3rd degree burn.

20. What should you provide for her burn on the lower extremity?

a. Cradle bed

b. Circulo electric bed

c. Bandage

d. Stryker fame

21. What is your of assessing the degree of her burn?

a. Rate the extent of burned area

b. Count the presence of papule observed

c. Observe presence of redness

d. Check location of burn

22. What would be your first aide measure?

a. Render cold compress

b. Apply topical antibiotic

c. Place her in the tub

d. Run tomato juice around the affected area

23. Using the rule of nines, which has the largest part of burns?

a. Face and neck

b. Right thigh and penis

c. Right upper arm and penis

d. Upper trunk

24. What is the minimum safe range for the hourly urine output from the indwelling catheter?

a. 90 – 120 ml

b. 20 – 30 ml
 c. 60 – 90 ml

d. 30 – 60 ml

Situation: a 3 yr old child Ria is admitted for cough and fever. Ria cries incessantly whenever her mother mrs.
Evangelista leaves her and con not be subdued by the nurses in ward. This behavior was observed on the first
day of admission.

25. Nurse Emily identifies one of the following as a factor in separation anxiety:

a. Mrs. Evangelista spanks ria for ebery misbehavior she have done

b. Mrs. Evangelista has over protected ria

c. Mrs. Evangelista is the only one caring for ria

d. Ria is the youngest child in the family

26. Freud postulated that temper tantrum is observed in which of the following?

a. Oral

b. Phallic

c. Anal

d. Latency

27. According to Erikson, young child sensitivity to anxiety in response to separation or pending separation
from significant persons like mother is a result of failure to complete one of the following
developmental tasks:

a. Trust

b. Autonomy

c. Identity

d. Initiative

28. Most indicative of pneumonia in children 3yrs of age who have cough and difficulty of breathing
include respiratory rate of:

a. 50cpm

b. 60cpm

c. More than normal breaths

d. 40 cpm

29. Ria is feeling better two days after confinement. One morning after nurse Amy gave her medication she
spit them out. Which of the following is a therapeutic statement?

a. Promise me you will not do that again

b. You will not get well if you will do that again ria

c. I know you did not mean to do that Ria

d. Why did you do that Ria?

Situation: nurse patient relationship is very important and before going on duty to a psychiatric ward and
handling patient the nurse must first be physically , emotionally, and spiritually stable.
 30. Unconscious response in which the patient experience feeling s and attitudes towards the nurse:

a. Counter-transference

b. Transference

c. Boundary violation

d. None of the above

31. A specific emotional response of a nurse to a patient characterized by intense love and caring towards
the patient or intense hostility, hatred, and anxiety in response to the resistance of the patient.

a. Counter-transference

b. Transference

c. Boundary violation

d. Resistance

32. Therapeutic impasses characterized by professional relationship turning into a social relationship
between nurse and patient.

a. Counter-transferece

b. Boundary violation

c. Resistance

d. Transference

33. The nurse reveals personal information to patient and the nurse accept free gifts coming from the
patient’s business, this is classified as:

a. Boundary violation

b. Transference

c. Counter-transference

d. Resistance

34. Which of the following indicates counter transference?

a. The nurse feels depressed after the group therapy of drowsiness during the session

b. All of the above

c. The nurse encourage dependence to patient or arguing with patient

d. Dreaming sexual or aggressive fantasies to the patient

Situation: Lan, a 20yr old college student was gang raped while on her way home. She was brought to the
hospital with bruises all over her body.

35. After discharge from the hospital Lani develops intense fear of being alone. This is known as one of the
following?

a. Phobia

b. Obsession

c. Compulsion
 d. Somatization

36. An appropriate nursing intervention would be which of the following?

a. Encourage her to socialize

b. Observe her regularly

c. Force her to participate in the scheduled activities

d. Always have someone to stay with her

37. Upon admission, she was crying uncontrollably and will not talk . initially the nurse identifies one of the
following:

a. Impaired physical mobility

b. Sensory perceptual alteration

c. Rape trauma syndrome

d. Impaired skin integrity

38. The refusal to talk is defense mechanism characterized by involuntary exclusion of painful; thought or
memory from awareness, which is one of the following:

a. Repression

b. Regression

c. Displacement

d. Projection

39. As the nurse assigned to take care of Lani, you can encourage her to talk by asking on of the following:

a. Do you want to talk to your mother?

b. Is there anything I can do to help you in this difficult situation

c. Are you sure you don’t want to talk?

d. Can you relate what exactly happened?

