funda exam

1 FOUNDATIONS OF NURSING PRACTICE

1. The major concepts that provide structure to the domain of nursing are the following EXCEPT:A. PersonB. EnvironmentC. Health D. Wellness

2. Orem’s theory focuses on the individual. Furthermore, it is problem oriented and is easily adaptable in varied clinical situations. It has three interconnecting theories which include the following EXCEPT:A. Theory of nursing systemsB. Theory of self-careC. Theory of self-care requisiteD. Theory of self-care deficit

3. Nurse May is caring for a 7-year old child suffering from diarrhea and is admitted to the unit for treatment of severe dehydration. Nurse May observes aseptic technique as she performs IV insertion. Whose theory is she applying?A. Nightingale’sB. Peplau’sC. Orem’sD. Roy’s

4. Nurse May assists the patient with Severe Dehydration in going to the rest room during episodes of diarrhea. Whose theory is she practicing?A. Parse’sB. Orem’sC. Watson’sD. Roy’s

5. When nurse May interacts with the patient and her family, she responds therapeutically. This action made by the nurse supports which of the following theories?A. AdaptationB. Behavioral SystemsC. Goal attainmentD. Interpersonal

6. Kimberly has been diagnosed to have Diabetes Mellitus. Despite her condition, she still goes to the office and excels in her profession. Kimberly can be considered healthy utilizing which of the following models identified y Smith?A. Clinical ModelB. Adaptation modelC. Role performance modelD. Eudaemonistic model

7. The world Health Organization’s definition of health basically encourages healthcare providers to:A. Provide holistic care to the different levels of clienteleB. Consider spiritual health in the plan of careC. Focus on physical health D. Develop caring attitude towards clients

8. Veronica is concerned with her ideal body weight. In order to keep her in shape, she does series of exercises in the morning. What veronica does in the morning speaks of:A. Mental HealthB. Physical HealthC. Emotional healthD. Social Health

9. Michael always has a positive attitude towards experiences. He is able to cope well with different life situations. Michael is:A. Physically healthyB. Emotionally healthy


C. Mentally healthyD. Socially Healthy

10. The World Health Organization clearly described health as:A. The state of emotional and physical wellnessB. The state of complete physical, mental and social well-being and not merely the absence

of diseaseC. The state of complete physical, mental, and spiritual well-being and not merely the absence

of infirmityD. The state of social and emotional wellness

11. All of the following are activities done under the secondary level of prevention EXCEPT:A. Daily intake of Vitamin CB. Breast Self ExaminationC. Blood Pressure ScreeningD. Testicular Self Examination

12. A patient diagnosed with Diabetes Mellitus is consistently monitoring his blood sugar level to make sure that it is controlled and within the normal range. This type of monitoring is under:A. The primary level of preventionB. The secondary level of preventionC. The tertiary level of preventionD. None of the above

13. Which of the following supports the activities done in the tertiary level of prevention?A. Regular ExerciseB. Breast self examinationC. Speech therapy D. Case finding

14. Which of the following models greatly emphasizes that a person can only be considered healthy if he/she is able to achieve self actualization?A. Clinical performance modelB. Adaptation modelC. Role performance modelD. Eudaemonistic model

15. For a person to achieve high level of wellness, the following factors must be considered EXCEPT:A. AwarenessB. EducationC. GrowthD. Disability

16. Nurse Bob is aware of the primary purpose of Assessment when he states that:A. Assessment is done to determine client’s strength, weaknesses, risks, and problemsB. Assessment is done to establish a database about the client’s perceived needs and

responses to health problemsC. Assessment is carried out to develop individualized care plan that specifies client’s goals and

expected outcomesD. Assessment is used to measure the degree to which goals have been achieved

17. The following are activities NOT being carried out during the assessment phase of the nursing process EXCEPT:A. Comparing data against standardsB. Clustering/grouping of dataC. Formulating nursing diagnosisD. Collecting data and review of client’s records

18. The following are considered covert data EXCEPT:A. Anxiety verbally reported by the clientB. Pain experienceC. Feelings of mental stress


D. Body temperature of 38.5 degree Celsius19. Nurse RP approaches a client for an interview. To elicit information, he asked, “Tell me more

about how you feel this morning”. This is an example of a/an:A. Open-ended questionB. Close-ended questionC. Complex questionD. Probing question

20. The following are examples of close-ended questions EXCEPT:A. Share with me your concernsB. Are you experiencing pain right now?C. On a scale of 1-10, how would you rate your pain?D. Do you understand why you are to undergo X-ray?

