Nursing Practice IV edgeworth

NURSING PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations (Part B) Situation 1 – Because of the serious consequences of severe burns, management requires a multidisciplin multidisciplinary ary approach. You have important responsibilities as a nurse. 1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burns 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 Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means? Your most accurate response would be: A. Structures beneath the skin are damage B. Dermis is partially damaged C. Epidermis and dermis are both damaged D. Epidermis is damaged 4. During the first 24 hours after the thermal injury, you should asses Sergio for: A. hypokalemia and hypernatremia B. hypokalemia and hyponatremia C. hyperkalemia and hyponatremia D. hyperkalemia and hypernatremia 5. Teddy 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 You recognize that this most likely indicates that Teddy Teddy is developing: A. Cerebral hypoxia C. metabolic acidosis B. Hypervolemia D. Renal failure Situation 2 – You You are now working as a staff nurse in a general hospital. You You have to be prepared to handle situations with ethico-legal and moral implifications. 6. You You are in night duty in surgical ward. One of your patients Martin is a prisoner who sustained an abdominal gunshot wound. He is being guarded by policeman from the local police unit. During your rounds you heard a commotion. You You saw the policeman trying to hit Martin. You asked why he was trying to hit Martin. He denied the matter. Which among the following activities will you do first? A. Write an accident 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 You are on morning duty in the medical ward. You 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 an 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 You are on duty in the medical ward. You You were asked to check the narcotics cabinet. You 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 You are on duty in the medical ward. The mother of your patient who is also a nurse, came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest. A. Start basic life support measures B. Call for the Code C. Bring the crash cart to the room D. Go to see Fiolo and assess for airway patency and breathing problems

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10. You You are admitting Jorge to the ward and you found out that he is HIV (+). Which among the ff. will you do first? A. Take Take note of it and plan to endorse this to next shift B. Keep this matter to yourself 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 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 11 vital signs the physician does which test as a screening test for colorectal cancer. A. Barium enema B. Carcinoembryonic antigen C. Annual digital rectal examination D. Proctosigmoidoscopy 12. To To confirm his impression of colorectal cancer, Larry will require which diagnostic study? A. Carcinoembryonic antigen B. Proctosigmoidoscopy 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 fiber 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, heart burn and eructation C. blood in the stools, anemia, and “pencil shaped” stools D. anorexia, hematemesis, and increased peristalasis 15. Several days prior to bowel surgery, 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 a specialty in nursing. You are participating in the OSTOMY CARE CLASS. 16. You 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 closed and contamination is no longer a danger D. The stools starts to become formed, around the 7th postoperative day 17. When preparing to teach Fermin how to irrigate 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 return demonstration of a 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. Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion C. Discontinues the insertion of fluid after only 500 ml of fluid has been instilled D. Clamps of the flow of fluid when felling uncomfortable 19. You 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 noticed a loss of sensation to touch in the stoma tissue.” C. The expulsion of flatus while the irrigating fluid is running out.”





Situation 5 – Ensuring safety is one of your most important responsibilities. You 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. W hen caring for him you should: A. empty the drainage system at the end of the shift B. clamp the chest tube when suctioning C. palpate the surrounding areas for crepitus D. change the dressing daily using aseptic techniques 22. Fanny, came in from PACU 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 To prevent recurrent attacks on Terry 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 had a laryngectomy and he is now for discharge. He 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 o f having Hepatitis A. his wife asks you about gamma globulin for herself and her household help. Your 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 “You should contact your physician immediately about getting gammaglobulin.” D. “A vaccine has been developed for this type of hepatitis” 27. Voltaire Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your Your best response would be: A. “You “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 solution used to treat Pseudomonas wound infection is: A. Dakin’s solution B. Half-strength hydrogen peroxide C. Acetic acid D. Betadine





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 an I.V I.V.. infusion was started. As a nurse assigned to Wendy what will be 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 last sense to be lost, as Judy’s nurse, what should you do? A. Tell Tell her family that probably she can’t hear them B. Talk loudly so that Wendy can hear you C. Tell 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 hemiparesis secondary to stroke? A. Place June on an upright lateral position B. Perform range of motion exercises C. Apply antiembolic stockings 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 environment 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 neurologic assessment on Walter, 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 o lder 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 changes associated with aging. A. Ineffective airway clearance B. Decreased alveolar surfaced area C. Decreased anterior-posterior chest diameter D. Hyperventilation 37. The older patient is at higher risk for incontinence 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





41. Which of the four phases of emergency management is defined as “sustained action that reduces or eliminates longterm risk to people and property from natural hazards and their effects.”? A. Recovery B. Mitigation C. Response D. Preparedness 42. You 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 family 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 with 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 reaction and management strategies for handling stress which may be instituted after a disaster? A. Clinical 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 lines and bleeds. Blood oozes on the surface of the overbed 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 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). W hat is your priority activity? A. Establish policies for surveillance and monitoring B. Do data gathering about the possible sources of infection (observation, chart review, 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. 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 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 You have been designated as a member of the task force to plan activities for the Cancer Consciousness Week. Your Your committee has 4 months to plan and implement the plan. You You are assigned to contact the various cancer support groups in your hospital. What will be your priority activity?





