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PSYCHIATRIC NURSING (SET B)

Prepared By: Dr. Lucila Espinosa
Philippine Nursing Licensure Examination
NAME:
Mental Health Nursing I
Situation I
You are a mental health nurse caring for a client with a diagnosis of major depression who has
attempted a suicide. Your client says to you, “I should have died. I’ve always been a failure. Nothing
even goes right for me”.
1. Which response demonstrates therapeutic communication?
a. “You have everything to live for”
b. “Why do you see yourself as a failure?”
c. “Feelings like this is all part of being depressed”
d. “You have been feeling like a failure for a while”
2. During your frequent irregular rounds, you noticed that she is still awake and verbalized, I haven’t
slept at all last night. “Which of the following responses will illustrate a therapeutic response from
your client?”
a. “I see”
b. “Really”
c. “You’re having a difficulty sleeping
d. “Sometimes, I have a trouble sleeping too”
3. Psychodynamic theory attributes the development of Major Depression to:
a. Anger form unmet developmental needs
b. Repressed sexuality
c. Current situational difficulties
d. Loss of cultural identity
4. Effective treatment of the client with a diagnosis of Major Depression involves:
a. Family therapy and medications
b. Individual therapy and medications
c. Cognitive – behavioral therapy
d. A combination of psychotherapy, medications and somatic therapies
5. In general, antidepressants work by
a. Making nor-epinephrine and serotonin more available
b. Blocking the release of serotonin
c. Stimulating the release of monoamine oxidase
d. Decreasing the abnormal electrical impulse in the brain
6. The appropriate activity for a depressed client should be:
a. Reading a novel
b. Playing chess
c. Taking a walk
d. Listening to music
7. Suicide precaution should be strictly observed when the client exhibits which of the following
manifestations:
a. The client feels weak and tired
b. The client expresses hostile feelings
c. The client has sudden cheerfulness
d. The client is agitated
8. You encountered a client named Carol who is experiencing disturbed thought process and believes
that her food is poisoned. Which communication technique should you use to encourage her to eat?
a. Using open-ended questions and silence
b. Sharing personal preferences regarding food choices
c. Documenting reasons why the client does not want to eat
d. Offering opinions about the necessity of adequate nutrition
9. The client is exhibiting?
 a. Auditory hallucination
b. Persecutory delusion
c. Gustatory hallucination
d. Somatic delusion
10. She spends hours at the locked door and shouting, “Let me out. There’s nothing wrong with me. I
don’t belong here”. What defense mechanism is the client implementing
a. Denial
b. Projection
c. Regression
d. Rationalization
11. You recognized which as being therapeutic communication techniques? Select all that apply.
1. Restating 4. Maintaining neutral responses
2. Listening 5. Providing acknowledgement and feedback
3. Asking the client, “why” 6. Giving advice, approval or disapproval
a. 1, 2, 4, 5 c. 1, 2, 5, 6
b. 1, 3, 4, 5 d. 2, 3, 5, 6
12. You are now preparing your client for termination phase of the nurse-client relationship. Which
nursing task is most appropriate for this phase?
a. Planning short-term goals
b. Making appropriate referrals
c. Developing realistic solutions
d. Identifying expected outcomes
13. You met a neighbor in a supermarket and says, “How is Carol doing? She is my best friend and was
admitted in your mental health facility a month ago.” Which is the most appropriate nursing
response?
a. “I cannot discuss any client situation with you”
b. “If you want to know about Carol, you need to ask her yourself”
c. “Only because you’re worried about a friend, I’ll tell you that she is improving”
d. “Being her friend you know she is having a difficult time and deserves her privacy”
14. You are working with a client who despite making all efforts was unable to rescue her three (3) year
old son trapped in a house fire. Which client – focused action should the nurse engage in during the
working phase of the nurse – client relationship.
a. Exploring the client’s ability to function
b. Exploring the client’s potential for self-harm
c. Inquiring about the client’s perception or appraisal of why the rescue was unsuccessful
d. Inquiring about and examining the client’s feelings for any that may block adaptive coping
15. You involved her in a group psychotherapy. What is your role during the termination stage of group
development?