21. Client’s emotional health history would include the following EXCEPT:A. Support systemsB. Body imageC. Self-conceptD. Cultural heritage

22. Michael obtains data about history of Diabetes, Hypertension, Cerebrovascular accident, and cancer among family members and relatives. The data gathered would be written in what portion of the nursing assessment?A. Psychosocial HistoryB. Environmental historyC. Family historyD. Past health history

23. The important skills needed to obtain precise information from your client are:A. Teaching and assessment of some body parts onlyB. Cognitive and teachingC. Psychomotor and CognitiveD. Good communication and Critical Thinking

24. Nursing Diagnosis is BEST described as:A. The identification of a disease condition based on a specific evaluation of physical signs and

symptomsB. The collection, organization, and verification of client’s current health concernsC. The clinical judgment about individual, family, and community responses to actual and

potential health problemsD. The process of comparing outcomes of nursing interventions against standards

25. The use of standard formal nursing diagnostic statements serves several purposes. These include:A. Nursing diagnoses offer a language to promote understanding between nurses about

client’s health problems to facilitate communication and care planningB. They distinguish the nurse’s role from that of a physicianC. Both A and BD. None of the above

26. The nursing process is a:A. Method for processing the care of many patientsB. Method for diagnosing and treating human responses to actual or potential health problemsC. Method for diagnosing diseaseD. Logical, systematic, problem solving method for providing nursing care

27. The provision of immediate care needed by the patient is the nurse’s concern. Hence, you establish priorities according to:A. Patient’s needsB. Doctor’s order


C. List of factors affecting patient’s conditionD. Family instructions

28. The most important benefit of the nursing process to the client is that:A. Helps them understand what nurses doB. Helps ensure quality nursing care that meets individuals needsC. Ensures efficient use of nursing time and resourcesD. Increases collaborative practice and job satisfaction

29. The nursing process is a dynamic process meaning:A. It is ever changing in response to the client’s needsB. Conveys the force or power of the health teamC. Allows the client to achieve new goals each dayD. Provides solutions for clients problems

30. The primary source of data collection is the:A. ClientB. FamilyC. DoctorD. Chart

31. An example of an objective data isA. DizzinessB. Joint painC. HeadacheD. Tachycardia

32. Nursing process is said to be client-centered when:A. The nurse organizes the plan of care according to clients problems rather than nursing

goalsB. It enables to respond to the changing health status of the clientC. Allows the client to achieve new goals each day together always with the nurse D. None of the aboveE. All of the above

33. Collection of Data from nursing history is part duringA. AssessmentB. DiagnosisC. PlanningD. ImplementationE. Evaluation

34. She saw the nursing process as interactive and stated that the process included three phases and these are client’s behavior, reaction of the nurse and the nursing actions.A. Hildegard PeplauB. Ida Jean OrlandoC. Dorothy JohnsonD. Lydia Hall

35. There are various types of nursing diagnoses wherein this type is one in which evidence about a health problem is unclear or the causative factor are unknown.A. Actual diagnosisB. High risk nursing diagnosisC. Possible nursing diagnosisD. Wellness diagnosis

36. A client is considered healthy according to the eudaemonistic model of healthA. When he realizes his full potentialB. As long as he is able to continue workingC. When he can adjust to changes in his environmentD. As long as he is able to adapt to stresses

37. At the end of an examination, the physician remarked to the client that he has no signs and symptoms of disease or illness. The client would be considered healthy by which level of healthA. Adaptive


B. Role PerformanceC. ClinicalD. Eudaemonistic

38. When using a health belief model, it is important to understand that the manner in which the person typically behaves about health and illness is most likely related to the:A. Availability of health and illness careB. Facts the patient has about health and illnessC. Perceptions of the patient about health and illnessD. Importance health practitioners attach to health and illness

39. According to this model, a man who works all day at his job as expected is healthy even though an X-ray film in his lung indicates tumor.A. Adaptive ModelB. EudaemonisticC. ClinicalD. Role Performance

40. Leavell and Clark’s Model about health describes:A. The interplay between agent, host and environment affecting health and illnessB. The multi-dimensional nature of persons as they interact within the environment to pursue

healthC. The relationship between a person’s belief and behaviorD. The interaction of the environment with well-being and illness

41. He describes the WELLNESS-ILLNESS Continuum as interaction of the environment with well-being and illness.A. CannonB. BernardC. DunnD. Clark

42. What regulates HOMEOSTASIS according to the theory of Walter Cannon?A. Positive feedbackB. Negative feedbackC. Buffer systemD. Various mechanisms

43. Is a multi-dimensional model developed by PENDER that describes the nature of persons as they interact within the environment to pursue healthA. Ecologic Model