Situation: Mrs. Zamora, a clinical instructor discussed some concepts in psychiatric nursing to the nursing
students.

40. During an initial encounter the patient says, “I don’t like you. I want another nurse”. The nurse
recognizes this is an example of which one of the following?

a. Transference

b. Resistance

c. Counter transference

d. Boundary notation

41. A technique that enhances communication is illustrated by one of the following statement:

a. What are you thinking about?

b. No one here would lie to you.

 c. What made you think that way?

d. Why did you do that?

42. Establishing trust and acceptance is the goal of which of the following phases of nurse relationship?

a. Pre-interaction

b. Termination

c. Working

d. Orientation

43. A nurse acts as parent surrogate when she does which one of the following?

a. Assists the patient and his family know their rights and responsibilities

b. Give reassurance to the patient

c. Assist the patient set limits for his behavior

d. Helps the patient participate in socially acceptable activities

44. The therapeutic use of self requires one of the following personal qualities of the nurse:

a. Self – awareness

b. Empathy

c. Self- understanding

d. Patience

Situation: A nurse is caring for a client who is suspected to be dependent on drugs.

45. What is the immediate factor that predisposes a person to have substance abuse?

a. Availability

b. Lack of advice from another person

c. Left alone in the house with plenty of money

d. An outlet for emotional problems

46. During detoxification, what substance is to be given?

a. Charcoal

b. Antihistamine

c. Calcium

d. Sedatives

47. Coccaine is classified as:

a. Narcotic

b. Anxiolytic

c. Psychostimulant
 d. Hallucinogen

48. The earliest sign of heroine withdrawal is:

a. Yawning

b. Nausea

c. Malaise

d. Vomiting

49. What should be done before rehabilitation of a patient with substance abuse?

a. Reprimand

b. Isolate the patient

c. Detoxify

d. Restrain the patient

Situation: Jonas, 32 years old has returned form Hong Kong and was admitted to St. John of God Hospital and
was tentatively diagnosed to have SARS.

50. Jonas is expected to have which of the following symptoms?

a. Fever and productive cough

b. Fever, rapid progressive respiratory compromise

c. Fever and dyspnes

d. Fever and cyanosis

51. Incubation period of SARS:

a. 2-8 days

b. 1-10 days

c. 1-5 days

d. 5-11 days

52. What is the causative agent of SARS?

a. Rhabdo virus

b. Influenza virus

c. Corona virus

d. Retro virus

53. Which of the following is the most serious complication of SARS:

a. Atelectasis

b. Respiratory cyanosis

c. Pulmonary congestion

d. Anaphylaxis
 54. The following countries where SARS originated includes the following except:

a. Philippines

b. Australia

c. China

d. Canada

Situation: A 20 year old client is being treated for pneumonia. He has persistent cough and complain of
coughing.

55. The nurse performed chest physiotherapy on the client. Before finishing the procedure, it is important to:

a. Tell the client to cough

b. Serve high protein, high carbohydrate diet

c. Place the head of your bed flat to help with coughing

d. Restrict fluids to help decrease the amount of sputum

56. What type of instruction could be given to help the reduce the discomfort he is having?

a. Splint your chest wall with pillow for comfort

b. Hold in your cough as much as possible

c. Place the head of your bed flat to help with coughing

d. Restrict fluids to help decrease the amount of sputum

57. A diagnosis of pneumonia is typically achieved by which of the following diagnostic test?

a. Chest x-ray

b. Nutritional intake

c. ABG analysis

d. Blood cultures

58. Which of the following organisms most commonly causes community acquired pneumonia in adults?

a. Streptococcus pneumonia

b. Haemophilus influenza

c. Klebsiella pneumonia

d. Staphylococcus aureus

59. The client has been treated with antibiotic therapy for left lower lobe pneumonia for 10 days. Which of
the following physical findings would lead the nurse to believe it is appropriate to discharge the client?

a. Continued dyspnea

b. Vesicular breath sounds in right base

c. Fever of 120 Farenheit

d. Respiratory rate of 32 breaths per minute

Situation: Nursing practice is governed bi difficult theoretical framework postulated by known theorists.