a. Acknowledging that the group has identified goals
b. Encouraging the accomplishment of the group’s work
c. Acknowledging the contributions of each group member
d. Encouraging members to become acquainted with one another
16. Which are the characteristics of the termination stage of group development? Select all that apply.
1. The group evaluates the experience
2. The real work of the group is accomplished
3. Group interaction involves superficial conversation
4. Group members become acquainted with each other
5. Some structuring of group norms, roles, and responsibilities takes place
6. The group explores members’ feelings about the group and the impending separation
a. 2, 5 b. 1, 6
c. 1 and 2 d. 3 and 4
17. You encountered a manic client who is monopolizing the group therapy session. What is the most
appropriate nursing action?
a. Ask the client to leave the group for this session only
b. Refer the client to another group that includes other manic patients
c. Tell the client to stop monopolizing in a firm but compassionate manner
d. Thank the client for the input but inform the client that now others need a chance to
contribute
18. Which describes the primary focus of milieu therapy?
 a. A form of behavior modification therapy
b. A cognitive approach to changing behavior
c. A living, learning or working environment
d. A behavioral approach to changing behavior
19. Which type of therapeutic approach has the characteristic that all team members are seen as equally
important in helping clients meet their goals?
a. Milieu therapy
b. Interpersonal therapy
c. Behavioral modification
d. Rational Emotive Therapy
20. Which nursing interventions are appropriate for your client with mania who is exhibiting manipulative
behavior? Select all that apply.
1. Communicate expected behavior to the client
2. Ensure that the client knows that they are not in charge of the nursing unit
3. Assist the client in identifying ways of setting limits on personal behavior
4. Follow through about the consequences of behavior in a non-punitive manner
5. Enforce rules by informing the client that they will not be allowed to attend therapy groups
6. Have the client state the consequences for behaving in ways that are viewed as unacceptable
a. 1, 2, 3, 4 b. 3, 4, 5, 6
c. 1, 3, 4, 6 d. 2, 3, 4, 5
21. You are planning activities for your client, diagnosed with mania with aggressive social behavior.
Which activity would be most appropriate?
a. Chess c. Pingpong
b. Writing d. Basketball
22. You observed that she is pacing, agitated and presenting aggressive gestures. Her speech pattern is
rapid and affect is belligerent. Based on these observations, what is your immediate priority of care?
a. Provide safety for the client and other clients on the unit
b. Provide the clients on the unit with a sense of comfort and safety
c. Assist the staff in caring for the client in a controlled environment
d. Offer the client a less stimulating area to calm down in and gain control
23. Your manic clients begin to make sexual advances towards visitors in the dayroom. When you firmly
state that this is inappropriate and will not be allowed, she becomes verbally abusive and threatens
physical violence on you. Based on the analysis of this situation, which intervention should you
implement?
a. Place the client in a seclusion for 30 minutes
b. Tell the client that the behavior is inappropriate
c. Escort the client to their room, with the assistance of other staff
d. Tell that their telephone privileges are revoked for 24 hours
24. You are conducting a group therapy session. During the session, your manic client consistently
disrupts the group’s interactions. Which intervention should you initially implement?
a. Setting limits on the client’s behavior
b. Asking the client to leave the group session
c. Asking another nurse to escort the client out of the group session
d. Telling the client that they will not be able to attend any future group sessions
25. Your client is experiencing disturbed thought process as a result of Schizophrenia Paranoid type. In
formulating nursing interventions with the members of the health care team, what best instruction
should you provide to the staff?
a. Increase socialization of the client with peers.
b. Avoid laughing or whispering in front of the client.
c. Begin to educate the client about the social support in the community.
d. Have the client sign a release of information to appropriate parties for assessment purposes.