B. Health Belief Model

C. Health Promotion Model

D. Health Prevention Model

44. Professor X has been attending physical therapy sessions after having a stroke that resulted in severe weakness of the left side of his body. This is part of:A. Primary preventionB. Secondary PreventionC. Tertiary PreventionD. Illness Prevention

45. She is the first one to coin the term “Nursing Process”. She introduced 3 steps of nursing process which are observation, ministration and validation.A. NightingaleB. JohnsonC. Rogers


D. Hall46. For her nursing is a theoretical system of knowledge that describes a process of

analysis and action related to care of the ill personA. KingB. HendersonC. RoyD. Leininger

47. Nursing is a unique profession, Concerned with all the variables affecting an individual’s response to stressors, which are intra, inter and extra personal in nature.A. NeumanB. JohnsonC. WatsonD. Parse

48. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health that he would perform unaided if he has the necessary strength, will and knowledge, and do this in such a way as to help him gain independence as rapidly as possible.A. HendersonB. AbdellahC. OremD. Peplau

49. Caring is the essence and central unifying, a dominant domain that distinguishes nursing from other health disciplines. Care is an essential human need.A. BennerB. WatsonC. LeiningerD. Swanson

50. Use Maslow’s hierarchy of human needs to prioritize the following patient problems from highest to lowest priority:

I. Disturbed body imageII. Ineffective airway clearanceIII. Spiritual distressIV. Impaired social interaction

A. II, IV, I, IIIB. III, I, IV, IIC. I, IV, III, IID. III, II, IV, I

Spirituality, Religion, Faith, Spiritual Development, and Spiritual Well-being are important points which the nurses must look into in their patients. The roles of the nurse in understanding their religious practices may also affect the nursing care they render and the nursing process that promote spiritual health across the life span of these clients.

51. Individuals of the Islamic religion have some dietary restrictions. They must avoid:a. Pork and alcoholb. Fish and caffeinec. Chicken and cow’s milkd. Beef and citrus

52. A Muslim client is dying. Because the nurse has discussed death with the family, she knows that:a. A Muslim must perform ritual cleansing and preparation of the body for burialb. The chaplain should be called to anoint the bodyc. If a religious leader is not available, she should baptize the client before he diesd. The family will not want to touch the body or remain in the room after the client dies

53. Which dietary adjustment would support a hospitalized Muslim’s spiritual wellness during Ramadan?

a. Arranging for only one large meal to be served in the middle of the dayb. Including whole grain foods and fresh fruit with each meal


c. Providing herbal teas and unleavened bread before each meald. Requesting that meals be served before dawn and after sunset

54. A young Roman Catholic female client just gave birth to a premature baby with very serious respiratory difficulties. It is important to know that based on the young mother’s religion, she may:

a. Want the infant to be baptized because its life is in dangerb. Be opposed to blood transfusionc. Want to receive Holy Communion as soon as possibled. Require that removed body part or tissues (such as the placenta) be buried

Nutrition is one of the basic components in life that is needed to be maintained. As nurses, we should know the normal concepts of it in order to assess clients with nutritional needs and plan their interventions. The following questions deal with nutrition.

55. What is the most important action a nurse can take in promoting good nutrition for a hospitalized 89-year-old Hispanic client?

a. Explain that tamales contain meat and spices that are not good for her.b. Request that the dietitian add peppers and tortillas to her menuc. Find out what the client likes to eat and try to include that in her dietd. Teach her the foods suggested by the Food Guide Pyramid

56. Which of the following clients may be exhibiting signs of poor nutritional status?a. A client whose hair is shiny, and neither dry nor oilyb. A client whose skin is dry and rough with a few bruisesc. A client whose tongue and mucous membranes are pink and moistd. A client whose body mass index is 26

57. Which of the following menus is acceptable for a client on a clear liquid diet?a. Milk, coffee, and apple juiceb. Tea, cola, and gelatinc. Water, tea, coffee and ice creamd. Milk, gelatin and cola

58. What should a nurse do to stimulate the appetite of a client who is not eating well?a. Have the family bring large, attractive portions of food to provide to the clientb. Provide food that the client likes and relieve symptoms of illnessc. Provide treatments before mealtime so the client doesn’t have to think about them

while eatingd. Provide meals after the client has been active because activity increases appetite

Fecal and Urinary Elimination are two important things which are needed to be monitored in man’s daily living. Nurses must know how to assist clients who has alterations in these areas.

59. An 80-year-old client is worried because she has not had a bowel movement every day. Which statement by her nurse reflects the best understanding of defecation patterns?

a. “A bowel movement each day is the normal pattern for most people. We will ask for a laxative order for you.”

b. “You shouldn’t worry until you have gone at least three days without a bowel movement.”

c. “You need to eat more fiber to stimulate daily bowel movements. Can I get you some prunes?”

d. “The number of bowel movements per week varies greatly. It can be quite normal to have only two or three bowel movements per week.”

