MEDICAL SURGICAL NURSING DEGREE OF QUESTION DIFFICULTY 4 Very hard quest !"# $%& Cha"'e !( a"s)er "* '!

!rre't+y , -ard quest !"# %.& Cha"'e !( a"s)er "* '!rre't+y $ M!derate+y hard quest !"# /%& !( a"s)er "* '!rre't+y 0 Easy quest !"# 11& ) ++ a"s)er the quest !" '!rre't+y SITUATION 2 Der3 d# A re* stered "urse# ) t"essed a" !+d )!4a" h t 5y a 4!t!r'y'+e )h +e 'r!ss "* a tra " ra +)ay6 The !+d )!4a" (e++ at the ra +)ay6 Der3 d Rushed at the s'e"e6 06 As a re* stered "urse# Der3 d 7"e) that the ( rst th "* that he ) ++ d! at the s'e"e s 8,9 A6 Stay ) th the :ers!"# E"'!ura*e her t! re4a " st ++ a"d I44!5 + ;e the +e* )h +e <h +e )a t "* (!r the a45u+a"'e6 =6 Lea3e the :ers!" (!r a (e) 4!4e"ts t! 'a++ (!r he+:6 C6 Redu'e the (ra'ture 4a"ua++y6 D6 M!3e the :ers!" t! a sa(er :+a'e6 $6 Der3 d sus:e'ts a h : (ra'ture )he" he "!t 'ed that the !+d )!4a">s +e* s 849 A6 Le"*the"ed# A5du'ted a"d I"ter"a++y R!tated6 =6 Sh!rte"ed# A5du'ted a"d E?ter"a++y R!tated6 C6 Sh!rte"ed# Addu'ted a"d I"ter"a++y R!tated6 D6 Sh!rte"ed# Addu'ted a"d E?ter"a++y R!tated6 ,6 The !+d )!4a" '!4:+a "s !( :a "6 @!h" "!t 'ed that the 7"ee s redde"ed# )ar4 t! t!u'h a"d s)!++e"6 @!h" "ter:rets that th s s *"s a"d sy4:t!4s are + 7e+y re+ated t! 8$9 A6 I"(e't !" C6 Thr!45!:h+e5 t s =6 I"(+a44at !" D6 De*e"erat 3e d sease 46 The !+d )!4a" t!+d @!h" that she has !ste!:!r!s sA Der3 d 7"e) that a++ !( the (!++!) "* (a't!rs )!u+d '!"tr 5ute t! !ste!:!r!s s e?'e:t 849 A6 -y:!thyr! d s4 =6 E"d sta*e re"a+ d sease C6 Cush "*>s D sease D6 Ta7 "* Fur!se4 de a"d Bhe"yt! "6 %6 Martha# The !+d )!4a" )as "!) I44!5 + ;ed a"d 5r!u*ht t! the e4er*e"'y r!!46 The CDray sh!)s a (ra'tured (e4ur a"d :e+3 s6 The ER Nurse )!u+d 'are(u++y 4!" t!r Martha (!r )h 'h !( the (!++!) "* s *" a"d sy4:t!4sE 8,9 A6 Ta'hy'ard a a"d -y:!te"s !" =6 Fe3er a"d =rady'ard a C6 =rady'ard a a"d -y:erte"s !" D6 Fe3er a"d -y:erte"s !" SITUATION2 Mr6 D6 R!Fas# A" !5ese ,% year !+d MS Br!(ess!r !( OLFU La*r! s ad4 tted due t! :a " " h s )e *ht 5ear "* F! "t6 The d a*"!s s )as Oste!arthr t s6 G6 As a "urse# y!u "stru'ted Mr6 R!Fas h!) t! use a 'a"e6 Mr6 R!Fas has a )ea7"ess !" h s r *ht +e* due

t! se+( 44!5 + ;at !" a"d *uard "*6 Y!u :+a" t! tea'h Mr6 R!Fas t! h!+d the 'a"e 849 A6 O" h s +e(t ha"d# 5e'ause h s r *ht s de s )ea76 =6 O" h s +e(t ha"d# 5e'ause !( re' :r!'a+ 4!t !"6 C6 O" h s r *ht ha"d# t! su::!rt the r *ht +e*6 D6 O" h s r *ht ha"d# 5e'ause !"+y h s r *ht +e* s )ea76 /6 Y!u a+s! t!+d Mr6 R!Fas t! h!+d the 'a"e 849 A6 0 I"'hes " (r!"t !( the (!!t6 =6 , I"'hes at the +atera+ s de !( the (!!t6 '6 G I"'hes at the +atera+ s de !( the (!!t6 D6 0$ I"'hes at the +atera+ s de !( the (!!t6 H6 Mr6 R!Fas )as d s'har*ed a"d G 4!"ths +ater# he 'a4e 5a'7 t! the e4er*e"'y r!!4 !( the h!s: ta+ 5e'ause he su((ered a 4 +d str!7e6 The r *ht s de !( the 5ra " )as a((e'ted6 At the reha5 + tat 3e :hase !( y!ur "urs "* 'are# y!u !5ser3e Mr6 R!Fas use a 'a"e a"d y!u "ter3e"e ( y!u see h 4 849 A6 M!3es the 'a"e )he" the r *ht +e* s 4!3ed6 =6 Lea"s !" the 'a"e )he" the r *ht +e* s) "*s thr!u*h6 C6 7ee:s the 'a"e G I"'hes !ut t! the s de !( the r *ht (!!t6 D6 -!+ds the 'a"e !" the r *ht s de6 SITUATION2 A+(red# a 4. year !+d '!"stru't !" )!r7er de3e+!:ed '!u*h# " *ht s)eats a"d (e3er6 -e )as 5r!u*ht t! the "urs "* u" t (!r d a*"!st ' stud es6 -e t!+d the "urse he d d "!t re'e 3e a =CG 3a'' "e dur "* 'h +dh!!d 16 The "urse :er(!r4s a Ma"t!u? Test6 The "urse 7"!)s that Ma"t!u? Test s a+s! 7"!)" as 809 A6 BBD =6 BDB C6 BDD D6 DBB 0.6 The "urse )!u+d "Fe't the s!+ut !" " )hat r!uteE 809 A6 IM =6 IV C6 ID D6 SC 006 The "urse "!tes that a :!s t 3e resu+t (!r A+(red s 8$9 A6 % 44 )hea+ =6 % 44 I"durat !" C6 0. 44 <hea+ D6 0. 44 I"durat !" 0$6 The "urse t!+d A+(red t! '!4e 5a'7 a(ter 8$9 A6 a )ee7 =6 4H h!urs C6 0 day D6 4 days 0,6 Ma"* A+(red retur"s a(ter the Ma"t!u? Test6 The test resu+t read BOSITIVE6 <hat sh!u+d 5e the

"urse>s "e?t a't !"E 8,9 A6 Ca++ the Bhys ' a" =6 N!t (y the rad !+!*y de:t6 (!r CCR e3a+uat !" C6 Is!+ate the :at e"t D6 Order (!r a s:utu4 e?a4 046 <hy s Ma"t!u? test "!t r!ut "e+y d!"e " the Bh + :: "esE 8$9 A6 It requ res a h *h+y s7 ++ed "urse t! :er(!r4 a Ma"t!u? test =6 The s:utu4 'u+ture s the *!+d sta"dard !( BT= D a*"!s s a"d t ) ++ de( " t 3e+y deter4 "e the e?te"t !( the 'a3 tary +es !"s C6 Chest C Ray Ca" d a*"!se the s:e' ( ' 4 'r!!r*a" s4 res:!"s 5+e (!r the +es !"s D6 A+4!st a++ F + : "!s ) ++ test :!s t 3e (!r Ma"t!u? Test 0%6 Ma"* A+(red s "!) a "e) T= :at e"t ) th a" a't 3e d sease6 <hat s h s 'ate*!ry a''!rd "* t! the DO-E 809 A6 I =6 II C6 III D6 IV 0G6 -!) +!"* s the durat !" !( the 4a "te"a"'e :hase !( h s treat4e"tE 8$9 A6 $ 4!"ths =6 , 4!"ths C6 4 4!"ths D6 % 4!"ths 0/6 <h 'h !( the (!++!) "* dru*s s UNLIIELY * 3e" t! Ma"* A+(red dur "* the 4a "te"a"'e :haseE 8,9 A6 R (a4: ' " =6 Is!" a; d C6 Etha45ut!+ D6 Byr d!? "e 0H6 A''!rd "* t! the DO-# the 4!st ha;ard!us :er !d (!r de3e+!:4e"t !( '+ " 'a+ d sease s dur "* the ( rst 849 A6 GD0$ 4!"ths a(ter =6 ,DG 4!"ths a(ter C6 0D$ 4!"ths a(ter D6 $D4 )ee7s a(ter 016 Th s s the "a4e !( the :r!*ra4 !( the DO- t! '!"tr!+ T= " the '!u"try 8$9 A6 DOTS =6 Nat !"a+ Tu5er'u+!s s C!"tr!+ Br!*ra4 C6 Sh!rt C!ursed Che4!thera:y D6 E?:a"ded Br!*ra4 (!r I44u" ;at !" $.6 Sus'e:t 5 + ty (!r the d sease 8 T= 9 s "'reased 4ar7ed+y " th!se ) th the (!++!) "* '!"d t !" e?'e:t 8,9 A6 $, Year !+d ath+ete ) th d a5etes "s : dus

