1. Answer: B. Vasodilatation
Sympathetic activation to the heart results in coronary vasodilation and increased coronary flow due to increased metabolic activity (increased heart rate, contractility) despite direct vasoconstrictor effects of sympathetic activation on the coronaries. This is termed “functional sympatholysis.”
2. Answer: D. Blood pressure will increase
Blood pressure elevation secondary to hypoglycemia has been demonstrated in human experimentation through the activation of the sympathoadrenal system.
3. Answer: A. Increase heat, thereby produce abatement of phagocytosis
The inflammatory response is a defense mechanism that evolved in higher organisms to protect them from infection and injury. Its purpose is to localize and eliminate the injurious agent and to remove damaged tissue components so that the body can begin to heal. The response consists of changes in blood flow, an increase in permeability of blood vessels, and the migration of fluid, proteins, and white blood cells (leukocytes) from the circulation to the site of tissue damage. An inflammatory response that lasts only a few days is called acute inflammation, while a response of longer duration is referred to as chronic inflammation.
4. Answer: C. Immediate Vasoconstriction
Inflammation can be divided into several phases. The earliest, gross event of an inflammatory response is temporary vasoconstriction, i.e. narrowing of blood vessels caused by contraction of smooth muscle in the vessel walls, which can be seen as blanching (whitening) of the skin.
5. Answer: C. The affected part will lose its normal function
A fifth consequence of inflammation is the loss of function of the inflamed area, a feature noted by German pathologist Rudolf Virchow in the 19th century. Loss of function may result from pain that inhibits mobility or from severe swelling that prevents movement in the area.
6. Answer: C. Purulent
Purulent effluent refers to a thick yellow, gray or green drainage that comes out of a wound when infection invades the area. The fluid contains pathogenic microorganisms along with white cells, inflammatory cells and dead or dying bacteria. When the wound is infected, the volume of the purulent exudate increases.
7. Answer: A. Redness on the affected area
Vasodilation occurs first at the arteriole level, progressing to the capillary level, and brings about a net increase in the amount of blood present, causing the redness and heat of inflammation.
8. Answer: D. Monocytes
Monocytes and their macrophage and dendritic-cell progeny serve three main functions in the immune system. These are phagocytosis, antigen presentation, and cytokine production. Phagocytosis is the process of uptake of microbes and particles followed by digestion and destruction of this material. Monocytes can perform phagocytosis using intermediary (opsonising) proteins such as antibodies or complement that coat the pathogen, as well as by binding to the microbe directly via pattern-recognition receptors that recognize pathogens.
9. Answer: C. Eosinophil
It is known that eosinophils appear as an aftermath of anaphylaxis in sensitized tissues that are reexposed to specific antigens.
10. Answer: A. Neutrophils
Activated neutrophils are capable of presenting antigens via MHCII, thereby stimulating T-cell activation and proliferation.
11. Answer: C. Pavementation
Pavementation or the sticking of white blood cells to the linings of the finest blood vessels (capillaries) when inflammation occurs is the first process that occurs in the inflammatory response after injury.
12. Answer: D. I don’t know the answer, perhaps I can tell you after I find it out later
13. Answer: C. Third intention
Healing by third intention is a method of closing a grossly contaminated wound in which the wound is left open until contamination has been markedly reduced and inflammation has subsided and then is closed by first intention. Also called delayed primary closure.
14. Answer: A. First intention
Healing by first intention aka. primary wound healing or primary closure describes a wound closed by approximation of wound margins or by placement of a graft or flap, or wounds created and closed in the operating room.
15. Answer: B. Second intention
Healing by second intention aka. secondary wound healing or spontaneous healing Describes a wound left open and allowed to close by epithelialization and contraction.
16. Answer: B. High protein, High calorie with Vitamin A and C rich foods
Even if you do not currently have any aches or pains, adding these foods into your diet can help prepare your body for healing if you should happen to get hurt.
17. Answer: A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues
This type of mechanical debridement is done by placing a wet (or moist) gauze dressing on your wound and allowing it to dry, wound drainage and dead tissue can be removed when you take off the old dressing.