60. Which of the following is the most appropriate outcome criterion for a client with constipation?a. The client will remain free of perianal irritation and odor.b. The client will participate actively in a bowel-training program.c. The client will consume a well-balanced diet that includes fiber and 8 to 10 glasses of

fluid daily.d. The client will be free of flatulence.


61. A client tells the nurse, “The need to urinate comes on me all of a sudden, and it feels as though I have to go immediately – that I can’t wait.” The nurse would chart that the client is experiencing:

a. Urinary frequencyb. Enuresisc. Urinary urgencyd. Dysuria

62. To promote normal urinary elimination for a client confined to bed, the nurse should:a. Warm the bed pan and help the client simulate normal voiding positionb. Apply cold water over the perineumc. Perform Crede’s maneuverd. Show the client how to inhibit the urge to void

63. When individuals are in a well or healthy state, their fluid output should be:a. Approximately the same as their fluid intakeb. Correlated very little with their fluid intakec. Higher than their fluid intaked. Lower than their fluid intake

64. A 75-year-old client has been hospitalized because of a stroke. He has left-sided weakness but is permitted to ambulate with a walker. To ensure the client’s safety when he is out of bed, the nurse should:

a. Restrict his activity to use of a wheelchairb. Follow him with a wheelchair as he walksc. See that he wears non-skid footweard. Apply a Posey restraint when he is in the chair

65. Which of the following is not a characteristic of an open system?a. It exchanges matter, energy or information with the environment.b. It is independent and sequestered from other systems.c. It allows sustaining elements to enter the system to nourish it.d. It is easily affected by changes in other systems.

66. 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 amputationb. A patient with second degree burnsc. A quadriplegic patientd. A patient entering the health care system after moving from wellness to illness

67. Faye, diagnosed with cancer of the breast, is scheduled to undergo chemotherapy. How should the nurse deal with the topic of hair loss with the client?

a. Discuss about hair loss as it occurs.b. Provide reading material about chemotherapy.c. Acknowledge that hair loss may be a difficult side effect and explore patient’s feelings

about this.d. Give the patient information about head scarf, hats or wigs.

68. Who among the following clients should be attended to first by the nurse?a. The client with cough and coldsb. The client with pain on the chestc. The client with fever due to infectiond. The client who is for discharge

69. The concept of man forms the foundation of nursing. To be able to provide individualized care, a nurse should understand Man. The following are concepts of man according to Rogers except:

a. Man is a being who is in constant contact with the environment.b. Man is a unified whole composed of parts which are interdependent and interrelated

with each other.c. Man is composed of subsystems and suprasystems.d. Man is greater than and different from the sum of all his parts.

70. When a client believes that in order for health to be maintained, the forces of nature must be in balance or in harmony with one another, what health belief does the client uphold?


a. Magico-religious health beliefb. Biomedical health beliefc. Holistic health beliefd. None of the above

71. A client who was admitted to a medical care facility due to a diagnosis of cancer verbalizes, “What did I do wrong to be punished with this disease?” What system of health belief does the client use to attribute the cause of his illness?

a. Magico-religious health beliefb. Scientific health beliefc. Holistic health beliefd. None of the above

72. Man has long attributed the cause of his illness or disease as something beyond what science or medicine can explain. As such, man has also sought folk healing methods in hopes of finding a cure. The following are reasons why people use traditional folk medicine, which one is not?

a. Folk medicine is thought to be more humanisticb. Limited access to scientific health carec. Folk healing is more culturally basedd. Folk healing is more frightening for the client

73. You are assigned to take care of a Korean patient who has limited knowledge of the English language. In order for you to have a fruitful interaction with the client, what should you not do?

a. Avoid using slang words, medical terminologies and abbreviations.b. Use gestures whenever necessary to emphasize what you are trying to convey.c. Increase the volume of your speech so the client can understand you better.d. Validate the client’s understanding of what is being said.

Situation: Miscommunication commonly occurs in intercultural interactions due to language and communication differences. As a nurse, it is your responsibility to conduct a cultural assessment of your client to establish a meaningful relationship. The following questions pertain to cultural assessment.

74. Which among the following components of cultural assessment can be seen as contributory in providing information that can be useful in giving a culturally-aligned nursing care?

a. Ethnic heritage, biocultural history, social organization, time orientationb. Subcultures, ethnicity, worldviewsc. Enculturation, assimilation, acculturationd. All of the above

75. In assessing for caring beliefs and practices, the following questions are usually asked. Which one is not?

a. “What do you do to keep yourself well?”b. “What do you do to show someone you care?”c. “Are we doing what you think we should be doing for you?”d. “How do you want us to talk to you?”