=6 $, Year !+d ath+ete ta7 "* +!"* ter4 De'adr!" thera:y a"d a"a5!+ ' ster! ds C6 $, Year !+d ath+ete ta7 "* ++e*a+ dru*s a"d a5us "* su5sta"'es D6 U"der"!ur shed a"d U"der)e *ht "d 3 dua+ )h! u"der*!"e *astre't!4y $06 D re't s:utu4 e?a4 "at !" a"d Chest C ray !( T= sy4:t!4at ' s " )hat +e3e+ !( :re3e"t !"E 809 A6 Br 4ary =6 Se'!"dary C6 Tert ary D6 Quarter+y SITUATION2 M 'h e+# A 4a+e :at e"t d a*"!sed ) th '!+!" 'a"'er )as "e)+y :ut " '!+!st!4y6 $$6 M 'h e+ sh!)s the =EST ada:tat !" ) th the "e) '!+!st!4y ( he sh!)s )h 'h !( the (!++!) "*E 8$9 A6 L!!7 at the !st!4y s te =6 Bart ' :ate ) th the "urse " h s da +y !st!4y 'are C6 As7 (!r +ea(+ets a"d '!"ta't "u45ers !( !st!4y su::!rt *r!u:s D6 Ta+7 a5!ut h s !st!4y !:e"+y t! the "urse a"d (r e"ds $,6 The "urse :+a"s t! tea'h M 'h e+ a5!ut '!+!st!4y rr *at !"6 As the "urse :re:ares the 4ater a+s "eeded# )h 'h !( the (!++!) "* te4 "d 'ates that the "urse "eeds (urther "stru't !"E 8,9 A6 B+a " NSS J N!r4a+ Sa+ "e =6 IDY @e++y C6 Ta: )ater D6 Irr *at !" s+ee3e $46 The "urse sh!u+d "sert the '!+!st!4y tu5e (!r rr *at !" at a::r!? 4ate+y 8,9 A6 0D$ "'hes =6 ,D4 "'hes C6 GDH "'hes D6 0$D0H "'hes $%6 The 4a? 4u4 he *ht !( rr *at !" s!+ut !" (!r '!+!st!4y s 8,9 A6 % "'hes =6 0$ "'hes C6 0H "'hes D6 $4 "'hes $G6 <h 'h !( the (!++!) "* 5eha3 !r !( the '+ e"t "d 'ates the 5est " t a+ ste: " +ear" "* t! 'are (!r h s '!+!st!4yE 809 A6 As7 t! de(er '!+!st!4y 'are t! a"!ther "d 3 dua+ =6 Br!4 ses he ) ++ 5e* " t! + ste" the "e?t day C6 A*rees t! +!!7 at the '!+!st!4y D6 States that '!+!st!4y 'are s the (u"'t !" !( the "urse )h +e he s " the h!s: ta+ $/6 <h +e rr *at "* the '+ e"t>s '!+!st!4y# M 'h e+ sudde"+y '!4:+a "s !( se3ere 'ra4: "*6 I" t a++y# the "urse )!u+d 809 A6 St!: the rr *at !" 5y '+a4: "* the tu5e =6 S+!) d!)" the rr *at !" C6 Te++ the '+ e"t that 'ra4: "* ) ++ su5s de a"d s "!r4a+

D6 N!t (y the :hys ' a" $H6 The "e?t day# the "urse ) ++ assess M 'h e+>s st!4a6 The "urse "!t 'ed that a :r!+a:sed st!4a s e3 de"t ( she sees )h 'h !( the (!++!) "*E 809 A6 A su"7e" a"d h dde" st!4a =6 A dus7y a"d 5+u sh st!4a C6 A "arr!) a"d (+atte"ed st!4a D6 Br!trud "* st!4a ) th s)!++e" a::eara"'e $16 M 'h e+ as7ed the "urse# )hat (!!ds ) ++ he+: +esse" the !d!r !( h s '!+!st!4y6 The "urse 5est res:!"se )!u+d 5e 849 A6 Eat e**s =6 Eat 'u'u45ers C6 Eat 5eet *ree"s a"d :ars+ey D6 Eat 5r!''!+ a"d s: "a'h ,.6 The "urse ) ++ start t! tea'h M 'h e+ a5!ut the te'h" ques (!r '!+!st!4y rr *at !"6 <h 'h !( the (!++!) "* sh!u+d 5e "'+uded " the "urse>s tea'h "* :+a"E 849 A6 Use %.. 4+ t! 0#... 4+ NSS =6 Sus:e"d the rr *a"t 4% '4 a5!3e the st!4a C6 I"sert the '!"e 4 '4 " the st!4a D6 I( 'ra4: "* !''urs# s+!) the rr *at !" ,06 The "urse 7"e) that the "!r4a+ '!+!r !( M 'h e+>s st!4a sh!u+d 5e 809 A6 =r '7 Red =6 Gray C6 =+ue D6 Ba+e B "7 SITUATION2 @a4es# A $/ 5as7et5a++ :+ayer susta "ed "ha+at !" 5ur" that requ red h 4 t! ha3e tra'he!st!4y due t! 4ass 3e u::er a r)ay ede4a6 ,$6 < +4a# - s s ster a"d a "urse s su't !" "* the tra'he!st!4y tu5e !( @a4es6 <h 'h !( the (!++!) "*# ( 4ade 5y < +4a "d 'ates that she s '!44 tt "* a" err!rE 8$9 A6 -y:er3e"t +at "* @a4es ) th 0..& !?y*e" 5e(!re a"d a(ter su't !" "* =6 I"st ++ "* , t! % 4+ "!r4a+ sa+ "e t! +!!se" u: se'ret !" C6 A::+y "* su't !" dur "* 'atheter ) thdra)a+ D6 Su't !" the '+ e"t e3ery h!ur ,,6 <hat s ;e !( su't !" 'atheter )!u+d < +4a use (!r @a4es# )h! s G (eet % "'hes " he *ht a"d )e *h "* a::r!? 4ate+y 04% +5sE 8$9 A6 Fr6 % =6 Fr6 0. C6 Fr6 0$ D6 Fr6 0H ,46 < +4a s us "* a :!rta5+e su't !" u" t at h!4e# <hat s the a4!u"t !( su't !" requ red 5y @a4es us "* th s u" tE 849 A6 $D% 44-*

=6 %D0. 44-* C6 0.D0% 44-* D6 $.D$% 44-* ,%6 I( a <a++ u" t s used# <hat sh!u+d 5e the su't !" "* :ressure requ red 5y @a4esE 849 A6 %.D1% 44-* =6 1%D00. 44-* C6 0..D0$. 44-* D6 0%%D0/% 44-* ,G6 < +4a )as sh!'7ed t! see that the Tra'he!st!4y )as d s+!d*ed6 =!th the ""er a"d !uter 'a""u+as )as re4!3ed a"d +e(t ha"* "* !" @a4es> "e'76 <hat are the $ equ :4e"t>s at Fa4es> 5eds de that '!u+d he+: < +4a dea+ ) th th s s tuat !"E 8,9 A6 Ne) set !( tra'he!st!4y tu5es a"d O?y*e" ta"7 =6 The!:hy++ "e a"d E: "e:hr "e C6 O5turat!r a"d Ie++y '+a4: D6 Ster +e sa+ "e dress "* ,/6 <h 'h !( the (!++!) "* 4eth!d ( used 5y < +4a ) ++ 5est assure that the tra'he!st!4y t es are "!t t!! t *ht+y :+a'edE 8$9 A6 < +4a :+a'es $ ( "*ers 5et)ee" the t e a"d "e'7 =6 The tra'he!t!4y 'a" 5e :u++ed s+ *ht+y a)ay (r!4 the "e'7 C6 @a4es> "e'7 3e "s are "!t e"*!r*ed D6 < +4a 4easures the t e (r!4 the "!se t! the t : !( the ear+!5e a"d t! the ? :h! d :r!'ess6 ,H6 < +4a 7"e) that @a4es ha3e a" adequate res: rat!ry '!"d t !" ( she "!t 'es that 809 A6 @a4es> res: rat!ry rate s 0H =6 @a4es> O?y*e" saturat !" s 10& C6 There are (ra"7 5+!!d su't !" (r!4 the tu5e D6 There are 4!derate a4!u"t !( tra'he!5r!"'h a+ se'ret !"s ,16 < +4a 7"e) that the 4a? 4u4 t 4e )he" su't !" "* @a4es s 809 A6 0. se'!"ds =6 $. se'!"ds C6 ,. se'!"ds D6 4% se'!"ds SITUATION 2 @ua" M *ue+ L!:e; K!5e+ Aya+a de =atu45a7a+ )as d a*"!sed ) th A'ute C+!se A"*+e G+au'!4a6 -e s 5e "* see" 5y Nurse @et6 4.6 <hat s:e' ( ' 4a" (estat !" )!u+d "urse @et see " A'ute '+!se a"*+e *+au'!4a that she )!u+d "!t see " a" !:e" a"*+e *+au'!4aE 8,9 A6 L!ss !( :er :hera+ 3 s !" =6 Irre3ers 5+e 3 s !" +!ss C6 There s a" "'rease " IOB D6 Ba " 406 Nurse Fet 7"e) that A'ute '+!se a"*+e *+au'!4a s 'aused 5y 8,9 A6 Sudde" 5+!'7a*e !( the a"ter !r a"*+e 5y the 5ase !( the r s

=6 O5stru't !" " tra5e'u+ar 4esh)!r7 C6 Gradua+ "'rease !( IOB D6 A" a5ru:t r se " IOB (r!4 H t! 0% 44-* 4$6 Nurse Fet :er(!r4ed a TONOMETRY test t! Mr6 =atu45a7a+6 <hat d!es th s test 4easures 809 A6 It 4easures the :er :hera+ 3 s !" re4a " "* !" the '+ e"t =6 Measures the I"tra O'u+ar Bressure C6 Measures the C+ e"t>s V sua+ A'u ty D6 Deter4 "es the T!"e !( the eye " res:!"se t! the sudde" "'rease " IOB6 4,6 The Nurse "!t 'es that Mr6 =atu45a7a+ 'a""!t a"y4!re deter4 "e RED (r!4 =LUE6 The "urse 7"e) that )h 'h :art !( the eye s a((e'ted 5y th s 'ha"*eE 8,9 A6 IRIS =6 BUBIL '6 RODS 8RETINA9 D6 CONES 8RETINA9 446 Nurse @et 7"!)s that Aque!us -u4!r s :r!du'e )hereE 849 A6 I" the su5 ara'h"! d s:a'e !( the 4e" "*es =6 I" the Latera+ 3e"tr '+es C6 I" the Ch!r! ds D6 I" the C + ary =!dy 4%6 Nurse @et 7"!)s that the "!r4a+ IOB s 8$9 A6 HD$0 44-* =6 $D/ 44-* '6 ,0D,% 44-* D6 0%D,. 44-* 4G6 Nurse @et )a"ts t! 4easure Mr6 =atu45a7a+>s CN II Fu"'t !"6 <hat test )!u+d Nurse @et 4:+e4e"t t! 4easure CN II>s A'u tyE 809 A6 S+ t +a4: =6 S"e++e">s Chart C6 <!!d>s + *ht D6 G!" !s'!:y 4/6 The D!'t!r !rders : +!'ar: "e6 Nurse Fet 7"!)s that the a't !" !( th s dru* s t! 849 A6 C!"tra't the C + ary 4us'+e =6 Re+a? the C + ary 4us'+e C6 D +ate the :u: +s D6 De'rease :r!du't !" !( Aque!us -u4!r 4H6 The d!'t!r !rders t 4!+!+ 8t 4!:t '96 Nurse Fet 7"!)s that the a't !" !( th s dru* s 849 A6 Redu'e :r!du't !" !( CSF =6 Redu'e :r!du't !" !( Aques!us -u4!r C6 C!"str 't the :u: + D6 Re+a?es the C + ary 4us'+e 416 <he" 'ar "* (!r Mr6 =atu45a7a+# @et tea'hes the '+ e"t t! a3! d 809