18. Answer: C. Compression of the local nerve endings by the edema fluids
Chemicals that stimulate nerve endings are released, making the area much more sensitive and the inflamed area is likely to be painful, especially when touched.
19. Answer: B. 1,3,4
20. Answer: D. Smoke cigarette around 3:00 A.M
The phrase “NPO After Midnight” is one of the most common in medicine. It is present not only in physician’s pre-operative orders, but repeated by nurses, ward secretaries and dietary workers. The goal of “NPO after midnight” was to ensure an empty stomach for the morning procedure.
21. Answer: B. Decrease Urine output
22. Answer: A. Directed towards helping an individual both physically and emotionally
Therapeutic nurse-patient communication helps nurses to build positive relationships with patients by showing warmth, respect, and empathy. It also increases confidence of the nurse by enabling nurses to ask for support, open up for feedbacks, and overcome anxiety. Therefore allows nurses to provide the best possible care for patients. Effective nurse-healthcare provider communications assure optimal patient-centered care.
23. Answer: B. Peplau
Peplau published her Theory of Interpersonal Relations in 1952, and in 1968, interpersonal techniques became the crux of psychiatric nursing. The nursing model identifies four sequential phases in the interpersonal relationship: orientation, identification, exploitation, and resolution.
24. Answer: A. Pre Orientation
Pre-orientation phase begins when the nurse is assigned to the patient. It includes all that the nurse thinks and does before interacting with the patient such as when the nurse review the client’s medical records.
25. Answer: B. Orientation
Orientation Phase begins when the nurse and the patient meet for the patient. In this phase, parameters of the relationship is done. Explanation of roles is also done during this phase which includes the responsibilities and expectation of the patient and nurse, with the expectations of both parties of what they can and can’t do. It is during the orientation phase when the nurse begins to know the patient.
26. Answer: C. Working
The working phase is highly individualized. it is more structured than the orientation phase- meaning most of the therapeutic work is done during this phase.
27. Answer: B. Positive regard
Unconditional positive regard often described as acceptance is the third core condition and this involves taking a non-judgemental attitude towards the client accepting and respecting them for who and what they are.
28. Answer: B. Positive regard
Refer to #27
29. Answer: A. It is a nervous energy
Stress is a normal physical response to events that make you feel threatened or upset your balance in some way. A nervous energy is more part of anxiety.
30. Answer: D. Martina is in Crisis
Martina is in Crisis. She feels sad and down during this tough time. She can have intense negative feelings for weeks, months or more.
31. Answer: D. The source of dread or uneasiness is from a recognized entity
Anxiety is a general term for several disorders that cause nervousness, fear, apprehension, and worrying. These disorders affect how we feel and behave, and they can manifest real physical symptoms. Mild anxiety is vague and unsettling, while severe anxiety can be extremely debilitating, having a serious impact on daily life.
32. Answer: D. Panic
Panic is the highest level of anxiety and is associated with dread, terror and a sense of impending doom. You may not be able to communicate, function or concentrate because you are unable to think rationally. You may start uncontrollably pacing and become increasingly active without absolute purpose.
33. Answer: B. Moderate
At this level, you lose the broader picture and focus only on the cause of the anxiety. You may not be able to pay attention like usual, and even though your perceptual field is narrowed, you are still able to solve a problem. Mild and moderate levels of anxiety are considered normal.
34. Answer: B. Dilated pupils
35. Answer: B. When the client starts to have a narrow perceptual field and selective inattentiveness
36. Answer: C. The client asks a question
37. Answer: A. Offer choices
38. Answer: D. “What makes you feel anxious?”
39. Answer: B. Concentrating on breathing without tensing the muscle, Letting go and repeating a word or sound after each exhalation
The Relaxation Response is essentially the opposite reaction to the “fight or flight” response. According to Dr. Benson, using the Relaxation Response is beneficial as it counteracts the physiological effects of stress and the fight or flight response.