26. You are now preparing your client with Schizophrenia Paranoid type with a history of command
hallucinations for discharge by providing instructions on interventions for managing hallucination and
delusion. Which statement in response to these instructions suggests to you that the client
understands the instruction?
a. “My medications aren’t likely to make me hear voices”
b. “I’ll go to support group and talk so that I don’t hurt anyone”
c. “It is not likely that I’ll hear things if I get enough sleep and eat well”
d. “When I begin to hallucinate I’ll call my nurse and talk about what I should do”
27. You are a Drug Abuse Treatment and Rehabilitation Center nurse, during the assessment of a newly
admitted Person Who Uses Drugs (PWUDs) named Robin which action should you take to plan
appropriate nursing care?
a. Ask the client why he started taking illegal drugs
b. Ask the client about the amount of drug use and its effect
c. Ask the client how long he thought that he could take drugs without someone finding out
d. Not ask any questions for fear that the client is in denial and may become assaultive
28. Upon data collection, Robin was known to be a substance dependent for three (3) years. What is the
most appropriate nursing diagnosis for him?
a. Alteration in social interaction
b. Alteration in sensory perception
c. Ineffective individual coping
d. Impaired adjustment
29. Carlos, age 35 was brought to the rehabilitation center for detoxification. He is a known alcoholic for
ten years. Upon assessment, the reason he was asked when was his last intake of alcohol is for you
to:
a. Specific period when withdrawal symptoms may set in
b. How far the dependency has progressed
c. To determine the development of delirium tremens
d. Severity of withdrawal client may experience
30. Carlos tells you how he hit his wife after an argument they had and ask if he would ever be forgiven.
Your best response is:
a. “You seem to have bad feelings about hitting your wife.”
b. “You may ask her when she visits you.”
c. “That depends if you’ll be good enough during your confinement.”
d. “If its ok with you we can discussed that during the family therapy.”
31. During the night, Carlos suddenly cries out as he saw shadows on the wall, “No, don’t take me,
nooh!!”. Your best response would be:
a. “What do the shadow mean to you Carlos?”
b. “Go back to sleep you’re just having a nightmare.”
c. “No one’s here but you and me Carlos, You’re safe here.”
d. “Tell me what you feel Carlos, I’m here to help.”
32. Carlos is noted to fabricate information due to his memory lapses. You are aware that this is done
to:
a. Maintain self-esteem
b. Gain sympathy
c. Manipulate others
d. Attract attention
33. Your attitude that can be most helpful to Carlos is?
a. Warm and accommodating
b. Firmly consistent yet accepting
c. Acceptance and permissiveness
d. Judgmental and moralistic
34. The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia
nervosa. Which assessment findings does the nurse expect to note? Select all that apply.
1. Dental decay 4. Electrolyte imbalances
2. Moist oily skin 5. Body weight well below ideal range
3. Loss of tooth enamel
a.1 2 3 c. 3 4 5
b. 1 3 4 d. 1 4 5
35. You are caring for a female client who was admitted to the mental health unit recently for anorexia
nervosa. When you entered the client’s room and noted, that the client is engaged in rigorous push-
ups. Which nursing action is most appropriate?
a. Interrupt the client and weigh her immediately
b. Interrupt the client and offer to take her for a walk
c. Allow the client to complete her exercise program
d. Tell the client that she is not allowed to exercise rigorously
36. A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A
newly admitted client will be assigned to this client’s room. Which client would be the best choice as
a roommate for the client with anorexia nervosa?
a. A client with pneumonia
b. A client undergoing diagnostic tests
c. A client who thrives on managing others
d. A client who could benefit from the client’s assistance at mealtime
37. You are a nurse in the department who is caring for a young female victim of sexual assault. The
client’s physical assessment is complete, and physical evidence has been collected. You note that the
client is withdrawn, confused, and at times physically immobile. How should the nurse interpret
these behaviors?
a. Signs of depression
b. Normal reactions to a devastating event
c. Evidence that the client is a high suicide risk
d. Indicative of the need for hospital admission
38. A client’s medication sheet contains a prescription for sertraline (Zoloft). To ensure safe
administration of the medication, how should you administer the dose?
a. On an empty stomach
b. At the same time each evening
c. Evenly spaced around the clock
d. As needed when the client complains of depression
39. A client with schizophrenia has been started on medication therapy with clozapine (Clozaril). You
should assess the results of which laboratory study to monitor for adverse effects from this
medication?
a. Platelet count
b. Blood glucose level
c. Liver function studies
d. White blood cell count
40. You noted that a client with schizophrenia and receiving an antipsychotic medication is moving her
mouth, protruding her tongue, and grimacing as she watches television. You determined that the
client is experiencing which medication complication?
