CARE OF CLIENTS WITH PHYSIOLOGIC AND PSYCHOSOCIAL ALTERATIONS 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 emergencyeven 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