40. Answer: A. Biofeedback
Biofeedback is a technique you can use to learn to control your body’s functions, such as your heart rate. With biofeedback, you’re connected to electrical sensors that help you receive information (feedback) about your body (bio). This feedback helps you focus on making subtle changes in your body, such as relaxing certain muscles, to achieve the results you want, such as reducing pain.
In essence, biofeedback gives you the power to use your thoughts to control your body, often to help with a health condition or physical performance. Biofeedback is often used as a relaxation technique.
41. Answer: C. Autogenic training
Autogenic Therapy (AT) is a powerful mind and body technique involving simple relaxation and body awareness exercises. These reduce the intensity of the body’s stress response, and replace it with a calmer physiological state in which self-healing naturally begins to occur.
42. Answer: D. Luvox
Luvox (fluvoxamine) is a selective serotonin reuptake inhibitor (SSRI) antidepressant. Fluvoxamine affects chemicals in the brain that may become unbalanced and cause obsessive-compulsive symptoms. It is frequently used along with benzodiazepine anxiolytics in clinics.
43: Answer: B. 2,3
Spiritual anxiety is the expression of fear of God’s wrath and punishment; fear that God might not take care of one, either immediately or in the future; and/or worry that God is displeased with one’s behavior. Spiritual guilt is an expression suggesting that one has failed to do the things which he should have done in life and/or done things which were not pleasing to God; articulation of concerns about the “kind” of life one has lived. Spiritual pain is the expression of discomfort of suffering relative to one’s relationship with God, verbalization of feelings of having a void or lack of spiritual fulfillment, and/or a lack of peace in terms of one’s relationship to one’s creator. And spiritual despair is the expression suggesting that there is no hope of ever having a relationship with God or of pleasing Him and/or a feeling that God no longer can or does care for one.
44. Answer: B. Spiritual Alienation
Spiritual alienation is the expressions of loneliness or the feeling that God seems very far away and remote from one’s everyday life, verbalization that one has to depend upon one’s self in times of trial or need, and/or a negative attitude toward receiving any comfort or help from God.
45. Answer: B. Spiritual Loss
Spiritual loss is the expression of feelings of having temporarily lost or terminated the love of God, fear that one’s relationship with God has been threatened, and/or a feeling of emptiness with regard to spiritual things.
46. Answer: C. Making observation
Making observation is a therapeutic observation that is verbalizing what is observed or perceived.
47. Answer: B. Restating
Restating lets client know whether an expressed statement has or has not been understood.
48. Answer: A. Reflecting
Reflecting directs questions or feelings back to client so that they may be recognized and accepted.
49. Answer: A. Reflecting
Reflecting is directing back to the patient questions, feelings, and ideas.
50. Answer: B. Restating
Restating is repeating the main idea expressed.
51. Answer: C. Voicing Doubt
Voicing doubt is expressing uncertainty as to the reality of client’s perception.
52. Answer: C. “Hello Mr. Tadle, You are here in the hospital, I am your nurse and you are a patient here”
This is an example of presenting reality. It is clarifying misconceptions that client may be expressing.
53. Answer: D. “Why are you so anxious? Please tell me more about your feelings Erik”
Requesting an explanation is an ineffective behavior and response.
54. Answer: C. Displacement
Displacement is the redirecting of thoughts feelings and impulses directed at one person or object, but taken out upon another person or object. People often use displacement when they cannot express their feelings in a safe manner to the person they are directed at.
55. Answer: A. Restitution
Restitution is the mechanism of relieving the mind of a load of guilt by making up or reparation (paying up with interest).
56. Answer: C. Lasts for 4 months
57: Answer: B. There is a triggering event
Crisis is any event that is, or is expected to lead to, an unstable and dangerous situation affecting an individual, group, community, or whole society.
58. Answer: B. Maturational
Maturational crisis a life crisis in which usual coping mechanisms are inadequate in dealing with a stress common to a particular stage in the life cycle or with stress caused by a transition from one stage to another.