A6 <at'h "* +ar*e s'ree" TVs =6 =e"d "* at the )a st C6 Read "* 5!!7s D6 G! "* !ut " the su" %.6 Mr6 =atu45a7a+ has u"der*!"e eye a"* !*ra:hy us "* a" I"tra3e"!us dye a"d (+u!r!s'!:y6 <hat a't 3 ty s '!"tra "d 'ated 44ed ate+y a(ter :r!'edureE 849 A6 Read "* "e)s:r "t =6 Ly "* d!)" C6 <at'h "* TV D6 L ste" "* t! the 4us ' %06 I( Mr6 =atu45a7a+ s re'e 3 "* : +!'ar: "e# )hat dru* sh!u+d a+)ays 5e a3a +a5+e " a"y 'ase syste4 ' t!? ' ty !''ursE 8$9 A6 Atr!: "e Su+(ate =6 B "d!+!+ 8V s7e"9 C6 Na+!?!"e -ydr!'h+!r de 8Nar'a"9 D6 Mes!r da; "e =esy+ate 8Sere"t +9 SITUATION 2 < de 7"!)+ed*e a5!ut the hu4a" ear# t>s :arts a"d t>s (u"'t !"s ) ++ he+: a "urse assess a"d a"a+y;e 'ha"*es " the adu+t '+ e"t>s hea+th6 %$6 Nurse =ude7 s d! "* a 'a+!r ' test "* t! h s :at e"t# A da# a %% year !+d u" 3ers ty :r!(ess!r )h! re'e"t+y )e"t "t! '!4a a(ter 5e "* 4au+ed 5y her d s*ru"t+ed ,rd year "urs "* stude"ts )h!4 she *a3e a (a + "* 4ar76 A(ter "st ++ "* a )ar4 )ater " the ear# =ude7 "!t 'ed a r!tary "ysta*4us t!)ards the rr *ated ear6 <hat d!es th s 4ea"sE 8$9 A6 I"d 'ates a CN VIII Dys(u"'t !" =6 A5"!r4a+ C6 N!r4a+ D6 I"'!"'+us 3e

%,6 Ear dr!:s are :res'r 5ed t! a" "(a"t# The 4!st a::r!:r ate 4eth!d t! ad4 " ster the ear dr!:s s 8$9 A6 Bu++ the : ""a u: a"d 5a'7 a"d d re't the s!+ut !" t!)ards the eardru4 =6 Bu++ the : ""a d!)" a"d 5a'7 a"d d re't the s!+ut !" !"t! the )a++ !( the 'a"a+ C6 Bu++ the : ""a d!)" a"d 5a'7 a"d d re't the s!+ut !" t!)ards the eardru4 D6 Bu++ the : ""a u: a"d 5a'7 a"d d re't the s!+ut !" !"t! the )a++ !( the 'a"a+ %46 Nurse =ude7 s de3e+!: "* a :+a" !( 'are (!r a :at e"t ) th Me" eres d sease6 <hat s the :r !r ty "urs "* "ter3e"t !" " the :+a" !( 'are (!r th s :art 'u+ar :at e"tE 809 A6 A r# =reath "*# C r'u+at !" =6 L!3e a"d =e+!"* "*"ess C6 F!!d# D et a"d Nutr t !" D6 Sa(ety %%6 A(ter 4ast! de't!4y# Nurse =ude7 sh!u+d 5e a)are that the 'ra" a+ "er3e that s usua++y da4a*e a(ter th s :r!'edure s 8,9 A6 CN I =6 CN II

C6 CN VII D6 CN VI %G6 The :hys ' a" !rders the (!++!) "* (!r the '+ e"t ) th Me" eres d sease6 <h 'h !( the (!++!) "* sh!u+d the "urse quest !"E 809 A6 D :e"hydra4 "e 8=e"adry+9 =6 Atr!: "e su+(ate C6 Out !( 5ed a't 3 t es a"d a45u+at !" D6 D a;e:a4 8Va+ u49 %/6 Nurse =ude7 s * 3 "* d etary "stru't !" t! a '+ e"t ) th Me" eres d sease6 <h 'h state4e"t ( 4ade 5y the '+ e"t "d 'ates that the tea'h "* has 5ee" su''ess(u+E 809 A6 I ) ++ try t! eat (!!ds that are +!) " s!d u4 a"d + 4 t 4y (+u d "ta7e =6 I 4ust dr "7 at+east ,#... 4+ !( (+u ds :er day C6 I ) ++ try t! (!++!) a %.& 'ar5!hydrate# ,.& (at a"d $.& :r!te " d et D6 I ) ++ "!t eat tur" :s# red 4eat a"d radd sh %H6 Bea'hy )as rushed 5y h s (ather# Ste3e" "t! the h!s: ta+ ad4 ss !"6 Bea'hy s '!4:+a " "* !( s!4eth "* 5u;; "* "t! her ears6 Nurse =ude7 assessed :ea'hy a"d (!u"d !ut It )as a" "se't6 <hat sh!u+d 5e the ( rst th "* that Nurse =ude7 sh!u+d try t! re4!3e the "se't !ut (r!4 :ea'hy>s earE 8,9 A6 Use a (+ash+ *ht t! '!a? the "se't !ut !( :ea'hy>s ear =6 I"st ++ a" a"t 5 !t ' ear dr!:s C6 Irr *ate the ear D6 B '7 !ut the "se't us "* a ster +e '+ea" (!r'e:s %16 F!++!) "* a" ear sur*ery# )h 'h state4e"t ( heard 5y Nurse =ude7 (r!4 the :at e"t "d 'ates a '!rre't u"dersta"d "* !( the :!st !:erat 3e "stru't !"sE 8$9 A6 A't 3 t es are resu4ed ) th " % days =6 I ) ++ 4a7e sure that I ) ++ '+ea" 4y ha r a"d (a'e t! :re3e"t "(e't !" C6 I ) ++ use stra) (!r dr "7 "* D6 I sh!u+d a3! d a r tra3e+ (!r a )h +e G.6 Nurse =ude7 ) ++ d! a 'a+!r ' test "* t! a '+ e"t )h! susta "ed a 5+u"t "Fury " the head6 -e "st ++ed a '!+d )ater " the '+ e"t>s r *ht ear a"d he "!t 'ed that "ysta*4us !''urred t!)ards the +e(t ear6 <hat d!es th s ( "d "* "d 'atesE 8$9 A6 I"d 'at "* a Cra" a+ Ner3e VIII Dys(u"'t !" =6 The test sh!u+d 5e re:eated a*a " 5e'ause the resu+t s 3a*ue C6 Th s s Gr!ss+y a5"!r4a+ a"d sh!u+d 5e re:!rted t! the "eur!sur*e!" D6 Th s "d 'ates a" "ta't a"d )!r7 "* 3est 5u+ar 5ra"'h !( CN VIII G06 A '+ e"t ) th Catara't s a5!ut t! u"der*! sur*ery6 Nurse =ude7 s :re:ar "* :+a" !( 'are6 <h 'h !( the (!++!) "* "urs "* d a*"!s s s 4!st a::r!:r ate t! address the +!"* ter4 "eed !( th s ty:e !( :at e"tE 809 A6 A"? ety RJT t! the !:erat !" a"d ts !ut'!4e =6 Se"s!ry :er'e:tua+ a+terat !" RJT Le"s e?tra't !" a"d re:+a'e4e"t C6 I"!)+ed*e de( ' t RJT the :re !:erat 3e a"d :!st !:erat 3e se+( 'are D6 =!dy I4a*e d stur5a"'e RJT the eye :a'7 "* a(ter sur*ery G$6 Nurse =ude7 s :er(!r4 "* a <E=ERS TEST6 -e :+a'ed the tu" "* (!r7 " the :at e"ts (!rehead a(ter

ta:: "* t !"t! h s 7"ee6 The '+ e"t states that the (!r7 s +!uder " the LEFT EAR6 <h 'h !( the (!++!) "* s a '!rre't '!"'+us !" (!r "urse =ude7 t! 4a7eE 849 A6 -e 4 *ht ha3e a se"s!ry hear "* +!ss " the +e(t ear =6 C!"du't 3e hear "* +!ss s :!ss 5+e " the r *ht ear C6 -e 4 *ht ha3e a se"s!ry hear "* +!ss " the r *ht hear# a"dJ!r a '!"du't 3e hear "* +!ss " the +e(t ear6 D6 -e 4 *ht ha3e a '!"du't 3e hear "* +!ss " the r *ht ear# a"dJ!r a se"s!ry hear "* +!ss " the +e(t ear6 G,6 A+ "* 4yr"a has Me" eres d sease6 <hat ty: 'a+ d etary :res'r :t !" )!u+d "urse =ude7 e?:e't the d!'t!r t! :res'r 5eE 8$9 A6 A +!) s!d u4 # h *h (+u d "ta7e =6 A h *h 'a+!r e# h *h :r!te " d etary "ta7e C6 +!) (at# +!) s!d u4 a"d h *h 'a+!r e "ta7e D6 +!) s!d u4 a"d restr 'ted (+u d "ta7e SITUATION 2 8 Fr!4 DEC 0110 NLE 9 A 4% year !+d 4a+e '!"stru't !" )!r7er )as ad4 tted t! a tert ary h!s: ta+ (!r "'essa"t 3!4 t "*6 Assess4e"t d s'+!sed2 )ea7 ra: d :u+se# a'ute )e *ht +!ss !( 6%7*# (urr!)s " h s t!"*ue# s+!) (+atte" "* !( the s7 " )as "!ted )he" the "urse re+eased her : "'h6 Te4:erature2 ,%6H C # =UN Creat " "e rat ! 2 0. 2 0# -e a+s! '!4:+a "s (!r :!stura+ hy:!te"s !"6 There )as "! "(e't !"6 G46 <h 'h !( the (!++!) "* s the a::r!:r ate "urs "* d a*"!s sE 809 A6 F+u d 3!+u4e de( ' t RJT (urr!) t!"*ue =6 F+u d 3!+u4e de( ' t RJT u"'!"tr!++ed 3!4 t "* C6 Dehydrat !" RJT su5"!r4a+ 5!dy te4:erature D6 Dehydrat !" RJT "'essa"t 3!4 t "* G%6 A::r!? 4ate+y h!) 4u'h (+u d s +!st " a'ute )e *ht +!ss !( 6%7*E 809 A6 %. 4+ =6 /%. 4+ C6 %.. 4+ D6 /% 4+ GG6 B!stura+ -y:!te"s !" s 809 A6 A dr!: =6 A dr!: C6 A dr!: D6 A dr!: " syst!+ ' :ressure +ess tha" 0. 44-* )he" :at e"t 'ha"*es :!s t !" (r!4 +y "* t! s tt "*6 " syst!+ ' :ressure *reater tha" 0. 44-* )he" :at e"t 'ha"*es :!s t !" (r!4 +y "* t! s tt "* " d ast!+ ' :ressure +ess tha" 0. 44-* )he" :at e"t 'ha"*es :!s t !" (r!4 +y "* t! s tt "* " d ast!+ ' :ressure *reater tha" 0. 44-* )he" :at e"t 'ha"*es :!s t !" (r!4 +y "* t! s tt "*