60. According to self care deficit theory, when the nurse is expected to accomplish all patients therapeutic
self care or to compensate for patient’s inability to engage in self care or when the patient needs
continuous guidance in self care is categorized as:

a. Partially compensatory

b. Wholly compensatory

c. Supportive education

d. Conservation of personal integrity

61. The four concepts common to nursing conceptual models:

a. Person, environment, health, nursing

b. Person, nursing, environment, medicine

c. Person, health, nursing, support system

d. Person, environment, psychology, nursing

62. Identified 14 Basic Needs and says that the unique function of a nurse is to assist client, sick or well in
the performance of these activities contributing to health it’s recovery or peaceful death.

a. Faye Abdellah

b. Ida Jean Orlando

c. Virginia Henderson

d. Imogene King

63. Identified 21 Nursinf Problem Areas:

a. Virginia Henderson

b. Faye Abdellah

c. Ida Jean Orlando

d. Imogene King

64. She introduced interpersonal and define nursing as an interpersonal process of therapeutic interactions
known as nurse-client relationship. She classified its phase as orientation, identification, exploitation and
resolution.

a. Lydia Hall

b. Hildegard Peplau

c. Martha Rogers

d. Sister Callista Roy

Situation: Arnilfo, age 36 is brought to the emergency room after threatening his parent with a knife. Diagnosis
is Personality disorder.
 65. A day after admission, Arnulfo is extremely agitated pacing back and forth. He mumbles to himself as
he paces. What could be the applicable initial nursing intervention?

a. Suggest to Arnulfo to go to his room

b. Request the male staff to retain Arnulfo

c. Observe him closely from safe distance and interact when necessary in a calm voice

d. Tell Arnulfo that if will not calm down, he will be placed in the isolation room

66. An appropriate nursing diagnosis based on the above behavior would be:

a. Potential for violence directed at others

b. Self esteem disturbance

c. Altered thought process

d. Sensory perceptual alteration

67. One morning, Arnulfo refuses his medication. The nurse should:

a. Force him to take the medication as ordered by the physician

b. Ask him why he is refusing the medication

c. Tell him that he needs the medication for his own good

d. Tell him its alright if he will not take his medication

68. To diffuse an impending hostile and violent behavior the appropriate intervention is:

a. Administer an antipyretic medication

b. Place him in the isolation room

c. Encourage him to verbalize his feeling of anger and anxiety

d. Leave him alone until he willingly talk about his feeling

69. The nurse includes this information in her assessment of the medical history

a. History of delusions and hallucination

b. History of violent behavior

c. Somatic changes he has noticed few weeks before admission

d. Previous psychiatric diagnosis

Situation: Ms. Elsa Cruz has fever with severe flank pain brought to the ER

70. Urinalysis was ordered for her, with your instruction about the examination, when can you take her urine
specimen?

a. Anytime as soon as there is specimen

b. AM only

c. Noon time if specimen is available

d. Evening before retiring

71. Intravenous pyelography was ordered, your nursing preparation would include the following, except:

a. Hydrating Ms. Cruz orally four hours before the procedure

b. NPO 8 hours before the test

c. Enema and AM

d. Check for history of allergies

72. By doing IVP, this would visualize her:

1. Bladder

2. Ureter and bladder

3. Bladder and kidneys

4. Ureter and kidneys

5. Ovary

a. 1 and 5

b. 3

c. 1 and 4

d. 4

73. Diagnosis of acute pyelonephritis has been established. Your nursing intervention includes the following
except:

a. Administer antibiotic

b. Measure I & O

c. Provide health teaching and discharge planning

d. Provide adequate comfort and rest

74. The least that you would include in your health teaching is:

a. Follow up culture

b. Signs and symptoms of recurrence and need to report

c. Low sodium diet compliance

d. Medication regimen

75. After the delivery of the baby, which of the following indicate a placental separation?

1. Protrusion of three or more inches of the umbilical cord

2. Gradual descent of the uterus further into the pelvis

3. Uterus becomes more firm and rounded

4. Sudden spurt of blood from the vagina

a. 1,3,4

b. 1,2,4

c. 2,3,4
 d. 1,2,3

Situation: Maxine, an ER nurse is preparing her equipments for blood transfusion to a patient who has massive
bleeding due to vehicular accident.

76. Initially, the nurse should let the blood flow at a rate of:

a. 10 gtts/min

b. 30 gtts/min

c. 20 gtts/min

d. 100 gtts/min

77. The only solution compatible during blood transfusion is:

a. Normal saline

b. Lactated Ringer’s

c. Balance Multiple Solution

d. Tap water

78. The intervention to patient with severe bleeding is:

a. Transfusion of whole blood

b. Transfusion of plasma

c. Infusion of plasma expanders

d. Infusion of NSS

79. During blood transfusion, the patient manifest tachycardia, distended neck veins and an increase in CVP
reading, the nurse should:

a. Stop infusion

b. Obtain vital signs

c. Increase the rate of infusion

d. Decrease the rate of infusion