Nursing Practice IV – Nursing Care of Client with Physiological and Psychosocial Alteration
Medical and Surgical Nursing / Psychology
PART 1 Board Exam test questions 1 - 50
NURSING PRACTICE IV – SET B
NURSING PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations (Part B)
MULTIPLE CHOICE
Situation 1 – Because of the serious consequences of severe burns, management requires a multidisciplinary 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, 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 implifications.
6. 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 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 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 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 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 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 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 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 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. Carcinoembryonic 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. 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, 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 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 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.”
D. When mucus is passed from the stoma between the irrigations.”
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 food that are easily digested and absorbed by my large intestines.”
B. Bland food so that my intestines do not become irritated.”
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 suctioning
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 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 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
gammaglobulin.”
D. “A vaccine has been developed for this type of hepatitis”
27. Voltaire develops a nosocomial respiratory tract infection. He ask you what that means? Your best response would be:
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 wound infection is:
A. Dakin’s solution
B. Half-strength hydrogen peroxide
C. Acetic acid
D. Betadine
30. Which of the following is the most reliable in diagnosing a wound infection?
A. Culture and sensitivity
B. Purulent drainage from a wound
C. WBC count of 20,000/μL
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 an 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 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 hemiparesis secondary to stroke?
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, 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 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
B. fever
C. pain
D. decreased breath sounds 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 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 long-term risk to people and property from natural hazards and their effects.”?
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 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. Debfriefing
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 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.
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 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?
A. Conduct health education on healthy life style
B. Be a triage nurse
C. Take the initial history and document findings
D. Act as a coordinator
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