G/6 <h 'h !( the (!++!) "* 4easures ) ++ "!t he+: '!rre't the :at e"t>s '!"d t !" 809 A6 O((er +ar*e a4!u"t !( !ra+ (+u d "ta7e t! re:+a'e (+u d +!st =6 G 3e e"tera+ !r :are"tera+ (+u d C6 Freque"t !ra+ 'are D6 G 3e s4a++ 3!+u4es !( (+u d at (reque"t "ter3a+ GH6 A(ter "urs "* "ter3e"t !"# y!u ) ++ e?:e't the :at e"t t! ha3e 809 06 Ma "ta " 5!dy te4:erature at ,G6% C $6 E?h 5 t retur" !( =B a"d Bu+se t! "!r4a+ ,6 Ma" (est "!r4a+ s7 " tur*!r !( s7 " a"d t!"*ue

46 Dr "7s (+u ds as :res'r 5ed A6 0#, =6 $#4 C6 0#,#4 D6 $#,#4 SITUATION2 8 Fr!4 @UN $..% NLE 9 A G% year !+d )!4a" )as ad4 tted (!r Bar7 "s!">s D sease6 The 'har*e "urse s *! "* t! 4a7e a" " t a+ assess4e"t6 G16 <h 'h !( the (!++!) "* s a 'hara'ter st ' !( a :at e"t ) th ad3a"'ed Bar7 "s!">s d seaseE 809 A6 D stur5ed 3 s !" =6 F!r*et(u+"ess C6 Mas7 + 7e (a' a+ e?:ress !" D6 Mus'+e atr!:hy /.6 The !"set !( Bar7 "s!">s d sease s 5et)ee" %.DG. years !+d6 Th s d s!rder s 'aused 5y 809 A6 I"Fur !us 'he4 'a+ su5sta"'es =6 -ered tary (a't!rs C6 Death !( 5ra " 'e++s due t! !+d a*e D6 I4:a r4e"t !( d!:a4 "e :r!du' "* 'e++s " the 5ra " /06 The :at e"t )as :res'r 5ed ) th +e3!d!:a6 <hat s the a't !" !( th s dru*E 809 A6 I"'rease d!:a4 "e a3a +a5 + ty =6 A't 3ates d!:a4 "er* ' re'e:t!rs " the 5asa+ *a"*+ a C6 De'rease a'ety+'h!+ "e a3a +a5 + ty D6 Re+ease d!:a4 "e a"d !ther 'ate'h!+a4 "e (r!4 "eur!+!* 'a+ st!ra*e s tes /$6 Y!u are d s'uss "* ) th the d et ' a" )hat (!!d t! a3! d ) th :at e"ts ta7 "* +e3!d!:aE 8,9 A6 V ta4 " C r 'h (!!d =6 V ta4 " E r 'h (!!d C6 Th a4 "e r 'h (!!d D6 V ta4 " =G r 'h (!!d /,6 O"e day# the :at e"t '!4:+a "ed !( d (( 'u+ty " )a+7 "*6 Y!ur res:!"se )!u+d 5e 8$9 A6 Y!u ) ++ "eed a 'a"e (!r su::!rt =6 <a+7 ere't ) th eyes !" h!r ;!" C6 I>++ *et y!u a )hee+'ha r D6 D!">t (!r'e y!urse+( t! )a+7 SITUATION2 8 Fr!4 @UN $..% NLE 9 Mr6 De+a Is+a# a '+ e"t ) th ear+y De4e"t a e?h 5 ts th!u*ht :r!'ess d stur5a"'es6 /46 The "urse ) ++ assess a +!ss !( a5 + ty " )h 'h !( the (!++!) "* areasE 8$9 A6 =a+a"'e =6 @ud*4e"t C6 S:ee'h D6 E"dura"'e /%6 Mr6 De+a Is+a sa d he 'a""!t '!4:rehe"d )hat the "urse )as say "*6 -e su((ers (r!42 809

A6 I"s!4" a =6 A:hra? a C6 A*"!s a D6 A:has a /G6 The "urse s a)are that " '!44u" 'at "* ) th a" e+der+y '+ e"t# the "urse ) ++ 809 A6 Lea" a"d sh!ut at the ear !( the '+ e"t =6 O:e" 4!uth ) de )h +e ta+7 "* t! the '+ e"t C6 Use a +!)D: t'hed 3! 'e D6 Use a 4ed u4D: t'hed 3! 'e //6 As the "urse ta+7s t! the dau*hter !( Mr6 De+a Is+a# )h 'h !( the (!++!) "* state4e"t !( the dau*hter ) ++ requ re the "urse t! * 3e (urther tea'h "*E 809 A6 I 7"!) the ha++u' "at !"s are :arts !( the d sease =6 I t!+d her she s )r!"* a"d I e?:+a "ed t! her )hat s r *ht C6 I he+: her d! s!4e tas7s he 'a""!t d! (!r h 4se+( D6 I++ tur" !(( the TV )he" )e *! t! a"!ther r!!4 /H6 <h 'h !( the (!++!) "* s 4!st 4:!rta"t d s'har*e tea'h "* (!r Mr6 De+a Is+a 8$9 A6 E4er*e"'y Nu45ers =6 Dru* C!4:+ a"'e C6 Re+a?at !" te'h" que D6 D etary :res'r :t !" SITUATION 2 I"!)+ed*e !( the dru* BROBANT-ELINE =ROMIDE 8Br!5a"th "e9 Is "e'essary " treat4e"t !( 3ar !us d s!rders6 /16 <hat s the a't !" !( th s dru*E 849 A6 I"'reases *+a"du+ar se'ret !" (!r '+ e"ts a((e'ted ) th 'yst ' ( 5r!s s =6 D ss!+3e 5+!'7a*e !( the ur "ary tra't due t! !5stru't !" !( 'yst "e st!"es C6 Redu'es se'ret !" !( the *+a"du+ar !r*a" !( the 5!dy D6 St 4u+ate :er sta+s s (!r treat4e"t !( '!"st :at !" a"d !5stru't !" H.6 <hat sh!u+d the "urse 'aut !" the '+ e"t )he" us "* th s 4ed 'at !" 849 A6 A3! d ha;ard!us a't 3 t es + 7e dr 3 "*# !:erat "* 4a'h "er es et'6 =6 Ta7e the dru* !" e4:ty st!4a'h C6 Ta7e ) th a (u++ *+ass !( )ater " treat4e"t !( U+'erat 3e '!+ t s D6 I 4ust ta7e d!u5+e d!se ( I 4 ssed the :re3 !us d!se H06 <h 'h !( the (!++!) "* dru*s are "!t '!4:at 5+e )he" ta7 "* Br!5a"th "eE 849 A6 Ca((e "e =6 NSAID C6 A'eta4 "!:he" D6 A+'!h!+ H$6 <hat sh!u+d the "urse te++ '+ e"ts )he" ta7 "* Br!5a"th "eE 849 A6 A3! d h!t )eathers t! :re3e"t heat str!7es =6 Ne3er s) 4 !" a 'h+!r "ated :!!+

C6 Ma7e sure y!u + 4 t y!ur (+u d "ta7e t! 0L a day D6 A3! d '!+d )eathers t! :re3e"t hy:!ther4 a H,6 <h 'h !( the (!++!) "* d sease )!u+d Br!5a"th "e e?ert the 4u'h "eeded a't !" (!r '!"tr!+ !r treat4e"t !( the d s!rderE 849 A6 Ur "ary rete"t !" =6 Be:t ' U+'er D sease C6 U+'erat 3e C!+ t s D6 G+au'!4a SITUATION 2 8 Fr!4 DEC $... NLE 9 Mr6 Fra"'!# /. years !+d# sudde"+y '!u+d "!t + (t h s s:!!"s "!r s:ea7 at 5rea7(ast6 -e )as rushed t! the h!s: ta+ u"'!"s' !us6 - s d a*"!s s )as CVA6 H46 <h 'h !( the (!++!) "* s the 4!st 4:!rta"t assess4e"t dur "* the a'ute sta*e !( a" u"'!"s' !us :at e"t + 7e Mr6 Fra"'!E 809 A6 Le3e+ !( a)are"ess a"d res:!"se t! :a " =6 Ba: ++ary re(+e?es a"d res:!"se t! se"s!ry st 4u+ C6 C!here"'e a"d se"se !( hear "* D6 Bate"'y !( a r)ay a"d adequa'y !( res: rat !" H%6 C!"s der "* Mr6 Fra"'!>s '!"d t !"s# )h 'h !( the (!++!) "* s 4!st 4:!rta"t t! "'+ude " :re:ar "* Fra"'!>s 5eds de equ :4e"tE 809 A6 -a"d 5e++ a"d e?tra 5ed + "e" =6 Sa"d5a* a"d tr!'ha"ter r!++s C6 F!!t5!ard a"d s:+ "t D6 Su't !" 4a'h "e a"d *+!3es HG6 <hat s the rat !"a+e (!r * 3 "* Mr6 Fra"'! (reque"t 4!uth 'areE 809 A6 -e ) ++ 5e th rsty '!"s der "* that he s d!es">t dr "7 e"!u*h (+u ds =6 T! re4!3e dr ed 5+!!d )he" t!"*ue s 5 tte" dur "* a se ;ure C6 The ta't +e st 4u+at !" dur "* 4!uth 'are ) ++ haste" retur" t! '!"s' !us"ess D6 M!uth 5reath "* s used 5y '!4at!se :at e"t a"d t>++ 'ause !ra+ 4u'!sa dy "* a"d 'ra'7 "*6 H/6 O"e !( the '!4:+ 'at !"s !( :r!+!"*ed 5ed rest s de'u5 tus u+'er6 <h 'h !( the (!++!) "* 'a" 5est :re3e"t ts !''urre"'eE 809 A6 Massa*e redde"ed areas ) th +!t !" !r ! +s =6 Tur" (reque"t+y e3ery $ h!urs C6 Use s:e' a+ )ater 4attress D6 Iee: s7 " '+ea" a"d dry HH6 I( Mr6 Fra"'!>s R *ht s de s )ea7# <hat sh!u+d 5e the 4!st a''urate a"a+ys s 5y the "urseE 849 A6 E?:ress 3e a:has a s :r!4 "e"t !" '+ e"ts ) th r *ht s ded )ea7"ess =6 The a((e'ted +!5e " the :at e"t s the R *ht +!5e C6 The '+ e"t ) ++ ha3e :r!5+e4s " Fud* "* d sta"'e a"d :r!:r !'e:t !" D6 C+ e"ts !r e"tat !" t! t 4e a"d s:a'e ) ++ 5e 4u'h a((e'ted SITUATION 2 8 Fr!4 @UN 01HH NLE 9 a $. year !+d '!++e*e stude"t )as rushed t! the ER !( BG- a(ter he (a "ted dur "* the r ROTC dr ++6 C!4:+a "ed !( se3ere r *ht + a' :a "6 U:!" :a+:at !" !( h s a5d!4e"# Er" e Fer7s e3e" !" s+ *ht :ressure6 =+!!d test )as !rdered6 D a*"!s s s a'ute a::e"d ' t s6