59. Answer: A. Situational
Situational crisis is an unexpected crisis that arises suddenly in response to an external event or a conflict concerning a specific circumstance.
60. Answer: C. Social
Social Crisis is the crisis which hampers the social life of an individual. It can include recession, World War, terrorism etc., these are the major factor which is responsible for social crisis.
61. Answer: D. Provide alternate coping mechanism
One of the goals for crisis intervention is that the victim and the counselor begin to collaboratively generate and explore alternatives for coping. Although this situation will be unlike any other experience before, the counselor should assist the individual in looking at what has worked in the past for other situations; this is typically the most difficult to achieve in crisis counseling.
62. Answer D. Milieu Therapy
The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s hospital experience are considered therapeutic.
63. Answer: C. 2,3,4
A therapeutic nurse-client relationship is established for the benefit of the client. It includes nurses working with the client to create goals directed at improving their health status. Goals are centered on the client’s values, beliefs and needs. A partnership is formed between nurse and client. The nurse empowers patient and families to get involved in their health. This relationship has three phases, a beginning (first time contact/introduction), a middle (develop a relationship to deliver care) and an end (the patient is no longer dependant on the nurse).
64. Answer: A. She has increased awareness of her environmental details
Mild anxiety is anxiety that is manageable without any additional techniques. Mild anxiety tends to be when you have irritating symptoms that don’t seem to go away, but otherwise don’t control you.
65. Answer: B. Provide opportunities to express feelings
Providing opportunities for the client to express his or her feelings will likely trigger his or her aggressiveness more.
66. Answer: D. What is that you said?
Clarification should be sought at each step of the way. The patient is usually quite aware when he is not being understood. Eventually he may cease trying to communicate. Peplau states that it is always possible to ask: What is that you said?
67. Answer: B. Ask the client to express feelings and concern
Asking the client to verbalize what she or he perceives may relieve the tension the client is feeling and he or she might be less likely to take action on ideas that are harmful or frightening.
68. Answer: B. Non verbal communication
Non verbal communication is considered as the most accurate expression of person’s thought and feelings. Nonverbal communication represents two-thirds of all communication.
69. Answer: B. Covert communication
“Overt” means “done or shown openly or plainly apparent” in the Oxford English dictionary. This can refer to all sorts of actions which are done in plain sight or with clear manifestations. “Covert,” on the other hand, means the exact opposite of overt – not openly acknowledged or displayed.
70. Answer: D. Discourages emotional bond
Emotional support is important in order for a nurse-client relationship to be effective. It is giving and receiving reassurance and encouragement done through understanding.
71. Answer: D. Resource oriented
72. Answer: A. POMR
Problem-oriented medical record (POMR) is a method of recording data about the health status of a patient in a problem-solving system. The POMR preserves the data in an easily accessible way that encourages ongoing assessment and revision of the health care plan by all members of the health care team.
73. Answer: D. Flow sheet
Flowsheet (in a patient record) is a graphic summary of several changing factors, especially the patient’s vital signs or weight and the treatments and medications given.
74. Answer: A. Kardex
The Kardex is a trademark for a card-filing system that allows quick reference to the particular needs of each patient for certain aspects of nursing care.
75. Answer: A. Mongol #2
Kardexes are a huge risk factor for med errors that is why they are written in pencil. They are not legal documents and are discarded when the patient is transferred out. And they are only as good as the nurse responsible for checking the orders
76. Answer: C. At the front metal plate of the chart
77. Answer: C. The primary basis of endorsement
Refer to #75.
78. Answer: A. The client has a blood pressure of 120/80, Temperature of 36.6 C Pulse rate of 120 and Respiratory rate of 22
Shortcuts would be safe to use on records when commenting on blood pressure, temperature, pulse rate, and respiratory rate respectively. Do not use an abbreviation unless you are sure that it is commonly understood and in general use.
79. Answer: B. Before meals
80. Answer: C. After meals
81. Answer: D. Once a day
82. Answer: B. with
83. Answer: C. one half
84. Answer: A. Martin starts exercising every morning and eating a balance diet after you taught her mag HL tayo program
Learning has been achieved by the patient if he or she applies and acts upon the teachings of the health care provider or the nurse. Verbalizing such learning does not guarantee an effective nurse teaching.