76. When meeting a client of different culture for the first time, it is important to make a good first impression in order to elicit client’s participation and obtain accurate assessment data. Which of the following demonstrates an ineffective way of encouraging client participation?

a. Greet the client and the family in their own language if you know it.b. Tell the client your purpose.c. Clarify if client wants a family member to be present.d. If client uses an interpreter, direct your question to the interpreter.

77. Which of the following clients is most at risk for fluid imbalance?a. an infant with diarrheab. an adolescent mowing the lawn on a hot dayc. a healthy 70-year-old man with a fractured wristd. a middle-aged woman who is vomiting

78. At 3:00 p.m. a client has 150 cc remaining in his IV bag. At 4:30 p.m. the nurse hangs a new 1000 cc bottle of IV fluid and when she checks it at 10:15 p.m., there is 700 cc left. In addition, during


the nurse's shift, the client drinks two 240 cc cartons of milk and 250 cc of water. He has had a liquid stool measuring 350 cc and has voided three times: 260 cc, 310 cc, and 175 cc. Which of the following should the nurse record on her I and O sheet?

a. intake = 940 cc; output = 745 ccb. intake = 1,340 cc; output = 745 ccc. intake = 1,180 cc; output = 1,095 ccd. intake = 1,640 cc; output = 1,095 cc

79. The nurse working throughout the night is having difficulty getting sleep during the day. Which of the following could explain this difficulty?

a. The nurse is resting too much at work.b. The nurse is not tired.c. The circadian synchronization is mismatched.d. The nurse is getting too much REM sleep.

80. A client presents to the clinic with chief complaint of fatigue and inability to sleep at night. Which nursing physical assessment findings would support the client's statement?

a. attentiveness with good postureb. puffy red eyes and irritabilityc. patient, understanding, and quiet demeanord. coordinated, rapid speech

81. What are the three basic concepts that must be considered in achieving good body mechanics?a. body alignment, balance, and coordinated body movementb. body alignment, inertia, and gravityc. center of gravity, balance, and base of supportd. coordinated body movement, strength, and posture

82. A 22-year-old client who is in the advanced stages of AIDS says to his primary nurse, "I know that I am not going to get better. I think I would like to pray, but I do not know how. I don't even know to whom." The most supportive response the nurse could make at this time would be:

a. "It is frightening to be facing the end of your life. I will pray for you."b. "I will call the chaplain to speak with you about this."c. "What do you want to say in your prayer?"d. "Many people your age have been alienated by religion."

83. When helping an elderly client bathe, the nurse also assesses his skin. Which finding is unexpected?

a. When pinched, the skin returns to place quickly.b. The skin of the face, arms, and legs is intact.c. The skin on the client's arms is smooth with some hair.d. The client has several abrasions on his chest and back.

84. The home health nurse wants to evaluate the mother's understanding of measures to prevent tooth decay in her children. Which statement indicates the mother understands the teaching?

a. "Their teeth need to be flossed daily."b. "Even young children can brush their teeth properly."c. "Sweet foods are less harmful if eaten between meals."d. "I should have a dentist check their teeth once a year."

85. A female client has an unpleasant body odor. What should the nurse do?a. Apply non-irritating dusting powder to the client's axillae and perineum.b. Shave the axillae and immediately apply underarm deodorant.c. Make sure that the client's skin is clean, and apply underarm deodorant.d. Apply lanolin lotion to her buttocks and perineum.

86. Which of the following are components of culture?A. Law, norms, and fashionsB. Mores, language and lawsC. Folkways, values and moresD. All of the above

87. According to Madeleine Leininger’s theory, caring values and behaviors are derived largely from a person’s:

A. Culture


B. ExperienceC. EducationD. Occupation

88. Which nursing activity BEST demonstrates the application of the Nightingale theory of Nursing?A. Working with a community group to improve air quality in the city.B. Taking a client to the chapel in a wheelchair.C. Manipulating a client’s energy fields through therapeutic touch.D. Focusing on communication and mutual goal setting.

89. Evaluate the following Nursing Theory: “Nursing interventions are performed within the context of the Nursing Process. They involve manipulating stimuli to support and promote independent functioning of the client, a biopsychosocial being.” Which of the four major concepts is missing or least developed?

A. Person/ clientB. Environment C. Health/ illnessD. Nursing

90. The following are characteristics of 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.

91. The health-illness continuum describes:A. The interaction between agent, host and environment.B. Interaction between the condition of the environment, health and illness.C. The preventive health behavior of the individual.D. All of these

92. The student nurse can be involved with health promotion as a significant person in helping the family in which of the following ways?