H16 <h 'h resu+t !( the +a5 test ) ++ 5e s *" ( 'a"t t! the d a*"!s sE 809 A6 R=C 2 46% TO % M ++ !" J 'u6 446 =6 -*5 2 0, t! 04 *4Jd+6 C6 B+ate+ets 2 $%.#... t! %..#... 'u6446 D6 <=C 2 0$#... t! 0,#...J'u644 1.6 Stat a::e"de't!4y )as "d 'ated6 Bre !: 'are )!u+d "'+ude a++ !( the (!++!) "* e?'e:tE 809 A6 C!"se"t s *"ed 5y the (ather =6 E"e4a STAT C6 S7 " :re: !( the area "'+ud "* the :u5 s D6 Re4!3e the Fe)e+r es 106 BreDa"esthet ' 4ed !( De4er!+ a"d atr!:h "e su+(ate )ere !rdered t! 2 8,9 A6 A++ay a"? ety a"d a::rehe"s !" =6 Redu'e :a " C6 Bre3e"t 3!4 t "* D6 Re+a? a5d!4 "a+ 4us'+e 1$6 C!44!" a"esthes a (!r a::e"de't!4y s 8,9 A6 S: "a+ =6 Ge"era+ C6 Cauda+ D6 -y:"!s s 1,6 B!st !: 'are (!r a::e"de't!4y "'+ude the (!++!) "* e?'e:t 809 A6 Ear+y a45u+at !" =6 D et as t!+erated a(ter (u++y '!"s' !us C6 Nas!*astr ' tu5e '!""e't t! su't !" D6 Dee: 5reath "* a"d +e* e?er' se 146 Ber t!" t s 4ay !''ur " ru:tured a::e"d ? a"d 4ay 'ause ser !us :r!5+e4s )h 'h are 8$9 06 -y:!3!+e4 a# e+e'tr!+yte 45a+a"'e $6 E+e3ated te4:erature# )ea7"ess a"d d a:h!res s ,6 Nausea a"d 3!4 t "*# r * d ty !( the a5d!4 "a+ )a++ 46 Ba++!r a"d e3e"tua++y sh!'7 A6 0 a"d $ =6 $ a"d , C6 0#$#, D6 A++ !( the a5!3e 1%6 I( a(ter sur*ery the :at e"t>s a5d!4e" 5e'!4es d ste"ded a"d "! 5!)e+ s!u"ds a::re' ated# )hat )!u+d 5e the 4!st sus:e'ted '!4:+ 'at !"E 809 A6 I"tussus'e:t !" =6 Bara+yt ' I+eus C6 -e4!rrha*e D6 Ru:tured '!+!" 1G6 NGT )as '!""e'ted t! su't !"6 I" 'ar "* (!r the :at e"t ) th NGT# the "urse 4ust 8$9

A6 Irr *ate the tu5e ) th sa+ "e as !rdered =6 Use ster +e te'h" que " rr *at "* the tu5e C6 ad3a"'e the tu5e e3ery h!ur t! a3! d 7 "7s D6 O((er s!4e 'e 'h :s t! )et + :s 1/6 <he" d! y!u th "7 the NGT tu5e 5e re4!3edE 809 A6 <he" :at e"t requests (!r t =6 A5d!4e" s s!(t a"d :at e"t as7s (!r )ater C6 A5d!4e" s s!(t a"d (+atus has 5ee" e?:e++ed D6 = a"d C !"+y S tuat !"2 A4a"da s su((er "* (r!4 'hr!" ' arter !s'+er!s s =ra " sy"dr!4e she (e++ )h +e *ett "* !ut !( the 5ed !"e 4!r" "* a"d )as 5r!u*ht t! the h!s: ta+# a"d she )as d a*"!sed t! ha3e 'ere5r!3as'u+ar thr!45!s s thus tra"s(erred t! a "urs "* h!4e6 1H6 <hat d! y!u 'a++ a STROIE that 4a" (ests a 5 ;arre 5eha3 !rE 849 A6 I"!r*a" ' Str!7e =6 I"!r*a" ' Bsy'h!ses C6 Or*a" ' Str!7e D6 Or*a" ' Bsy'h!ses 116 The 4a " d ((ere"'e 5et)ee" 'hr!" ' a"d !r*a" ' 5ra " sy"dr!4e s that the (!r4er 8$9 A6 O''urs sudde"+y a"d re3ers 5+e =6 Is :r!*ress 3e a"d re3ers 5+e C6 te"ds t! 5e :r!*ress 3e a"d rre3ers 5+e D6 O''urs sudde"+y a"d rre3ers 5+e 0..6 <h 'h 5eha3 !r resu+ts (r!4 !r*a" ' :sy'h!sesE 849 A6 Me4!ry de( ' t =6 D s!r e"tat !" C6 I4:a red @ud*e4e"t D6 I"a::r!:r ate a((e't

MEDICAL SURGICAL NURSING DISCLAIMER : Care has been taken to verify that all answers and rationale below are a !rate" #lease o$$ent !% if yo! noti ed any errors or ontradi tions to $aintain a !ra y and %re ision of the answers as not to $islead the readers" &'!dek DEGREE () *UES+I(N DI))ICUL+, 6 2 : . . . . /ery hard 0!estion1 234 Chan e of answerin5 orre tly 7ard 0!estion1 384 Chan e of answerin5 orre tly Moderately hard 0!estion1 934 of answerin5 orre tly Easy 0!estion1 ;;4 will answer the 0!estion orre tly

SI+UA+I(N : Dervid1 A re5istered n!rse1 witnessed an old wo$an hit by a $otor y le while rossin5 a train railway" +he old wo$an fell at the railway" Dervid R!shed at the s ene" :" As a re5istered n!rse1 Dervid knew that the first thin5 that he will do at the s ene is <6= A" Stay with the %erson1 En o!ra5e her to re$ain still and I$$obili>e the le5 while ?hile waitin5 for the a$b!lan e" '" Leave the %erson for a few $o$ents to all for hel%" C" Red! e the fra t!re $an!ally" D. Move the person to a safer place. @ +he old wo$an is in the $iddle of a train railway" It is very !nsafe to i$$obili>e here le5s and re$ain still at the $iddle of a railway onsiderin5 that a train $i5ht o$e anyti$e while waitin5 for an a$b!lan e" Safety is the !t$ost i$%ortan e at this %oint" If letter D is not a$on5 the hoi es and the sit!ation is a little less dan5ero!s1 the answer will be A" Re$e$ber that in all ases of e$er5en ies1 re$ovin5 the vi ti$ fro$ the s ene to a $! h safer %la e is a %riority" 2" Dervid s!s%e ts a hi% fra t!re when he noti ed that the old wo$anAs le5 is <-= A" Len5thened1 Abd! ted and Internally Rotated" '" Shortened1 Abd! ted and EBternally Rotated" C" Shortened1 Add! ted and Internally Rotated" D. Shortened, Adducted and Externally Rotated. @ SADDER sho!ld be yo!r keyword" A hi% fra t!re will %rod! e a S7(R+ENED1 ADDUC+ED AND EC+ERNALL, R(+A+ED eBtre$ity" +reat$ent will evolve in astin5 the le5 and %!ttin5 it in a EC+ENSI(N1 NEU+RALL, #(SI+I(NED and SLIG7+ IN+ERNAL R(+A+I(N" In 7i% %rosthesis1 +he n!rse sho!ld $aintain the lientAs le5 in

)LECI(N1 EC+ERNAL R(+A+I(N and A'DUC+I(N to %revent the dislo ation of the %rosthesis fro$ the a etab!l!$" +ake note of the differen e be a!se I $istakenly answered the LA++ER in astin5 a hi% fra t!re thinkin5 that it is si$ilar to a the le5 %ositionin5 in hi% dislo ation" D!st i$a5ine a %atient with a ast that has his le5 in A'DUC+I(N1 EC+ERNAL R(+A+I(N AND )LECI(N" It will a!se fleBion ontra t!res" 6" +he old wo$an o$%lains of %ain" Dohn noti ed that the knee is reddened1 war$ to to! h and swollen" Dohn inter%rets that this si5ns and sy$%to$s are likely related to <2= A" Infe tion C" +hro$bo%hlebitis B. Inflammation D" De5enerative disease @ After a tra!$a1 Infla$$ation will start al$ost instantly" Infe tion o !rse 2-&-E ho!rs after bone fra t!re and not i$$ediately" +hro$bo%hlebitis o !rs within - to 9 days of hos%itali>ation after %rolon5ed i$$obili>ation" +here is no eviden e that the lient has a de5enerative disease and de5enerative diseases will $anifest in variety of ways and not after a tra!$a" -" +he old wo$an told Dohn that she has osteo%orosisF Dervid knew that all of the followin5 fa tors wo!ld ontrib!te to osteo%orosis eB e%t <-= A. Hypothyroidism '" End sta5e renal disease C" C!shin5As Disease D" +akin5 )!rose$ide and #henytoin" @ '1C1D all ontrib!tes to bone de$inirali>ation eB e%t 7,#(+7,R(IDISM" 7y%erthyroidis$ will ontrib!te to bone de$inirali>ation as well as 7y%er%arathyroidis$ d!e to the in rease in #+71 It will a!se the $ove$ent of al i!$ fro$ the bone to the blood a!sin5 7,#ERCALCEMIA" ESRD will a!se in rease in #7(#7SA+E d!e to its %oor eB retion" +he a$o!nt of %hos%hate is inversely %ro%ortional to the a$o!nt of al i!$" C!shin5 disease %ro$otes bone de$inerali>ation as well as $edi ations like di!reti s and anti onv!lsants" 3" Martha1 +he old wo$an was now I$$obili>ed and bro!5ht to the e$er5en y roo$" +he C&ray shows a fra t!red fe$!r and %elvis" +he ER N!rse wo!ld aref!lly $onitor Martha for whi h of the followin5 si5n and sy$%to$sG <6= A. achycardia and Hypotension '" )ever and 'rady ardia C" 'rady ardia and 7y%ertension D" )ever and 7y%ertension