A. Parkinsonism
B. Tardive dyskinesia
C. Hypertensive crisis
D. Neuroleptic malignant syndrome
41. You are caring for a client who has been identified as a victim of physical abuse. In planning care for
the client, which is the priority nursing action?
a. Adhering to the mandatory abuse-reporting laws
b. Notifying the case worker of the family situation
c. Removing the client from any immediate danger
d. Obtaining treatment for the abusing family member
42. You assessed a client with the admitting diagnosis of bipolar affective disorder, mania. Which client
symptoms require your immediate action?
a. Incessant talking and sexual innuendoes
b. Grandiose delusions and poor concentration
c. Outlandish behaviors and inappropriate dress
d. Nonstop physical activity and poor nutritional intake
43. You are planning a treatment care for a client who has been off the streets for several years. The
client has delusions, and frequently responds to auditory hallucinations. Which of the following client
needs would be the priority?
a. Self-esteem
b. Love and belongings
c. Self-actualization
d. Physical safety
44. Your role in tertiary prevention is:
a. Prevent the spread of disease
b. Promote mental health through anticipatory guidance
c. Case finding to limit severity of disease
d. Prevent the crippling defects of illness through rehabilitation programs
45. In the application of the nursing process, the nursing diagnoses are prioritized according to:
a. The established goals of care
b. The nurses’ priority of care
c. Life threatening potential
d. Focus on resolution of patient’s problems
46. Mrs. Aguilar age 40 was admitted because bouts of insomnia, nervousness and poor concentration
becoming worst in the last 6 months. What is the initial responsibility of the nurse?
a. Assess her level of anxiety
b. Encourage husband to stay with her
c. Orient her to the unit
d. Administer medication to allay anxiety
47. During the orientation phase of the Nurse-Client-Relationship your appropriate topic would be:
a. Effective coping pattern
b. Facts about stress and coping
c. Mrs. Aguilar’s perception of her illness
d. Feelings about her family
48. All of the following are physical responses to anxiety EXCEPT:
a. Perspiration
b. Headache
c. Increased pulse and respiration
d. Forgetfulness
49. In planning the discharge of a client with chronic anxiety, the goal should focus on which of the
following?
a. Eliminating all anxiety from daily situations
b. Ignoring feelings of anxiety
c. Identifying anxiety producing situations
d. Continued contact with crisis counselor
50. Primary gain associated with Somatoform Disorders, is referred to as:
a. Financial compensation from disability
b. Relief from anxiety associated with conflict
c. Love and attention from support system
d. Financial aid from relatives
51. Management of client with Somatoform Disorders includes the following EXCEPT:
a. Use of Matter-of-fact attitude
b. Help develop insight into his/her condition
c. Help use effective coping skills to reduce stress and anxiety
d. Ignore somatic complains
52. The desired outcome for the nursing care of client with Hypochondriasis is:
a. Nurse will respond in an authoritative manner when client complains pain
b. Client will seek 2nd opinion from healthcare providers
c. Client will state the relationship between life events and physical symptoms
d. Nurse will reinforce physical symptoms experienced by the client
53. You are working with a client who has Dissociative Disorder you understand that this disorder is
likely to begin as a/an:
a. Gradual loss of memory
b. Means to avoid responsibilities
c. Effect of Drug abuse
d. Protective defense against anxiety
54. Nursing intervention for patients with Dissociative Disorder should be based on your understanding
that:
a. Patients can recall is identity if he wants to
b. Memory Loss is due to their dislike of their original personality
c. Patient can recall his anxiety when anxiety subsides
d. Memory loss is due to an emotional conflict or an external stressor
55. Romy, 14y/o was admitted to a medical ward due to bronchial asthma after learning that his mother
is leaving for UK to work as a nurse. Romy’s behavioral symptoms may be conveying which of the
following message?
