CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS Part I

CARE OF CLIENTS WITH PHYSIOLOGIC AND

PSYCHOSOCIAL ALTERATIONS part I

Situation 1 - Because of the serious consequences of

severe burns management requires a multi disciplinary

approach. You have important responsibilities as a

nurse.

1. While Sergio was lighting a barbecue grill with a

lighter fluid, his shirt burst into flames. The most

effective way to extinguish the flames with as little

further damage as possible is to:

a. log roll on the grass/ground

b. slap the flames with his hands

c. remove the burning clothes

d. pour cold liquid over the flames

2. Once the flames are extinguished, it is most

important to:

a. cover Sergio with a warm blanket

b. give him sips of water

c. calculate the extent of his burns

d. assess the Sergio's breathing

3. Sergio is brought to the Emergency Room after the

barbecue grill accident. Based on the assessment of the

physician, Sergio sustained superficial partial thickness

bums on his trunk, right upper extremities ad right

lower extremities. His wife asks what that means. Your

most accurate response would be:

a. Structures beneath the skin are damaged

b. Dermis is partially damaged

c. Epidermis and dermis are both damaged

d. Epidermis is damaged

4. During the first 24 hours after thermal injury, you

should assess Sergio for

a. hypokalemia and hypernatremia

b. hypokalemia and hyponatremia

c. hyperkalemia and hyponatremia

d. hyperkalemia and hypernatremia

5. Teddy, who sustained deep partial thickness and full

thickness burns of the face, whole anterior chest and

both upper extremities two days ago, begins to exhibit

extreme restlessness. You recognize that this most

likely indicates that Teddy is developing:

a. Cerebral hypoxia

b. Hypervolemia

c. Metabolic acidosis

d. Renal failure .

Situation 2 - You are now working as a staff nurse in a

general hospital. You have to be prepared to handle

situations with ethico-legal and moral implications.

6. You are on night duty in the surgical ward. One of

our patients Martin is prisoner who sustained an

abdominal gunshot wound. He is being guarded by

policemen from the local police unit. During your

rounds you heard a commotion. You saw the policeman

trying to hit Martin. You asked why he was trying to

hurt Martin. He denied the matter. Which among the

following activities will you do first?

a. Write an incident report

b. Call security officer and report the incident

c. Call your nurse supervisor and report the incident :

d. Call the physician on duty

7. You are on morning duty in the medical ward. You

have 10 patients assigned to you. During your

endorsement rounds, you found out that one of your

patients was not in bed. The patient next to him

informed you that he went home without notifying the

nurses. Which among the following will you do first?

a. Make and incident report

b. Call security to report the incident

c. Wait for 2 hours before reporting

d. Report the incident to your supervisor

8. You are on duty in the medical ward. You were asked

to check the narcotics cabinet. You found out that what

is on record does not tally with the drugs used. Which

among the following will you do first?

a. Write an incident report and refer the matter to the

nursing director

b. Keep your findings to yourself

c. Report the matter to your supervisor

d. Find out from the endorsement any patient who

might have been given narcotics

9. You are on duty in the medical ward. The mother of

your patient who is also a nurse came running to the

nurse station and informed you that Fiolo went into

cardiopulmonary arrest. Which among the following

will you do first?

a. Start basic life support measures

b. Call for the Code

c. Bring the crush cart to the room

d. Go to see Fiolo and assess for airway patency and

breathing problems

10. You are admitting Jorge to the ward and you found

out that he is positive for HIV. Which among the

following will you do first?

a. Take note of it and plan to endorse this to next shift

b. Keep this matter to your self

c. Write an incident report

d. Report the matter to your head nurse

Situation 3 - Colorectal cancer can affect old and

younger people. Surgical procedures and other modes of

treatment are done to ensure quality of life. You are

assigned in the Cancer institute to care of patients with

this type of cancer.