@ he$orrha5e res!lts in severin5 of the vas !lar s!%%ly of the bone of the fe$!r and the %elvis d!e to the fra t!re leadin5 to bleedin5 a!sin5 the sHs of ta hy ardia and hy%otension" SI+UA+I(N: Mr" D" RoIas1 An obese 63 year old MS #rofessor of (L)U La5ro is ad$itted d!e to %ain in his wei5ht bearin5 Ioint" +he dia5nosis was (steoarthritis" J" As a n!rse1 yo! instr! ted Mr" RoIas how to !se a ane" Mr" RoIas has a weakness on his ri5ht le5 d!e to self i$$obili>ation and 5!ardin5" ,o! %lan to tea h Mr" RoIas to hold the ane <-= A" (n his left hand1 be a!se his ri5ht side is weak" B. !n his left hand, "ecause of reciprocal motion. C" (n his ri5ht hand1 to s!%%ort the ri5ht le5" D" (n his ri5ht hand1 be a!se only his ri5ht le5 is weak" @ Re i%ro al $otion is a very i$%ortant as%e t of rehabilitation" Mr" RoIas has a weakness on his ri5ht le5" If a h!$an $oves his ri5ht le51 the left ar$ will a o$%any the $ove$ent of the ri5ht le5" +hat is what yo! all RECI#R(CAL M(+I(N whi h is innate1 nat!ral and re0!ired to $aintain balan e" Mr" RoIas has weakness in his RIG7+ LEG" If we %!t the ane on his ri5ht ar$1 +he lient will then be left UNSU##(R+ED when he !se his stron5er le5 <LE)+ LEG= and stand with his weaker le5 <RIG7+ LEG= d!e to the fa t that the o%%osite ar$ $!st a o$%any the $ove$ent of the o%%osite le5 <RIG7+ ARM=" In a $ore easier ter$1 Always %!t the ane on the o%%osite of the weaker side" A is not orre t be a!se the lient is N(+ he$i%le5i and will never be orre t to reason o!t why the ane $!st always be at the o%%osite of the weaker side1 it will always be d!e to re i%ro al $otion" 9" ,o! also told Mr" RoIas to hold the ane <-= A" : In hes in front of the foot" '" 6 In hes at the lateral side of the foot" c. # Inches at the lateral side of the foot. D" :2 In hes at the lateral side of the foot" @ Re$ove o%tion A1 the lient will ki k off the ane if it was in the front of the foot" Re$ove o%tion D be a!se that is too far and will a!se the ane to %oorly s!%%ort the lient be a!se the side1 not the ti%1 is to! hin5 the 5ro!nd" At 6 in hes1 i$a5ine how short it is and will a!se a very %oor s!%%ortin5 base" +he orre t answer is anywhere fro$ J to :8 in hes for both r!t hes and ane" E" Mr" RoIas was dis har5ed and J $onths later1 he a$e ba k to the e$er5en y roo$ of the hos%ital be a!se he s!ffered a $ild stroke" +he ri5ht side of the brain was affe ted" At the rehabilitative %hase of yo!r n!rsin5 are1 yo! observe Mr" RoIas !se a ane and yo! intervene if yo! see hi$ <-=

A. Moves the cane $hen the ri%ht le% is moved. '" Leans on the ane when the ri5ht le5 swin5s thro!5h" C" kee%s the ane J In hes o!t to the side of the ri5ht foot" D" 7olds the ane on the ri5ht side" @ If the ri5ht side of the brain is affe ted1 weakness will always be C(N+RALA+ERAL and therefore1 Mr" RoIas will have weakness on his left side" Earlier I told yo! that ane is held on the o%%osite side of the weaker side1 whi h in this sit!ation1 will be on the RIG7+" I$a5ine if the lient $oves his RIG7+ LEG to5ether witht the RIG7+ CANE1 it already violated the LA? () RECI#R(CAL M(+I(N" Movin5 the ri5ht le5 will re0!ire Mr" RoIas to $ove his left ar$ and not the ane1 whi h is on his ri5ht" SI+UA+I(N: Alfred1 a -8 year old onstr! tion worker develo%ed o!5h1 ni5ht sweats and fever" 7e was bro!5ht to the n!rsin5 !nit for dia5nosti st!dies" 7e told the n!rse he did not re eive a 'CG va ine d!rin5 hildhood ;" +he n!rse %erfor$s a Manto!B +est" +he n!rse knows that Manto!B +est is also known as <:= A. &&D '" #D# C" #DD D" D## @ ##D stands for %!rified %rotein derivative" It is !sed to he k for +' eB%os!re" All lients who had 'CG need not %erfor$ this test be a!se they will always be K " :8" +he n!rse wo!ld inIe t the sol!tion in what ro!teG <:= A" IM '" I/ '. ID D" SC @ A ?heal is reated intrader$ally and then it is $arked and ti$ed" readin5 will be done within 2 to 6 days" ::" +he n!rse notes that a %ositive res!lt for Alfred is <2= A" 3 $$ wheal '" 3 $$ Ind!ration C" :8 $$ ?heal D. () mm Induration @ :8 $$ Ind!ration < redness = is onsidered %ositive for individ!als with o$%etitive i$$!ne res%onse" ?heals are not $eas!red1 they will not any$ore

enlar5e" A 3 $$ ind!ration is onsidered %ositive for %atients with AIDS or i$$!no o$%ro$ised" :2" +he n!rse told Alfred to o$e ba k after <2= A" a week B. *+ hours C" : day D" - days @ Clients are asked to o$eba k within 2 to 6 days for the readin5" :6" Man5 Alfred ret!rns after the Manto!B +est" +he test res!lt read #(SI+I/E" ?hat sho!ld be the n!rseAs neBt a tionG <6= A. 'all the &hysician '" Notify the radiolo5y de%t" for CCR eval!ation C" Isolate the %atient D" (rder for a s%!t!$ eBa$ @ +he n!rse has no a!thority order the radiolo5y de%art$ent for a hest B ray eval!ation nor order for a s%!t!$ eBa$" +he lient need not be isolated be a!se Manto!B test do not deter$ine the a tiveness of the disease" :-" ?hy is Manto!B test not ro!tinely done in the #hili%%inesG <2= A" It re0!ires a hi5hly skilled n!rse to %erfor$ a Manto!B test '" +he s%!t!$ !lt!re is the 5old standard of #+' Dia5nosis and it will definitively deter$ine the eBtent of the avitary lesions C" Chest C Ray Can dia5nose the s%e ifi $i roor5anis$ res%onsible for the lesions D. Almost all ,ilipinos $ill test positive for Mantoux est @ al$ost all fili%inos tests %ositive for $anto!B test d!e to the fa t that 'CG are re0!ired and +' eB%os!re in the o!ntry is f!ll$inant" All individ!als va inated with 'CG will test #(SI+I/E for $anto!B test all their lives" :3" Man5 Alfred is now a new +' %atient with an a tive disease" ?hat is his ate5ory a ordin5 to the D(7G <:= A. I '" II C" III D" I/ @ Cate5ory I %atients are those with a newly dia5nosed +' whose s%!t!$ !lt!re are %ositive" II are for those who have rela%ses while III are those with ne5ative s%!t!$

!lt!re b!t %ositive hest B ray1 or #+' Mini$al" :J" 7ow lon5 is the d!ration of the $aintenan e %hase of his treat$entG <2= A" 2 $onths '" 6 $onths '. * months D" 3 $onths @ Clients in ate5ory I will have 2 $onths IN+ENSI/E and - $onths $aintenan e treat$ent" :9" ?hi h of the followin5 dr!5s is UNLILEL, 5iven to Man5 Alfred d!rin5 the $aintenan e %haseG <6= A" Rifa$%i in '" Isonia>id '. Etham"utol D" #yridoBine @ Dr!5s 5iven in the $aintenan e %hase in l!des Rifa$%i in and Isonia>id" Etha$b!tol is 5iven on the intensive %hase alon5 with rifa$%i in and isonia>id" #yridoBine is 5iven d!rin5 Isonia>id treat$ent to %revent %eri%heral ne!ritis in ontrast in treat$ent of %arkinsonMs with levodo%a1 #yridoBine or /'J is restri ted" :E" A ordin5 to the D(71 the $ost ha>ardo!s %eriod for develo%$ent of lini al disease is d!rin5 the first <-= A. #-(. months after '" 6&J $onths after C" :&2 $onths after D" 2&- weeks after @ A ordin5 to the de%art$ent of health1 the $ost ha>ardo!s %eriod for develo%$ent of lini al disease is d!rin5 the first J to :2 $onths"

