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CARE OF CLIENTS WITH
PHYSIOLOGIC AND
PSYCHOSOCIAL ALTERATIONS
Situation 1 - Because of the serious
consequences of severe burnsmanagement 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 handsc. 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 blanketb. give him sips of water
c. calculate the extent of his burnsd. 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
damagedb. 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 hypernatremiab. 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 hypoxiab. 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 situationswith 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 reportb. Call security officer and report the
incident
c. Call your nurse supervisor and report
the incident :
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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 eructationc. 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 primarilyto:
a. promote rest of the bowel by
minimizing peristalsis
b. reduce the bacterial content of the
colonc. empty the bowel of solid waste
d. soften the stool by retaining water in
the colon
Situation 4 - ENTEROSTOMAL
THERAPY is now considered especiallyin 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 Fermincan sit comfortably on the commode
b. Fermin can lie on the side
comfortably, about the 3rd postoperativeday
c. The abdominal incision is close and
contamination is no longer a dangerd. 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 hoursc. 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 stomab. Hands the irrigating bag on the
bathroom door doth hook during fluidinsertion
c. Discontinues the insertion of fluid
after only 500 ml of fluid had been
insertiond. 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 theirrigating tub into the stoma.
b. If I notice a loss of sensation to touch
in the stoma tissue."
c. The expulsion of flatus while theirrigating 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
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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 theoperation, 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 toprevent complications.
21. Randy has chest tubes attached to
a pleural drainage system. Whencaring 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 forcrepitus
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 ankled. 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 physicalactivity
24. Herbert has a laryngectomy andhe 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 occurb. 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 drainaged. blood replacement
Situation 6 - Infection can causedebilitating consequences when host
resistance is compromised and virulence
of microorganisms and environmentalfactors 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
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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. stomatitisb. 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 acidd. 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 ofcomplications 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 functionc. 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 themb. Talk loudly so that Wendy can hear
you
c. Tell her family who are in the roomnot 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
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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 subarachnoidhemorrhage 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 windowc. 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 meningitisb. 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 thequality of life it is important to provide
quality care to our older patients. There
are frequently encountered situations andissues 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 chestdiameter
d. Hyperventilation
37. The older patient is at higher risk
for in inconvenience because of:
a. dilated urethrab. 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 problemc. functional decline
d. drug toxicity
39. Cardiac ischemia in an olderpatient 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. feverc. pain
d. decreased breath sound with crackles
Situation 9 - A "disaster" is a large-scale
emergencyeven a small emergency
left unmanaged may turn into a disaster.
Disaster preparedness is crucial and iseverybody's business. There are agencies
that are in charge of ensuring prompt
response. Comprehensive EmergencyManagement (CEM) is an integrated
approach to the management of
emergency program and activities for allfour emergency phases (mitigation,
preparedness, response, and recovery),
for all type of emergencies and disasters
(natural, man-made, and attack) and for
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all levels of government and the private
sector.
41. Which of the four phases of
emergency management is defined as
"sustained action that reduces oreliminates long-term risk to people
and properly from natural hazards
and the effect"?
a. Recovery
b. Mitigation
c. Responsed. Preparedness
42. You are a community health nurse
collaborating with the Red Cross andworking 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 preventionb. 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 hourswill threat to life or limb
b. has injuries that are life threatening
but survival is good with minimalintervention
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 orpotentially 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 recognitionof stress reactions and management
strategies for handling stress which
may be instituted after a disaster?
a. Critical incident stress management
b. Follow-upc. 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 membersparticipate 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. Ammoniad. Bleach
47. You are a member of the infection
control team, of the hospital. Based on
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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 priorityactivity?
a. Establish policies for surveillance andmonitoring
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 problemwith 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 andstart your session taking into
consideration their distance from your
officeb. Contact the nurse-in-charge and find
out from her the reason for the referral
c. Determine their learning needs then
prioritized. 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 withthe task force before contacting the
support groups
c. Determine the VIPs and Celebritieswho 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 planningstage 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
lifestyleb. Be a triage nurse
c. Take the initial history and document
findingsd. Act as a coordinator