11. Larry, 55 years old, who is suspected of having

colorectal cancer, is admitted to the CI. After taking the

history and vital signs the physician does which test as

a screening test for colorectal cancer.

a. Barium enema

b. Carcinoembryonig antigen

c. Annual digital rectal examination

d. Proctosigmoidoscopy

12. To confirm his impression of colorectal cancer, Larry

will require which diagnostic study?

a. carcinoembryonic antigen

b. proctosigmoidbscopy

c. stool hematologic test

d. abdominal computed tomography (CT) test

13. The following are risk factors for colorectal cancer,

EXCEPT:

a. inflammatory bowels

b. high fat, high fiver diet

c. smoking

d. genetic factors-familial adenomatous polyposis

14. Symptoms associated with cancer of the colon

include:

a. constipation, ascites and mucus in the stool

b. diarrhea, heartburn and eructation

c. blood in the stools, anemia, and pencil-shaped, stools

d. anorexia, hematemesis, and increased peristalsis

15. Several days prior to bowel surgery, Larry may be

given sulfasuxidine and neomycin primarily to:

a. promote rest of the bowel by minimizing peristalsis

b. reduce the bacterial content of the colon

c. empty the bowel of solid waste

d. soften the stool by retaining water in the colon

Situation 4 - ENTEROSTOMAL THERAPY is now

considered especially in nursing. You are participating in

the OSTOMY CARE CLASS.

16. You plan to teach Fermin how to irrigate the

colostomy when:

a. The perineal wound heals and Fermin can sit

comfortably on the commode

b. Fermin can lie on the side comfortably, about the 3rd

postoperative day

c. The abdominal incision is close and contamination is

no longer a danger

d. The stool starts to become formed, around the 7th

postoperative day

17. When preparing to teach Fermin how to irrigate his

colostomy, you should plan to do the procedure:

a. When Fermin would have normal bowel movement

b. At least 2 hours before visiting hours

c. Prior to breakfast and morning care

d. After Fermin accepts alteration in body image

18. When observing a rectum demonstration of

colostomy irrigation, you know that more teaching is

required if Fermin:

a. Lubricates the tip of the catheter prior to inserting

into the stoma

b. Hands the irrigating bag on the bathroom door doth

hook during fluid insertion

c. Discontinues the insertion of fluid after only 500 ml of

fluid had been insertion

d. Clamps off the flow of fluid when feeling

uncomfortable

19. You are aware that teaching about colostomy care

is understood when Fermin states, "I will contact my

physician and report:

a. If I have any difficulty inserting the irrigating tub into

the stoma.”

b. If I notice a loss of sensation to touch in the stoma

tissue."

c. The expulsion of flatus while the irrigating fluid is

running out."

d. When mucus is passed from the stoma between

irrigation."

20. You would know after teaching. Fermin that dietary

instruction for him is effective when he states, "It is

important that I eat:

a. Soft foods that are easily digested and absorbed by my

large intestine."

b. Bland food so that my intestines do not become

irritate."

c. Food low in fiber so that there is less stool."

d. Everything that I ate before the operation, while

avoiding foods that cause gas."

Situation 5 - Ensuring safety is one of your most

important responsibilities. You will need to provide

instructions and information to your clients to prevent

complications.

21. Randy has chest tubes attached to a pleural

drainage system. When caring for him you should:

a. empty the drainage system at the end of the shift

b. clamp the chest tube when auctioning

c. palpate the surrounding areas for crepitus

d. change the dressing daily using aseptic techniques

22. Fanny came in from PACU after pelvic surgery. As

Fanny's nurse you know that the sign that would be

indicative of a developing thrombophlebitis would be:

a. a tender, painful area on the leg

b. a pitting edema of the ankle

c. a reddened area at the ankle

d. pruritus on the calf and ankle

23. To prevent recurrent attacks on Terry who has

acute glumerulonephritis, you should instruct her to:

a. seek early treatment for respiratory infections

b. take showers instead of tub bath

c. continue to take the same restrictions on fluid intake

d. avoid situations that involve physical activity

24. Herbert has a laryngectomy and he is now for

discharge. Re verbalized his concern regarding his

laryngectomy tube being dislodged. What should you

teach him first?

a. Recognize that prompt closure of the tracheal opening

may occur

b. Keep calm because there is no immediate emergency

c. Reinsert another tubing immediately

d. Notify the physician at once

25. When caring for Larry after an exploratory chest

surgery and pneumonectomy, your priority would be to

maintain:

a. supplementary oxygen

b. ventilation exchange

c. chest tube drainage

d. blood replacement

Situation 6 - Infection can cause debilitating

consequences when host resistance is compromised and

virulence of microorganisms and environmental factors

are favorable. Infection control is one important

responsibility of the nurse to ensure quality of care.