A. Become a better familyB. Prevent diseaseC. Control their symptomsD. Modify health promotion behaviors

93. As part of discharge health teachings for a post-operative patient, the student nurse in collaboration with a Physical Therapist teaches a client exercises that will prevent complications. Exercise in this situation is categorized as:

A. Primary level preventionB. Secondary level preventionC. Tertiary level preventionD. None of the above

94. Which of the following is an example of a secondary level of prevention?a. Organizing summer sports activities for childrenb. Holding seminars on reproductive health counsellingc. Assisting an amputated man walk with his crutchesd. Submitting self for mammography

95. Which among the 10 carative factors in nursing by Jean Watson is identified with self-giving?A. AltruismB. Instilling faith and hopeC. Helping- Trusting RelationshipD. None of the above

96. Which among of the following is TRUE of Leininger’s theory?a. Human caring is demonstrated in more than one ways among cultures.b. Caring is culturally derived.c. Different cultures have similar expectations of seeking care.d. All of the abovee. All except C

97. Which among the following is TRUE of the goal of the above theory?


a. Used as a basis toward an understanding of care of different culturesb. To provide culture specific carec. Respect of client’s cultured. All of the abovee. All except C

98. Which of the following is INCORRECT statement of nursing diagnosis?a. High Risk for ineffective airway clearance related to pneumoniab. High Risk for injury related to dizzinessc. Constipation related to decreases activity and fluids as manifested by small, hard,

formed stool in three daysd. Anxiety related to insufficient knowledge regarding surgical experience

99. Which of the following would NOT be a basis for establishing priorities in client care?a. Actual problems take precedence over potential concernsb. Attend to equipment and contraptions first, such as IV fluids, urinary catheter,

drainage tubes before the clientc. Airway should always be given highest priorityd. Clients with unstable condition should be given priority over those with stable

conditions100. Which of the following is an incorrect statement of outcome procedure?

a. Ambulates 30 feet with cane before dischargeb. Discusses fears and concerns regarding the surgical procedure during preoperative

teachingc. Demonstrates proper coughing technique after the teaching sessiond. Re-establishes normal pattern of bowel elimination

101. A collaborative problem is indicated instead of a nursing or medical diagnosis when:a. Both medical and nurse interventions are requires to treat the problemb. The nurse cannot take independent action to treat the problemc. Nursing interventions are the primary actions requires to treat the problemd. No medical diagnosis can be determined

102. Under which circumstance is it acceptable practice for the nurse to document a nursing activity before it is carried out?

a. When the activity is a routineb. When the activity occurs at regular intervalsc. When the activity is being carried out immediatelyd. It is never acceptable

103. The client has a high-priority nursing diagnosis of risk for impaired integrity related to the need for several weeks of imposed bed rest. When evaluating the care plan after 1 week, the nurse finds that the client has not developed impaired skin integrity. The most appropriate action with regards to the care plan would be to:

a. Delete the diagnosis since the problem has not occurredb. Keep the diagnosis since the risk factors are still presentc. Modify the nursing diagnosis to impaired immobilityd. Demote the nursing diagnosis to a lower priority

104. The nursing process is a:E. Method for processing the care of many patientsF. Method for diagnosing and treating human responses to actual or potential health

problemsG. Method for diagnosing diseaseH. Logical, systematic, problem solving method for providing nursing care

105. The provision of immediate care needed by the patient is the nurse’s concern. Hence, you establish priorities according to:

A. Patient’s needsB. Doctor’s orderC. List of factors affecting patient’s conditionD. Family instructions

106. The most important benefit of the nursing process to the client is that:


A. Helps them understand what nurses doB. Helps ensure quality nursing care that meets individuals needsC. Ensures efficient use of nursing time and resourcesD. Increases collaborative practice and job satisfaction

107. The nursing process is a dynamic process meaning:A. It is ever changing in response to the client’s needsB. Conveys the force or power of the health teamC. Allows the client to achieve new goals each dayD. Provides solutions for clients problems

108. According to this model, a man who works all day at his job as expected is healthy even though an X-ray film in his lung indicates tumor.