85. Answer: C. Thorndike
After several experiments on animals and learning development, Thorndike posited that learning was actually merely a change in behavior as a result of a consequence. Furthermore, if an action brought a reward, it was stamped into the mind and available for recall later. These two suppositions together came to be known as the Law of Effect, and now inform much of what we know about operant conditioning and behaviorism.
86. Answer: D. Do not teach a client when he is in pain
Pain tells us something is wrong. Pain does not suggest that the patient is ready to listen and perceive properly the teaching that the nurse may impart.
87. Answer: C. Psychomotor
Bloom’s Taxonomy model is in three parts, or ‘overlapping domains’. Again, Bloom used rather academic language, but the meanings are simple to understand: The learner should benefit from development of knowledge and intellect (Cognitive Domain); attitude and beliefs (Affective Domain); and the ability to put physical and bodily skills into effect – to act (Psychomotor Domain).
88. Answer: A. Cognitive
Refer to #87.
89. Answer: C. Therapeutic communication is a reciprocal interaction based on trust and aimed at identifying patient needs and developing mutual goals
Therapeutic communication is a process in which the nurse consciously influences a client or helps the client to a better understanding through verbal or nonverbal communication. Therapeutic communication involves the use of specific strategies that encourage the patient to express feelings and ideas and that convey acceptance and respect.
The goal of therapeutic communication is to increase self-worth or decrease psychological distress by collecting information to determine the illness, assessing and modifying the behavior, and providing health education.
90. Answer: D. The nurse should understand that patients might test her before trust is established
A therapeutic nurse-patient relationship is defined as a helping relationship that’s based on mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the gratification of your patient’s physical, emotional, and spiritual needs through your knowledge and skill.
91. Answer: A. Validation
92. Answer: D. 1,2,3,4
Documentation in nursing is also an integral part of providing quality and safe care to patients. Qualities of a good recording include Brevity, Completeness and chronology, Appropriateness and Accuracy.
93. Answer: C. Seems agitated
Being accurate is very important. For example, do not use vague terms such as “good urine output.” How many cc’s are “good?” Chart the specific amount and be accurate on things that you see and observe.
94. Answer: B. Demonstration
In teaching through demonstration, patients are set up to potentially conceptualize material more effectively.
95. Answer: A. It is growth facilitating
You can help your patient achieve harmony in mind, body, and spirit when engaging in a therapeutic relationship based on effective communication that incorporates caring behaviors. It’s a win-win situation in which you and your patient can experience growth by sharing “the moment” with each other.
96. Answer: A. Tell the patient that deep breathing and coughing exercises is needed to promote good breathing, circulation and prevent complication
Deep breathing and coughing will decrease your risk for a lung infection. Take a deep breath and hold it for as long as you can. Let the air out and then cough strongly. Deep breaths help open your airway. You may be given an incentive spirometer to help you take deep breaths. Put the plastic piece in your mouth and take a slow, deep breath. Then let the air out and cough. Repeat these steps 10 times every hour.
97. Answer: B. Notify the attending physician
98. Answer: C. Active listening on what the patient says
Assessment of the patient experiencing pain is the cornerstone to optimal pain management. However, the quality and utility of any assessment tool is only as good as the clinician’s ability to thoroughly focus on the patient. This means listening empathically, believing and legitimizing the patient’s pain, and understanding, to the best of his or her capability, what the patient may be experiencing. A health care professional’s empathic understanding of the patient’s pain experience and accompanying symptoms confirms that there is genuine interest in the patient as a person. This can influence a positive pain management outcome.
99. Answer: B. Knowing yourself
It is important for the nurse to know herself to identify kinds of behavior of ideas that make her anxious and to seed help for her problems. Otherwise, she is likely to add new problems to those with which the patient is already struggling.
100. Answer: D. Read it yourself then, Have the client read the material