26. Honrad, who has been complaining of anorexia and

feeling tired, develops jaundice. After a workup he is

diagnosed of having Hepatitis A. His wife asks you

about gamma globulin for herself and her household

help. Your most appropriate response would be:

a. "Don't worry your husband's type of hepatitis is no

longer communicable"

b. "Gamma globulin provides passive immunity for

Hepatitis B"

c. "You should contact your physician immediately about

getting gamma globulin."

d. "A vaccine has been developed for this type of

hepatitis"

27. Voltaire develops a nosocomial respiratory tract

infection. He asks you what that means.

a. "You acquired the infection after you have been

admitted to the hospital."

b. "This is a highly contagious infection requiring

complete isolation."

c. "The infection you had prior to hospitalization flared

up."

d. "As a result of medical treatment, you have acquired a

secondary infection.''

28. As a nurse you know that one of the complications

that you have to watch out for when caring for Omar

who is receiving total parenteral nutrition is:

a. stomatitis

b. hepatitis

c. dysrhythmia

d. infection

29. A solution used to treat Pseudomonas would

infection is:

a. Dakin's solution

b. Half-strength hydrogen peroxide

b. Acetic acid

d. Betadine

30. Which of the following is most reliable in diagnosing

a wound infection?

a. Culture and sensitivity

b. Purulent drainage from a wound

c. WBC count of 20,000/pL

d. Gram stain testing

Situation 7 - As a nurse you need to anticipate the

occurrence of complications of stroke so that life

threatening situations can be prevented.

31. Wendy is admitted to the hospital with signs and

symptoms of stroke. Her Glasgow Coma Scale is 6 on

admission. A central venous catheter was inserted and

an I.V. infusion was started. As a nurse assigned to

Wendy what will he your priority goal?

a. Prevent skin breakdown

b. Preserve muscle function

c. Promote urinary elimination

d. Maintain a patent airway

32. Knowing that for a comatose patient hearing is the

best last sense to be lost, as Judy's nurse, what should

you do?

a. Tell her family that probably she can't hear them

b. Talk loudly so that Wendy can hear you

c. Tell her family who are in the room not to talk

d. Speak softly then hold her hands gently

33. Which among the following interventions should

you consider as the highest priority when caring for

June who has hemiparersis secondary to stroke?

a. Place June on an upright lateral position

b. Perform range of motion exercises

c. Apply antiembolic stocking

d. Use hand rolls or pillows for support

34. Ivy, age 40, was admitted to the hospital with a

severe headache, stiff neck and photophobia. She was

diagnosed with a subarachnoid hemorrhage secondary

to ruptured aneurysm. While waiting for surgery, you

can provide a therapeutic by doing which of the

following?

a. honoring her request for a television

b. placing her bed near the window

c. dimming the light in her room

d. allowing the family unrestricted visiting privileges

35. When performing a neurological assessment on

Walter, you find that his pupils are fixed and dilated.

This indicated that he:

a. probably has meningitis

b. is going to be blind because of trauma

c. is permanently paralyzed

d. has received a significant brain injury

Situation 8 - With the improvement in life expectancies

and the emphasis in the quality of life it is important to

provide quality care to our older patients. There are

frequently encountered situations and issues relevant to

the older, patients.

36. Hypoxia may occur in the older patients because of

which of the following physiologic changer associated

with aging.

a Ineffective airway clearance

b. Decreased alveolar surface area

c. Decreased anterior-posterior chest diameter

d. Hyperventilation

37. The older patient is at higher risk for in

inconvenience because of:

a. dilated urethra

b. increased glomerular filtration rate

c. diuretic use

d. decreased bladder capacity

38. Merle, age 86, is complaining of dizziness when she

stands up. This may indicate:

a. dementia

b. a visual problem

c. functional decline

d. drug toxicity

39. Cardiac ischemia in an older patient usually

produces:

a. ST-T wave changes

b. Very high creatinine kinase level

c. chest pain radiating to the left arm

d. acute confusion

40. The most dependable sign of infection in the older

patient is:

a. change in mental status pain

b. fever

c. pain

d. decreased breath sound with crackles

Situation 9 - A "disaster" is a large-scale emergency—

even a small emergency left unmanaged may turn into a

disaster. Disaster preparedness is crucial and is

everybody's business. There are agencies that are in

charge of ensuring prompt response. Comprehensive

Emergency Management (CEM) is an integrated

approach to the management of emergency program

and activities for all four emergency phases (mitigation,

preparedness, response, and recovery), for all type of

emergencies and disasters (natural, man-made, and

attack) and for all levels of government and the private

sector.