A. Adaptive ModelB. EudaemonisticC. ClinicalD. Role Performance

109. Which component of the nursing process tells you to what extent nursing care goals were achieved?

a. Planningb. Assessmentc. Evaluationd. Implementation

110. You are taking care of a post CVA patient in the ICU to prevent contractures on his paralyzed side. You are practicing what level of prevention?

a. Primaryb. Secondaryc. Tertiaryd. Health promotion

111. A community health nurse establishes that the people need to know about Dengue hemorrhagic fever, thus together with his colleagues they had to make a health education about the abovementioned need. They are practicing what level of prevention?

a. Primaryb. Secondaryc. Tertiaryd. None of the above

112. An alcoholic individual just came home after a month hospitalization, since restrictions had been imposed to him by his physician. He decided to agree to join a support group for people who were known to be alcoholics. What level of prevention is this?

a. Primaryb. Secondaryc. Tertiaryd. None of the above

113. Which of the following is a secondary subjective data?a. A spouse states that the client loss all his appetiteb. A nurse noted a dull sound upon percussing the client’s abdomenc. A client states severe pain when walking upstairsd. The nurse palpates edema in the lower extremities

114. A diabetic patient is still capable of excelling in her endeavors as a nurse entrepreneur. Moreover, she still could carry out her ADLs despite her chronic disease. She can be considered healthy based from which of the following models?

A. Clinical performance modelB. Adaptation modelC. Role performance modelD. Eudaemonistic model

115. A 45-year old man has achieved all his aspirations in life. He has successfully sent his children to school and was able to build a clinic of his own to practice his profession as a general


physician. Which of the following models would support man’s feelings of fulfillment and contentment?


116. Which of the following models greatly emphasizes that a person is healthy when he/she is capable of adapting with the demands of both the internal and external environment?


117. A student nurse explains to the class that based from her readings, a person is healthy if manifestations of a disease are absent and unhealthy if signs and symptoms of a disease are present. The student nurse supports which of the following health care models?


118. A 35-year old woman always takes her daily vitamins and performs leg exercises to protect her from any type of infection. This practice can be considered under:

A. The primary level of preventionB. The secondary level of preventionC. The tertiary level of preventionD. None of the above

119. Breast self and testicular examinations are under which of the following levels of prevention?

A. PrimaryB. SecondaryC. TertiaryD. None of the above

120. A stroke patient underwent a speech therapy to aid her in verbally expressing her thoughts. Speech therapy can be considered under which of the following levels of prevention?


121. A diabetic patient strictly adheres to the treatment regimen given by her doctor. She injects insulin by herself using the subcutaneous route. Self administration of insulin by diabetic patients is under which of the following levels of prevention?


122. All of the following are activities done under the secondary level of prevention EXCEPT:A. Testicular Self ExamB. Blood pressure screeningC. Breast Self ExamD. Passive range of motion exercises

123. The student nurse asked his tutor about the activities done in the primary level of prevention. The tutor responds by mentioning the following activities. SELECT ALL THAT APPLY

1. Daily intake of Iron supplements for women2. Regular muscle exercises3. Deep breathing exercises4. Taking a bath daily5. Immunization


A. 1,2,3,4,5B. 1,2,3,4C. 1,2,3D. 1,2,4

124. Which objective data is needed when assessing a patient diagnosed with secondary hypertension?

A. Pulse rateB. Pain experienceC. Respiratory rateD. Blood pressure

125. A nurse is assessing client’s response to pain using a scale from 1-10 to a client diagnosed with Pancreatic cancer. The data that will be obtained from the client is considered:

A. ObjectiveB. SubjectiveC. Part of the nursing diagnosisD. None of the above

126. In the nursing diagnosis, “Alteration in Comfort: Pain related to traumatized nerve endings”, which is said to be the qualifier?

A. PainB. Alteration in comfortC. Traumatized nerve endingsD. Comfort

127. Etiology is said to be:A. The problemB. The cause C. The manifestationsD. The qualifier

128. Which of the following diagnoses is correctly written?A. Risk for Fall related to ageB. Alteration in Body Temperature: Hyperthermia related to increased pyrogens in the

bodyC. Fever related to microbial invasionD. Tachycardia related to caffeine intake

129. Which of the following is an independent nursing action?A. Administration of drugsB. Nebulization therapyC. Chest PhysiotherapyD. Encouraging deep breathing exercise

Situation: Nurse Kim, a newly hired nurse is caring for the patients assigned under his care.

130. One of Nurse Kim’s patient suffered from Dengue and is about to be discharge. He provided the client health teachings on how to protect himself from contracting the disease again. The client based on the nursing systems of Orem is considered as:

a. Wholly-compensatoryb. Partially-compensatoryc. Supportive-educatived. Self-Care Deficit

131. During his rounds, he changed all the linens of his clients and opened all the windows of the rooms. He also asked the nursing aid to refill the water containers of his patients with fresh clean water. Nurse Kim’s action at this point is consistent to which of the following theories?

a. Virginia Henderson’s theoryb. Florence Nightingale’s theoryc. Imogene King’s theoryd. Martha Roger’s theory


132. Throughout Kim’s shift, he tried to talk to each of his patients, listening to them attentively and provides them with sound health teachings. During these conversations, nurse Kim utilizes therapeutic communication techniques. At this point, Nurse Kim must be utilizing what theory?