a. “I am alone and helpless”
b. “I hate you for leaving me”
 c. “Everyone needs attention”
d. “I deserved to be punished”
56. The initial goal in the nursing care for Romy is:
a. Teach relaxation technique
b. Encourage verbalization of feelings and concerns
c. Teach alternative ways of coping
d. Alleviate the patient’s physical symptoms
57. The individual with essential hypertension is thought to;
a. Suppress anger and hostility
b. Fear social interactions with others
c. Project feelings onto environment
d. Deny responsibility for own behavior
58. Mr. Jose, bank executive is described by his subordinates as meticulous, scrupulous and wants every
work to be on time. What physical illness would he be vulnerable?
a. Essential Hypertension
b. Bronchial Asthma
c. Migraine
d. Dermatitis
59. An appropriate nursing diagnosis for Mr. Jose would be:
a. Alteration on health maintenance related to knowledge deficit
b. Ineffective individual coping related to inadequate psychological resources
c. Ineffective denial related to poorly developed defensive function
d. Altered thought process related to withdrawal to the self
60. Linda was admitted to the Psychiatric unit exhibiting elation, incessant chattering and hyperactivity.
Which of the following nursing diagnostic categories would hold the highest priority for her?
a. Hopelessness
b. Potential for injury
c. Personality identity disturbance
d. Ineffective individual coping
61. Linda starts saying, “You will be promoted. Just go to Malacanang, see my cousin Duterte. She is
experiencing:
a. Illusion
b. Verbigeration
c. Hallucination
d. Delusion
62. Sensing that people don’t believe her, she shouted, “I’m really the cousin of Duterte. Why don’t you
believe me? I own 10 buildings in Makati and the Fort Area. Your effective approach of the nurse
should be to:
a. listen attentively
b. leave her to a co-patient
c. start presenting reality
d. give reasons for not believing her
63. The primary reason for assigning a private room for Linda is:
a. decrease environmental stimuli
b. prevent the patient’s excessive activity from disturbing others
c. deter the patient from interrupting the nurses
d. provide the patient with a quiet place to think about her problems
64. The highest priority nursing intervention for a hyperactive patient like Linda would be:
a. discourage her from manipulating the staff
b. prevent her assaulting other patients
c. protect her against suicidal attempts
d. provide adequate food and fluid intake
65. Linda is placed on Lithium therapy. Early sign of toxicity include:
a. tinnitus
b. vomiting
c. ataxia
d. stupor
66. The therapeutic blood lithium level is:
a. 2.5 MEq/L and above
 b. 1.5 – 2.5 MEq/L
c. 0.5 – 1.5 MEq/L
d. 1.5 – 2.0 MEq/L
67. To reduce overt aggression from a manic patient the following are appropriate measures EXCEPT:
 a. Participation in competitive games
b. Encouraging relaxation techniques
c. Reduction in environmental stimuli
d. Encourage client to discuss angry feelings
68. The biochemical theory of manic behavior may be related to:
a. Neurotransmitter deficiency
b. Excessive level of Norepinephrine
c. Increased cholinergic activity
d. Increased noreadrenergic activity
69. Lorna is diagnosed with Borderline Personality Disorder. Which symptoms would you expect to
assess related to her expression of anger?
a. Controlled, subtle anger
b. Inappropriate, intense anger
c. Inability to recognize anger
d. Substitution of physical symptoms
70. Lorna tells the you that you are the best nurse in the hospital, and then tells you are cruel when
you set limits on her behavior. You interpret this behavior as:
a. Denial
b. Splitting
c. Rationalization
d. Projection
71. During your morning medication, Mang Nano, a patient with dementia, could not be located in the
unit. Later he was found walking aimlessly in front of the hospital. When asked he say that his
only son is coming to bring him home. What should you do?
a. Encourage him to interact with other patients
b. Explain to him that his medication time should be followed
c. Reorient him to reality and assess the reason for the behavior
d. Hold him by his hands and gently guide him back to his room
72. Assessment data of Mang Nano reveals disorientation to time and place after dark. You interpret
this finding as:
a. Amnesia
b. Degeneration
c. Perseveration
d. Sundown syndrome
73. The family of the client with Alzheimer’s disease asks the nurse about what to expect as the
disease progress. Your answer is based on which fact?