41. Which of the four phases of emergency

management is defined as "sustained action that

reduces or eliminates long-term risk to people and

properly from natural hazards and the effect"?

a. Recovery

b. Mitigation

c. Response

d. Preparedness

42. You are a community health nurse collaborating

with the Red Cross and working with disaster relief

following a typhoon which flooded and devastated the

whole province. Finding safe housing for survivors,

organizing support for the family, organizing counseling

debriefing sessions and securing physical care are the

services you are involved with. To which type of

prevention are these activities included.

a. Tertiary prevention

b. Primary prevention

c. Aggregate care prevention

d. Secondary prevention

43. During the disaster you see a victim with a green

tag, you know that the person:

a. has injuries that are significant and require medical

care but can wait hours will threat to life or limb

b. has injuries that are life threatening but survival is

good with minimal intervention

c. indicates injuries that are extensive and chances of

survival are unlikely even with definitive care

d. has injuries that are minor and treatment can be

delayed from hours to days

44. The term given to a category of triage that refers to

life threatening or potentially life threatening injury or

illness requiring immediate treatment:

a. Immediate

b. Emergent

c. Non-acute

d. Urgent

45. Which of the following terms refer to a process by

which the individual receives education about

recognition of stress reactions and management

strategies for handling stress which may be instituted

after a disaster?

a. Critical incident stress management

b. Follow-up

c. Defriefing

d. Defusion

Situation 10 - As a member of the health and nursing

team you have a crucial role to play in ensuring that all

the members participate actively is the various tasks

agreed upon,

46. While eating his meal, Matthew accidentally

dislodges his IV line and bleeds. Blood oozes on the

surface of the over-bed table. It is most appropriate

that you instruct the housekeeper to clean the table

with:

a. Acetone

b. Alcohol

c. Ammonia

d. Bleach

47. You are a member of the infection control team, of

the hospital. Based on a feedback during the meeting of

the committee there is an increased incidence of

pseudomonas infection in the Burn Unit (3 out of 10

patients had positive blood and wound culture). What

is your priority activity?

a. Establish policies for surveillance and monitoring

b. Do data gathering about the possible sources of

infection (observation, chart review, interview)

c. Assign point persons who can implement policies

d. Meet with the nursing group working in the burn unit

and discuss problem with them feel

48. Part of your responsibility as a member of the

diabetes core group is to get referrals from the various

wards regarding diabetic patients needing diabetes

education. Prior to discharge today 4 patients are

referred to you. How would you start prioritizing your

activities?

a. Bring your diabetes teaching kit and start your session

taking into consideration their distance from your office

b. Contact the nurse-in-charge and find out from her the

reason for the referral

c. Determine their learning needs then prioritize

d. involve the whole family in the teaching class

49. You have been designated as a member of the task

force to plan activities for the Cancer Consciousness

Week. Your committee has 4 months to plan and

implement the plan. You are assigned to contact the

various cancer support groups in your hospital. What

will be your priority activity?

a. Find out if there is a budget for this activity

b. Clarify objectives of the activity with the task force

before contacting the support groups

c. Determine the VIPs and Celebrities who will be invited

d. Find out how many support groups there are in the

hospital and get the contact number of their president

50. You are invited to participate in the medical mission

activity of your alumni association. In the planning

stage everybody is expected to identify what they can

do during the medical mission and what resources are

needed. You though it is also your chance to share what

you can do for others. What will be your most

important role where you can demonstrate the impact

of nursing health?

a. Conduct health education on healthy lifestyle

b. Be a triage nurse

c. Take the initial history and document findings

d. Act as a coordinator

Situation 11 - One of the realities that we are confronted

with is'6w mortality. It is important for us nurses to be

aware of how we view suffering, pain, illness, and even

our death as well as its meaning. That way we can help

our patients cope with death and dying.