:;" +his is the na$e of the %ro5ra$ of the D(7 to ontrol +' in the o!ntry <2= A" D(+S B. /ational u"erculosis 'ontrol &ro%ram C" Short Co!rsed Che$othera%y D" EB%anded #ro5ra$ for I$$!ni>ation @ National t!ber !losis ontrol %ro5ra$ is the na$e of the %ro5ra$ of the D(7 to ontrol and eradi ate +' in the o!ntry" D(+S refers to the S+RA+EG, !sed by the

de%art$ent in treatin5 +' %atients" E#I is not a %ro5ra$ for +' ontrol altho!5h 'CG is one of the va ine 5iven in this %ro5ra$" 28" S!s e%tibility for the disease < +' = is in reased $arkedly in those with the followin5 ondition eB e%t <6= A. .0 1ear old athlete $ith dia"etes insipidus '" 26 ,ear old athlete takin5 lon5 ter$ De adron thera%y and anaboli steroids C" 26 ,ear old athlete takin5 ille5al dr!5s and ab!sin5 s!bstan es D" Underno!rished and Underwei5ht individ!al who !nder5one 5astre to$y @ N!trition1 Lon5 ter$ i$$!nos!%ression and dr!5 ab!se are all fa tors that affe ts the resistan e of an individ!al in a 0!irin5 o$$!ni able diseases" (ther fa tors in l!des eBtre$es of a5es1 %oor environ$ental sanitation1 %overty and %oor livin5 onditions" Diabetes insi%id!s does not1 in anyway alter a %ersons i$$!ne res%onse" 2:" Dire t s%!t!$ eBa$ination and Chest C ray of +' sy$%to$ati is in what level of %reventionG <:= A" #ri$ary B. Secondary C" +ertiary D" *!arterly @ National board eBa$ loves askin5 abo!t level of %revention" Mastery with the %ri$ary1 se ondary and tertiary levels of %revention is a $!st" All dia5nosti 1 ase findin5 and treat$ent belon5s to the se ondary level of %revention" SI+UA+I(N: Mi hiel1 A $ale %atient dia5nosed with olon an er was newly %!t in olosto$y" 22" Mi hiel shows the 'ES+ ada%tation with the new olosto$y if he shows whi h of the followin5G <2= A" Look at the osto$y site B. &articipate $ith the nurse in his daily ostomy care C" Ask for leaflets and onta t n!$bers of osto$y s!%%ort 5ro!%s D" +alk abo!t his osto$y o%enly to the n!rse and friends @ A t!al %arti i%ation onveys %ositive a e%tan e and adI!st$ent to the altered body i$a5e" Altho!5h lookin5 at the osto$y site also onveys a e%tan e and adI!st$ent1 #arti i%atin5 with the n!rse to his daily osto$y are is the 'ES+ ada%tation a lient an $ake d!rin5 the first few days after olosto$y reation" 26" +he n!rse %lans to tea h Mi hiel abo!t olosto$y irri5ation" As the n!rse %re%ares the $aterials needed1 whi h of the followin5 ite$ indi ates that the n!rse

needs f!rther instr! tionG <6= A. &lain /SS 2 /ormal Saline '" L&, Delly C" +a% water D" Irri5ation sleeve @ +he olon is not sterile1 nor the sto$a h" +a% water is !sed in ene$a irri5ation and not NSS" Altho!5h so$e lients wo!ld %refer a distilled1 $ineral or filtered water1 NSS is not always ne essary" L, Delly is !sed as the l!bri ant for the irri5ation t!be and is inserted 6&- in hes into the olosto$y %ointin5 towards the RIG7+" Irri5ation sleeve is !se to dire t the flow of the irri5ated sol!tion o!t of the sto$a h and into the bed%an or toilet" 2-" +he n!rse sho!ld insert the olosto$y t!be for irri5ation at a%%roBi$ately <6= A" :&2 in hes B. 0-* inches C" J&E in hes D" :2&:E in hes @ Re$e$ber 6&- in hes" +hey are both !sed in the re tal t!be and olosto$y irri5ation t!be insertion" : to 2 in hes is too short and $ay s%ill o!t the irri5ant o!t of the sto$a" Startin5 fro$ J in hes1 it wo!ld be too lon5 already and $ay %erforate the bowel" 23" +he $aBi$!$ hei5ht of irri5ation sol!tion for olosto$y is <6= A" 3 in hes B. (. inches '. (+ inches D" 2- in hes @ If yo! will answer in the CG)NS and NCLEC1 C will be the orre t answer" A ordin5 to 'RUNNER AND SUDDAR+7S and Sa!nders1 +he hei5ht of the olosto$y irri5ation ba5 sho!ld be han5in5 above the lients sho!lder at aro!nd :E in hes" A ordin5 to M(S',1 :2 in hes sho!ld be the $aBi$!$ hei5ht" A ordin5 to Li%%inn ots1 :E in hes is the $aBi$!$ hei5ht" A ordin5 the the board of eBa$iners1 :2 in hes sho!ld be the $aBi$!$ hei5ht and an :E in hes irri5ant hei5ht wo!ld a!se ra%id flow of the irri5ant towards the olosto$y" +herefore1 answer in the lo al board sho!ld only be at :2 in hes" 2J" ?hi h of the followin5 behavior of the lient indi ates the best initial ste% in learnin5 to are for his olosto$yG <:= A" Ask to defer olosto$y are to another individ!al

'" #ro$ises he will be5in to listen the neBt day '. A%rees to loo3 at the colostomy D" States that olosto$y are is the f!n tion of the n!rse while he is in the hos%ital @ +he lient $ade the best initial ste% in learnin5 to are for his olosto$y on e he looks at the site" +his is the start of the lientMs a e%tan e on his altered body i$a5e" A1' and D delays learnin5 and shows the lientMs disintrest re5ardin5 olosto$y are" 29" ?hile irri5atin5 the lientAs olosto$y1 Mi hiel s!ddenly o$%lains of severe ra$%in5" Initially1 the n!rse wo!ld <:= A. Stop the irri%ation "y clampin% the tu"e '" Slow down the irri5ation C" +ell the lient that ra$%in5 will s!bside and is nor$al D" Notify the %hysi ian @ Sto%%in5 the irri5ation will also sto% the ra$%in5 and %ain" D!rin5 the first few days of irri5ation1 +he lient will feel %ain and ra$%in5 as soon as the irir5ant to! hes the bowel" +his will start to lessen on e the lient 5ot a !sto$ed to olosto$y irri5ation" Slowin5 down the irri5ation will not sto% the %ain" +ellin5 the lient that it is nor$al and will s!bside event!ally is not a e%table when a lient eB%erien es %ain" #ain is all en o$%asin5 and always a %riority over anythin5 else in $ost sit!ations" Notifyin5 the %hysi ian will not be hel%f!l and !ne essary" 2E" +he neBt day1 the n!rse will assess Mi hielAs sto$a" +he n!rse noti ed that a %rola%sed sto$a is evident if she sees whi h of the followin5G <:= A" A s!nken and hidden sto$a '" A d!sky and bl!ish sto$a C" A narrow and flattened sto$a D. &rotrudin% stoma $ith s$ollen appearance @ A refers to a retra ted sto$a1 ' refers to a sto$a that is 5ettin5 a very %oor blood s!%%ly" C is a des ri%tion of stenosis of the sto$a" 2;" Mi hiel asked the n!rse1 what foods will hel% lessen the odor of his olosto$y" +he n!rse best res%onse wo!ld be <-= A" Eat e55s '" Eat ! !$bers '. Eat "eet %reens and parsley D" Eat bro oli and s%ina h @ Lin hay and #e hay hel%s lessen the odor of the olosto$y" S%ina h1 bro oli1 Cabba5e1 C! !$bers1 #atola or bottle 5o!rd also hel% lessen the odor 'U+ are 5as

for$ers" E55s are not re o$$ended be a!se they are known to a!se !n%leasant odors in %atients with olosto$y" 68" +he n!rse will start to tea h Mi hiel abo!t the te hni0!es for olosto$y irri5ation" ?hi h of the followin5 sho!ld be in l!ded in the n!rseAs tea hin5 %lanG <-= A" Use 388 $l to :1888 $l NSS B. Suspend the irri%ant *4 cm a"ove the stoma C" Insert the one - $ in the sto$a D" If ra$%in5 o !rs1 slow the irri5ation @ : in hes is e0!al to 2"3- $" Convert the $ if yo! are not fa$iliar" -3 $ is aro!nd :9 in hes whi h is ideal for olosto$y irri5ation" Any val!e fro$ :2 to :E is a e%ted as the olosto$y irri5ant hei5ht" +a% water is !sed as an irri5ant and is inf!sed at roo$ te$%erat!re" - $ is a little bit short for the ideal 6&- in hes" If ra$%in5 o !rs S+(# the irri5ation and ontin!e when is s!bsides" 6:" +he n!rse knew that the nor$al olor of Mi hielAs sto$a sho!ld be <:= A. Bric3 Red '" Gray C" 'l!e D" #ale #ink @ +he sto$a sho!ld be RED in olor" #ale %ink are o$$on with ane$i or dehydrated %atients who lost a lot of blood after an o%eration" 'l!e sto$a indi ated yanosis or alteration in %erf!sion" Sto$as are not eB%e ted to be Gray" SI+UA+I(N: Da$es1 A 29 basketball %layer s!stained inhalation b!rn that re0!ired hi$ to have tra heosto$y d!e to $assive !%%er airway ede$a" 62" ?il$a1 7is sister and a n!rse is s! tionin5 the tra heosto$y t!be of Da$es" ?hi h of the followin51 if $ade by ?il$a indi ates that she is o$$ittin5 an errorG <2= A" 7y%erventilatin5 Da$es with :884 oBy5en before and after s! tionin5 '" Instillin5 6 to 3 $l nor$al saline to loosen !% se retion C" A%%lyin5 s! tion d!rin5 atheter withdrawal D. Suction the client every hour @ +his is !ne essary" S! tionin5 is done on #RN basis and not every ho!r" A1' and C are all orre t %ro esses of s! tionin5 a tra heosto$y" 66" ?hat si>e of s! tion atheter wo!ld ?il$a !se for Da$es1 who is J feet 3 in hes in hei5ht and wei5hin5 a%%roBi$ately :-3 lbsG <2=

A" )r" 3 '" )r" :8 C" )r" :2 D. ,r. (+ @ +he hei5ht is 5iven and it looks like Ia$es is a very tall individ!al" +he $aBi$!$ hei5ht of s! tion t!be is !sed" fr :2&:E are !sed for ad!lts while J&E are !sed in hildren"

6-" ?il$a is !sin5 a %ortable s! tion !nit at ho$e1 ?hat is the a$o!nt of s! tion re0!ired by Da$es !sin5 this !nitG <-= A" 2&3 $$75 '" 3&:8 $$75 '. ()-(4 mmH% D" 28&23 $$75 @ A is !sed in %ediatri lients" ' is for hildren and C is for ad!lts" 28&23 $$75 is too $! h for a %ortable s! tion !nit and is not re o$$ended" 63" If a ?all !nit is !sed1 ?hat sho!ld be the s! tionin5 %ress!re re0!ired by Da$esG <-= A" 38&;3 $$75 '" ;3&::8 $$75 '. ())-(.) mmH% D" :33&:93 $$75 @ A is !sed in %ediatri lients" ' is for hildren and C is for ad!lts" :33&:93 $$75 is too $! h for a wall s! tion !nit and is not re o$$ended" 6J" ?il$a was sho ked to see that the +ra heosto$y was dislod5ed" 'oth the inner and o!ter ann!las was re$oved and left han5in5 on Da$esA ne k" ?hat are the 2 e0!i%$entAs at Ia$esA bedside that o!ld hel% ?il$a deal with this sit!ationG <6= A" New set of tra heosto$y t!bes and (By5en tank '" +heo%hylline and E%ine%hrine '. !"turator and 5elly clamp D" Sterile saline dressin5 @ In an e$er5en y like this1 +he first thin5 the n!rse sho!ld do is $aintainin5 the airway %aten y" ?ith the ann!nlas dislod5ed1 +he sto$a will stenosed and narrows 5ivin5 Ia$es an obstr! ted airway" +he n!rse wo!ld insert the kelly la$% to o%en the sto$a and lo k the la$% in %la e to $aintain it o%en while she !ses an obt!rator as to %revent f!rther stenosis of the sto$a" An obt!rator is a %art of the