A. Conduct health education on healthy life style B. Be a triage nurse C. Take Take the initial history and document findings D. Act as a coordinator

ANSWER KEY NURSING PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations (Part B) Situation 1 – Because of the serious consequences of severe burns, management requires a multidisciplin multidisciplinary ary approach. You have important responsibilities as a nurse. 1. While Sergio was lighting a barbecue grill with a lighter fluid, his shirt burns into flames. The most effective way to extinguish the flames with as little further damage as possible is to: log roll on the grass/ground 2. Once the flames are extinguished, it is most important to: assess the Sergio’s breathing 3. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means? Your most accurate response would be: Epidermis and dermis are both damaged 4. During the first 24 hours after the thermal injury, you should asses Sergio for: hyperkalemia and hyponatremia 5. Teddy 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 You recognize that this most likely indicates that Teddy Teddy is developing: metabolic acidosis Situation 2 – You You are now working as a staff nurse in a general hospital. You You have to be prepared to handle situations with ethico-legal and moral implifications. 6. You You are in night duty in surgical ward. One of your patients Martin is a prisoner who sustained an abdominal gunshot wound. He is being guarded by policeman from the local police unit. During your rounds you heard a commotion. You You saw the policeman trying to hit Martin. You asked why he was trying to hit Martin. He denied the matter. Which among the following activities will you do first? Call your nurse supervisor and report the incident 7. You You are on morning duty in the medical ward. You 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? Report the incident to your supervisor 8. You You are on duty in the medical ward. You You were asked to check the narcotics cabinet. You You found out that what is on record does not tally with the drugs used. Which among the following will you do first? Report the matter to your supervisor 9. You You are on duty in the medical ward. The mother of your patient who is also a nurse, came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest. Bring the crash cart to the room 10. You You are admitting Jorge to the ward and you found out that he is positive for HIV HIV.. Which among the following will you do first? 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 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 11. vital signs the physician does which test as a screening test for colorectal cancer.







14. Symptoms associated with cancer of the colon include: blood in the stools, anemia, and “pencil shaped” stools 15. Several days prior to bowel surgery, surgery, Larry may be given sulfasuxidine and neomycin primarily to: reduce the bacterial content of the colon Situation 4 – ENTEROSTOMAL THERAPY is now considered a specialty in nursing. You are participating in the OSTOMY CARE CLASS. 16. You You plan to teach Fermin how to irrigate the colostomy when: The stools starts to become formed, around the 7th postoperative day 17. When preparing to teach Fermin how to irrigate colostomy, you should plan to do the procedure: When Fermin would have normal bo wel movement 18. When observing a return demonstration of a colostomy irrigation, you know that more teaching is required if Fermin: Hangs the irrigating bag on the bathroom door cloth hook during fluid insertion 19. You You are aware that teaching about colostomy care is understood when Fermin states, “I will contact my physician and report: If I have any difficulty inserting the irrigating tub into the stoma.” 20. You You would know after teaching Fermin that dietary instruction for him is effective when he states, “It is important that I eat: A. 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 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. W hen caring for him you should: palpate the surrounding areas for crepitus 22. Fanny, came in from PACU PACU after pelvic surgery. As Fanny’s nurse you know that the sign that would be indicative of a developing thrombophlebitis would be: a tender, painful area on the leg 23. To To prevent recurrent attacks on Terry Terry who has acute glumerulonephritis, you should instruct her to: seek early treatment for respiratory infections 24. Herbert had a laryngectomy and he is now for discharge. He verbalized his concern regarding his laryngectomy tube being dislodged. What should you teach him first? Notify the physician at once 25. When caring for Larry after an exploratory chest surgery and pneumonectomy, your priority would be to maintain: ventilation exchange 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 o f having Hepatitis A. his wife asks you about gamma globulin for herself and her household help. Your Your most appropriate response would be: “You “Y ou should contact your physician immediately about getting gammaglobulin.”





32. Knowing that for a comatose patient hearing is the last sense to be lost, as Judy’s nurse, what should you do? 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 hemiparesis secondary to stroke? Perform range of motion exercises 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 environment by doing which of the following? dimming the light in her room 35. When performing a neurologic assessment on Walter, Walter, you find that his pupils are fixed and dilated. This indicated that he: 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 o lder 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 changes associated with aging. Decreased alveolar surfaced area 37. The older patient is at higher risk for incontinence because of: decreased bladder capacity 38. Merle, age 86, is complaining of dizziness when she stands up. This may indicate: functional decline 39. Cardiac ischemia in an older patient usually produces: Acute confusion 40. The most dependable sign of infection in the older patient is: change in mental status Situation 9 – A “disaster” “disaster” is a large-scale emergency—even a small emergency left unmanaged may turn into a disaster 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 programs and activities for all four emergency phases (mitigation, preparedness, response, and recovery), for all types 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 longterm risk to people and property from natural hazards and their effects.”? Mitigation 42. You 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 family To which type of prevention are these activities included: Tertiary prevention 43. During the disaster you see a victim with a green tag, you know that the person: has injuries that are minor and treatment can be delayed from hours to days





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 today,, 4 patients are referred to you. How would you start prioritizing your activities? Determine their learning needs then prioritize 49. You You have been designated as a member of the task force to plan activities for the Cancer Consciousness Week. Your Your committee has 4 months to plan and implement the plan. You You are assigned to contact the various cancer support groups in your hospital. What will be your priority activity? Clarify objectives of the activity with the task force before contacting the support groups 50. You 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 thought 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 in health? Conduct health education on healthy life style

Nursing Practice IV edgeworth

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