1b. LOC Questions: The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues.0 = Answers both questions correctly1 = Answers one question correctly2 = Answers neither question correctly

2. What is the most likely diagnosis for the patient?

Situation: Nurse Chona Mae is handling patients in Ward 11. The following questions apply.1.    When assessing the client's pain level, what will the nurse determine is the most reliable indicator of the pain?*1 pointA. Client's ethnic backgroundB. Client's report of symptomsC. Client's vital signsD. Extent of client's injury2.    The mother of an infant asks the nurse what a communicating hydrocephalus is. What is the nurse’s best response?*1 pointA. There is obstruction in the passageway of CSF in the brain.B. It is caused by impaired CSF reabsorption even without obstruction.C. There is increased absorption of CSF in the brain.D. The ventricles produce more CSF than the normal rate of production.3.     The nurse just hung the packed RBC to be transfused to the patient for 20 drops per minute. After how long must the nurse observe the patient for any adverse reaction?*1 pointA. 30 minutesB. 20 minutesC. 15 minutesD. 10 minutes4.    A pregnant mother in the health center complains to leg cramps especially during the night. Which of the following is an appropriate teaching by the nurse?*1 pointA. Stretch your foot towards your knees.B. Apply cold compress for 15 minutes.C. Apply warm compress for 20 minutes.D. Have a bed rest whenever leg cramps begin.5.    A client needs surgery to relieve an intestinal obstruction. The nurse receives the following set of orders for the client. Which of the following orders should the nurse question before performing? *1 pointA. Tap water enemas until clear.B. Out of bed as tolerated.C. Neomycin sulfate 1 g P.O. every 4 hours.D. Betadine scrub to abdomen.SITUATION: A 50-year old male is brought to the emergency room by two policemen for stab wound at the left thorax. He is bleeding and has difficulty breathing. You are the ER nurse.6. You would position the patient: *1 pointA. On his left side with head elevatedB. On his right side in bed with a pillow supporting his left armC. On his back with feet elevatedD. In High-fowler's position with left side supported7. You place a large pressure dressing over the stab wound. The purpose of this action is to: *1 pointA. seal off major vesselsB. protect the pleuraC. prevent additional contaminationD. maintain negative intrathoracic pressure8. You encourage the patient to perform deep breathing exercises. This is to: *1 pointA. Counteract respiratory acidosisB. Increased blood volumeC. Expand the residual volumeD. Decrease partial pressure of oxygen9. The patient complains of severe pain following surgical repair of the wound. You should do which of the following:*1 pointA. Administer analgesicB. Take the vital signsC. Assure the patient that pain is normal in his situationD. Tell the patient to rest10. You assess the patient. You should be primarily concerned with the:*1 pointA. amount of serosanguinous drainageB. blood pressure and papillary responseC. quality and depth of respirationsD. degree and level of painSITUATION: Mang Kanoris a 58-year old with a long-standing history of alcoholism. He started binge drinking when he was 22 years old. On Friday the 13th, he was admitted to the hospital with ascites and difficulty of breathing. The doctor’s tentative medical diagnosis was liver cirrhosis.11.    The nurse performs which intervention as a priority measure to assist Mang Kanor with breathing?*1 pointA. Repositions side to side every 2 hoursB. Elevates the head of the bed 60 degreesC. Auscultates the lung fields every 4 hoursD. Encourages deep breathing exercises every 2 hours12.    To confirm the doctor’s tentative diagnosis, he scheduled Mang Kanor to have a liver biopsy. Before the procedure, it is most important for the nurse to assess Mang Kanor’:*1 pointA. Tolerance for painB. Allergy to iodine or shellfishC. History of nausea and vomitingD. Ability to lie still and hold the breath13.    Since liver biopsy may pose a risk to the patient, the nurse is aware that what additional precautions must she observe prior to the procedure? Check liver function test result*1 pointA. Check coagulation test resultB. Check BUN & serum Creatinine levelsC. Check patient’s lipid profileSituation: Care of the aging individual presents one of the greatest challenges for nurses. Julia is aware that aging individuals experience many losses and are vulnerable to depression and feelings of low self-worth. Lolo Teryo was seen by a nurse in the ER who was reported to be becoming increasingly withdrawn. He eats little food and has lost some weight. His wife died 6 years ago and attended the funeral of his best friend a month ago and after which behavioral changes began.14.    In her admission, the nurse observes an open sore on Lolo Teryo’s arm. When asked about it he says he scraped it on the fence 2 weeks ago and the lesion was smaller than it was. The nurse may analyze the data as*1 pointA. He might be trying to commit suicideB. Delay in healing might indicate super imposed skin cancerC. Diminished inflammatory response in elderlyD. Age related changes on the skin and maldistribution of fats15.    Lolo Teryo is deaf on his right side. Which is the most appropriate nursing intervention for communicating with Lolo Teryo?*1 pointA. Speak loudly to his earB. Speak to him from a position on his left sideC. Speak face-to face in a low pitched voiceD. Speak face-to-face in a high pitched voice

In establishing an objective threshold, which of the following tests is most appropriate?Question 14Answera.verbal reportsb.forcedchoice recognitionc.free recalld.localization judgments

1a. Level of Consciousness: The investigator must choose a response, even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.0 = Alert; keenly responsive1 = Not alert, but arousable by minor stimulation to obey, answer, or respond2 = Not alert, requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped)3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, areflexic

Criteria for effectiveness of examinationsQuestion 5Answera.Validityb.Reliabilityc.all of the aboved.Objectivity.