a. Improvement depends on the treatment given
b. Improvement can occur when underlying medical problems are treated
c. The disorder occurs in a chronic, progressive manner over time
d. The disorder typically involves periods of remission and exacerbation
74. Which nursing intervention would be most appropriate for Mang Nano if he is upset and agitated?
a. Decreased environmental stimuli while remaining with the client
b. Firmly tell the client that the behavior is not acceptable
c. Offer medication that will have a calming effect
d. Question the client about the cause of the problem
75. A client was admitted in your unit with the chief complaint of increasing confusion for about a
month. Which assessment question to the family will differentiate delirium from dementia?
a. How long have you noticed the confusion in your family member?
COACHING WITH THE ICONS 9
 b. Has there been a history of dementia in a family?
c. Do you think something happened that was upsetting to your family member?
d. Does your family member live alone or with someone?
76. In the late stages of Alzheimer’s disease, which of the following outcomes would be most realistic
for your client?
a. The client will verbalize increased feelings of self-worth
b. The client will identify life areas that require alterations due to illness
c. The client will maintain reality orientation
d. The client will remain safe in the least restrictive environment
77. You are an out-patient Department Nurse, you encountered, Adam is in his senior year in Nursing.
He is an active student leader, an honor student and a part-time tutor. He has little time to rest
and often complains of having difficulty in falling asleep, especially at night. He can be suffering
from:
a. Initial insomnia
b. Intermittent insomnia
c. Maintenance insomnia
d. Terminal insomnia
78. How can you help Adam overcome his Insomnia?
a. Ask him to lessen his food intake
b. Limit activities just before bedtime
c. Advise him to buy sleep meds
d. Ask him to drink warm coffee
79. Mr. Rivera 30 y/o experienced sudden wave of overwhelming sleepiness in his job and this
problem lasted for more than a month. What can be the appropriate nursing intervention for
persons with narcolepsy?
a. Ask him to drink at least 4-5 cups of espresso especially during working hours
b. Offer a tall glass of warm milk
c. Suggest taking scheduled naps
d. Tell him to always bring an Ipod or Discman filled with dance tune
80. The mother of an 8 y/o boy remarked, “I’m sick and tired of washing his soiled bed sheets twice a
week. This has been going on for 2 months. What can I do to lessen the episode of my son’s
bedwetting?” the best answer to her query is:
a. Transfer him to a sleeping mat
b. Punish him for his bedwetting
c. Ask him to wear snuggly fit diapers
d. Empty his bladder before sleeping
81. Barbie, a 20 y/o college student was admitted to your unit because of uncontrolled eating and
self-induced vomiting. She has been diagnosed with Bulimia Nervosa. What would be your
appropriate nursing intervention for her?
a. Observed Barbie for the next 24 hrs. for any incidence of purging
b. Tell Barbie that she’ll be forced to eat soon after purging
c. Tell Barbie that she’ll be given extra food tray
d. Barbie must be observed two hours after each meal
82. One of the most common characteristic of persons suffering from Bulimia is binge-eating. This
refers to:
