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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