a. Interpersonal Relations Modelb. Neuman’s Systems Modelc. Science of Unitary Human Beingd. The theory of human becoming

133. A Muslim client is also assigned under the care of Nurse Kim. Since the client is in a private room, Nurse Kim offered the bed of the client to face Mecca. Nurse Kim is utilizing Leininger’s theory is performing which of the following modes of action?

a. Cultural accommodation and negotiationb. Cultural preservation and maintenancec. Culture restructuring and repatterningd. None of the above

134. A 89 years old male patient suffering from Alzheimer’s was also assigned under Nurse Kim’s care. In improving the quality of life of the client, Nurse Kim should utilize which of the following theories?

a. The Theory of Human Becomingb. Environmental Theory of Nursingc. Self-Care Deficit Nursing Theoryd. Adaptation Model

Situation: Nurses should become well-verse with the utilization of the nursing process in meeting the health promotion and illness prevention needs of patients.

135. Priorities are set to help the nurse anticipate and sequence nursing interventions when a client has multiple problems. Priorities are determined by the clients:

A. Urgency of problemsA. Physician and the private nurseB. Future well beingC. Non-emergent client needs

136. Of the following choices, which best exemplifies an expected outcome that was written in measurable terms?

a. The client will be able to regain healthb. The client will be able to move his legs every 6 hoursc. The client will be able to experience less paind. The client will be able to demonstrate a decrease in BP from 140/90 to 120/80.

137. The main purpose of implementing planned nursing interventions is to:a. Identify the client’s strengths and weaknessesb. Determine how to reduce or resolve the identified problemsc. Assist the client in meeting the desired goals, promote health, and prevent illnessd. It concentrates alone in the restoration of the physical well being

138. Which of the following diagnoses is correctly defined?a. Imbalance nutrition r/t diabetesb. Imbalanced gas exchange r/t asthmac. Ineffective airway clearance r/t tuberculosisd. Alteration in body temperature: Hyperthermia r/t increased pyrogen in the body

139. The PRIORITY nursing diagnosis for an obese client would be:a. Risk for infectionb. Fluid volume excessc. Alteration in body temperature: Hypothermiad. Imbalanced nutrition: More than body requirement

140. Nurse Abby is aware that her patient Vladimir had undergone diaphragmatic incision. She knew that this will contribute to some complications later on. She therefore is expected to develop which type of nursing diagnosis?


a. Actualb. Probablec. Possibled. Risk

141. Mr. Qui Fu had been diagnosed to have hypertension a decade ago. Since then, he had maintained low sodium diet to control his blood pressure. His practice is viewed as:

A. His personal beliefB. His health beliefC. His cultural beliefD. His superstitious belief

142. Which of the following behaviors is not expected when a client assumes sick role?A. The client takes medication as prescribed by the physicianB. The client seeks for sick leaveC. The client consults a physician because of headache and perceived feverD. The client ignores his dizziness with the hope that it will be relieved

143. Ronnie and Priscilla are newlywed couple. On their first night together, they are expected to fulfil which of their needs according to Maslow?

A. Physiologic NeedsA. Safety and SecurityB. Self EsteemC. Self Actualization

144. The primary purpose of the evaluation phase of the nursing process is to determine whether:

a. the desired outcome have been metb. the client’s condition has changedc. nursing activities were effectived. nursing activities were carried out

145. Which of the following does not describe an appropriate guideline for writing a nursing diagnosis?

a. State the diagnosis based on problems not the needb. Use medical terminology to describe the probable cause of the patient’s responsec. Use nursing terminology to describe the patient’s responsesd. Use statements that assist in planning the independent nursing interventions

146. Which characteristic of nursing process addresses the individualized care a client must receive?

a. Efficientb. Effectivec. Humanisticd. Organized and Systematic

147. Which of the following is the primary focus in the evaluation of nursing care?a. Documentation of nursing careb. Results of nursing actionc. Plan a nursing cared. Self-care status of the client

148. Of the following, which step of the implementation phase of the nursing process is performed first?

a. Carrying out nursing ordersb. Determining the need for assistancec. Reassessing the clientd. Documenting intervention

149. Wellness clinics and health education activities have been integrated to render appropriate services. Which of the following purposes least likely help the client in case of these health promotion activities?

a. Maintain maximum functionb. Reduce risk factorc. Promote habits related to health care


d. Manage stress150. What is wrong with the following desired outcome? “Client will be able to climb one

flight of stairs without shortness of breath.”a. It is not measurable.b. Behavioral terms are not used.c. No target time is given.d. Nothing is wrong.

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