a. Insatiable appetite
b. Eating unusually large amount of food over a short period of time
c. Self-induced vomiting
COACHING WITH THE ICONS 10
 d. Use of laxatives, diuretics and enemas to compensate for calories consumed
83. Alice, 18 y/o was admitted to your unit due to rapid weight loss associated with Anorexia Nervosa.
The nursing diagnosis identified in her present condition is:
a. Altered nutrition less than body requirements
b. Impaired gas exchange
c. Alteration in perception
d. Anxiety
84. The most important goal for clients with eating disorders such as anorexia nervosa is:
a. Be able to cope with stress and conflicts
b. Develop a more realistic body image
c. Be able to identify significant others
d. Develop a positive outlook in life
85. Alice’s refusal to eat serves the primary purpose of allowing her to:
a. Gain the sympathy of others
b. Gain a sense of control and power
c. Remain free from anxiety
d. Openly assert her own identity
86. When 40year old Tom was admitted to your unit, he frequently exposes himself to female staff
nurses. He derives pleasure at the sight of shrieking woman. This behavior is known as:
a. Necrophilia
b. Sadism
c. Voyeurism
d. Exhibitionism
87. You respond to this behavior by:
a. Ignoring his behavior, realizing that he has low self-esteem
b. Informing him that the behavior is unacceptable, limit setting is appropriate
c. Holding a ward meeting where the appropriate behavior is discussed
d. Ask the Psychiatrist to confront Tom’s behavior
88. In order to get into areas of sex life of a patient, the nurse must first be:
a. Secure about her own sexuality
b. Knowledgeable in what is proper and what is improper sexual behavior
c. Keen about the varieties of sexual expressions
d. Interested, natural and human
89. When you see a patient who masturbates publicly, what is the best approach to follow?
a. Provide privacy and leave the patient
b. Warn the patient that masturbation can lead to serious illnesses
c. Report the incident to the head nurse and record the observation
d. Tell the patient that masturbation is an unacceptable behavior
90. Baffy, 25 y/o was sexually abused by a pedicab driver while on her way home from work one
evening as a cashier in a 24hour convenience store. She was brought to the ER with bruises all
over her body. She was crying uncontrollably and appears to be very anxious. You can
therapeutically communicate with her, saying:
a. “You are very upset, calm yourself first Baffy. I can’t understand you”
b. “I know something terrible and horrifying happened to you”
c. “Would you like to relate to me what happened?”
d. “Can you identify your abuser?”
91. Emergency care to be given for Rape victims are as follows:

COACHING WITH THE ICONS 11

 1. If victim calls the hospital, tell her not to bathe, shower, wash or change clothes, just go
the directly to the hospital
2. Provide privacy and be judgmental
3. Stay with the victim, focus on physical safety and emotional security
4. Assist in pelvic examination to collect evidences such as semen stains
a. 1, 2, 3
b. 2, 3, 4
c. 1, 2, 4
d. 1, 3, 4
92. In providing nursing care for Baffy during her acute stress reaction to rape trauma you can apply
which of the following?
a. Collaboration with community agencies
b. Crisis intervention techniques
c. Physical assessment
d. Teaching and Learning principles
93. To become a patient advocate to rape victims, you should note the following responsibilities:
a. Since this is a legal case, call the press
b. Isolate the patient first to provide privacy while attending to other patients
c. Postpone the physical examination until the patient is calm
d. Perform thorough physical assessment and document objectively all evidences of rape
94. Sheila, 5 years old, was diagnosed as autistic since she was 1year old. This disorder is
characterized by:
a. Anxiety induced involuntary stereotype motor movements
b. Inappropriate behavior, poor attention span with impulsivity
c. Negativistic, hostile and defiant behavior
d. Failure to develop interpersonal skills
95. At her age, Sheila is at what stage of social development?
a. Industry vs Inferiority
b. Initiative vs Guilt
c. Trust vs Mistrust
d. Autonomy vs Shame and Doubt
96. The best strategy that the nurse can use to provide a trusting relationship with an autistic child
like Sheila is to:
a. Reinforce positive behavior trough praise and rewards
b. Explain to the child activities and routines
c. Provide a structured environment
d. Convey warmth through touch
97. A distinguishing factor that separates conduct disorder from oppositional defiant disorder in
children include the following:
a. Obvious symptoms at birth
b. Violation of rights of others
c. Opposition to authority
d. Angry outburst
98. Prevention of mental retardation begins:
a. As soon as pregnancy is suspected
b. With family planning
c. During the first trimester of pregnancy
d. During the second trimester of pregnancy
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99. The real issue in school phobia is not the school itself, but the:
a. Separation from the mother
b. Teacher
c. School work
d. Hostile classmate
100. The parents of a child with Attention Deficit Hyperactivity disorder tells you that they have
tried everything to calm their child and nothing has worked. Which action is most appropriate
initially?
a. Actively listen to the parents concern before planning interventions
b. Encourage the parents to discuss these issues with the mental health team
c. Provide literature regarding the disorder and its management
d. Tell the parents they are overreacting to the problem

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