NG+ %a ka5e in l!ded by $ost $an!fa t!rers to 5!ide the %hysi ian or n!rses in insertin5 the o!ter ann!la" 69" ?hi h of the followin5 $ethod if !sed by ?il$a will best ass!re that the tra heosto$y ties are not too ti5htly %la edG <2= A. 6ilma places . fin%ers "et$een the tie and nec3 '" +he tra heoto$y an be %!lled sli5htly away fro$ the ne k C" Da$esA ne k veins are not en5or5ed D" ?il$a $eas!res the tie fro$ the nose to the ti% of the earlobe and to the Bi%hoid %ro ess" @ ?il$a sho!ld %la e 2 fin5ers !nderneath the tie to ens!re that it is not too ti5ht nor too loose" Letter D is the $eas!re$ent for NG+ insertion and is !nrelated to tra heosto$y" 6E" ?il$a knew that Da$es have an ade0!ate res%iratory ondition if she noti es that <:= A. 7ames8 respiratory rate is (+ '" Da$esA (By5en sat!ration is ;:4 C" +here are frank blood s! tion fro$ the t!be D" +here are $oderate a$o!nt of tra heobron hial se retions @ an RR of :E $eans that Da$es is not ta hy%nei and has an ade0!ate air eB han5e" (By5en sat!ration sho!ld be $ore than ;34" )rank blood is not eB%e ted in the s! tion t!be" A sli5ht tin5ed of blood in the t!be is a e%table and eB%e ted" A$o!nt of se retion are not in anyway related in assessin5 the res%iratory ondition of a %erson and so is the a$o!nt of blood in the t!be" 6;" ?il$a knew that the $aBi$!$ ti$e when s! tionin5 Da$es is <:= A. () seconds '" 28 se onds C" 68 se onds D" -3 se onds @ A ordin5 to o!r reviewers and le t!rers1 :8 to :3 se onds is the $aBi$!$ s! tion ti$e" '!t a ordin5 to al$ost all forei5n books I read1 it sho!ld only be :8 se onds at $aB" I %refer followin5 Sa!nders1Mosby and Li%%inn ots when they are all !nited" SI+UA+I(N : D!an Mi5!el Lo%e> Nobel Ayala de 'at!$bakal was dia5nosed with A !te Close An5le Gla! o$a" 7e is bein5 seen by N!rse Det" -8" ?hat s%e ifi $anifestation wo!ld n!rse Det see in A !te lose an5le 5la! o$a that she wo!ld not see in an o%en an5le 5la! o$aG <6=

A" Loss of %eri%heral vision '" Irreversible vision loss C" +here is an in rease in I(# D. &ain @ +here is N( #AIN in o%en an5le 5la! o$a" A1'1C are all %resent in both 5la! o$as in l!din5 the low %ress!re 5la! o$a" #ain is absent be a!se the in rease in intra o !lar %ress!re is not initiated abr!%tly" It is 5rad!al and %ro5ressive and will lead to !noti ed loss of %eri%heral vision" #ain is %resent in a !te lose an5le 5la! o$a be a!se there is a s!dden los!re or narrowin5 of the anal of s hle$$" +herefore if yo! will be ask what sHs is o$$on in both1 answer IRRE/ERSI'LE L(SS () #ERI#7ERAL /ISI(N" -:" N!rse Iet knew that A !te lose an5le 5la! o$a is a!sed by <6= A. Sudden "loc3a%e of the anterior an%le "y the "ase of the iris '" (bstr! tion in trabe !lar $eshwork C" Grad!al in rease of I(# D" An abr!%t rise in I(# fro$ E to :3 $$75 @ S!dden blo ka5e of the an5le will a!se sHs of a !te an5le los!re 5la! o$a" ' and C are all related to o%en an5le 5la! o$a" D is insi5nifi ant1 If the lient bends or o!5h1 I(# an in rease fro$ E to as $! h as 68 $$75 b!t then ret!rn a5ain to nor$al" -2" N!rse Iet %erfor$ed a +(N(ME+R, test to Mr" 'at!$bakal" ?hat does this test $eas!res <:= A" It $eas!res the %eri%heral vision re$ainin5 on the lient B. Measures the Intra !cular &ressure C" Meas!res the ClientAs /is!al A !ity D" Deter$ines the +one of the eye in res%onse to the s!dden in rease in I(#" @ +ono$etry $eas!res the I(#" Nor$al ran5e is E to 2: $$75" -6" +he N!rse noti es that Mr" 'at!$bakal annot any$ore deter$ine RED fro$ 'LUE" +he n!rse knew that whi h %art of the eye is affe ted by this han5eG <6= A" IRIS '" #U#IL " R(DS <RE+INA= D. '!/ES 9RE I/A: @ '!NES Are res%onsible for '!L(R /ISI(N and DA, /ISI(N1 they are very sensitive to RED LIG7+ that is why red li5hts are !se to 5!ide the elderly towards the

bathroo$ when they wake !% to !rinate" Rods are res%onsible for ni5ht vision" +hey are sensitive to bl!e and 5reen li5hts" --" N!rse Det knows that A0!eo!s 7!$or is %rod! e whereG <-= A" In the s!b ara hnoid s%a e of the $enin5es '" In the Lateral ventri les C" In the Choroids D. In the 'iliary Body @ A7 is %rod! ed in the CILIAR, '(D," It is filtered by the trabe !lar $eshwork into the anal of s hle$$" -3" N!rse Det knows that the nor$al I(# is <2= A. +-.( mmH% '" 2&9 $$75 " 6:&63 $$75 D" :3&68 $$75 -J" N!rse Det wants to $eas!re Mr" 'at!$bakalAs CN II )!n tion" ?hat test wo!ld N!rse Det i$%le$ent to $eas!re CN IIAs A !ityG <:= A" Slit la$% B. Snellen8s 'hart C" ?oodAs li5ht D" Gonios o%y @ CN II is the o%ti nerve" +o assess its a !ity1 SnellenMs hart is !sed" Slit la$% is the one yo! see in the !s!al Eye 5lasses sho% where in1 yo! need to look into its bino !lar&like holes and the o%to$etrist is on the other side to $a5nify the str! t!res of the eye to assess 5ross da$a5e and str! t!re" ?oods li5ht is a 'LUE LIG7+ !sed in der$atolo5y" It is !se to $ark lesions !s!ally a!sed skin infe tion" Gonios o%y is the an5le $eas!re$ent of the eye" -9" +he Do tor orders %ilo ar%ine" N!rse Iet knows that the a tion of this dr!5 is to <-= A. 'ontract the 'iliary muscle '" RelaB the Ciliary $!s le C" Dilate the %!%ils D" De rease %rod! tion of A0!eo!s 7!$or @ ?hen the iliary $!s les ontra t1 %!%ils onstri t and the an5le widens a!sin5 an in rease A7 o!tflow and de rease I(#" RelaBin5 the iliary $!s le will a!se $ydriasis or dilation1 it is !sed as a %re o% $eds for atara t s!r5ery and eye

eBa$ination to better vis!ali>e the str! t!res behind the iris" A and C are the sa$e" (ther dr!5s like betaBolol1 A>eta>ola$ide and e%ine%hrine are the dr!5s !sed to de rease A7 %rod! tion" -E" +he do tor orders ti$olol <ti$o%ti =" N!rse Iet knows that the a tion of this dr!5 is <-= A" Red! e %rod! tion of CS) B. Reduce production of A;ueous Humor C" Constri t the %!%il D" RelaBes the Ciliary $!s le @ All the eye dro%s the ends in (L(L de reases A7 %rod! tion" +hey are 'E+A 'L(CLERS" ?at h o!t for the SHS of on5estive heart fail!re1 brady ardia1 hy%otension and arryth$ias" -;" ?hen arin5 for Mr" 'at!$bakal1 Det tea hes the lient to avoid <:= A" ?at hin5 lar5e s reen +/s B. Bendin% at the $aist C" Readin5 books D" Goin5 o!t in the s!n @ 'endin5 at the waist in rease I(# and sho!ld be avoided by %atients with 5la! o$a" +reat$ent for 5la! o$a is !s!ally for life" #atients are 5iven laBatives to avoid stratinin5 at the stool" +hey sho!ld avoid all a tivities that will lead to s!dden I(# in rease like bendin5 at the waist" Clients sho!ld bend at the knees" 38" Mr" 'at!$bakal has !nder5one eye an5io5ra%hy !sin5 an Intraveno!s dye and fl!oros o%y" ?hat a tivity is ontraindi ated i$$ediately after %ro ed!reG <-= A. Readin% ne$sprint '" Lyin5 down C" ?at hin5 +/ D" Listenin5 to the $!si @ +he lient had an eye an5io5ra%hy" Eye an5io5ra%hy re0!ires the !se M,DRIA+ICS %re&%ro ed!re" It is done by inIe tin5 an Intraveno!s dye and vis!ali>es the flow of the dye thro!5ht the fl!oros o%y alon5 the vessels of the eye" +his is to assess $a !lar de5eneration or neovas !lari>ations < %roliferation of new vessels to o$%ensate for ontin!o!s r!%t!re and ane!rys$s of the eBistin5 vessels = Mydrati s !s!ally takes J ho!rs to a day to wear off" If lient !ses a $ydrati 1 his %!%il wil dilate $akin5 it UNA'LE to fo !s on loser obIe ts" (nly A ne essitates the onstri tion of the %!%il to fo !s on a near obIe t1 whi h Mr"'at!$bakals eye annot %erfor$ at this ti$e"

3:" If Mr" 'at!$bakal is re eivin5 %ilo ar%ine1 what dr!5 sho!ld always be available in any ase syste$i toBi ity o !rsG <2= A. Atropine Sulfate '" #indolol </isken= C" NaloBone 7ydro hloride <Nar an= D" Mesorida>ine 'esylate <Serentil= @ Atro%ine s!lfate is !se to reverse the effe ts of syste$i toBi ity of %ilo ar%ine" Nar an is the antidote for res%iratory de%ression a!sed by nar oti s like $or%hine and de$erol" Serentil is an anti%sy hoti " SI+UA+I(N : ?ide knowled5e abo!t the h!$an ear1 itAs %arts and itAs f!n tions will hel% a n!rse assess and analy>e han5es in the ad!lt lientAs health" 32" N!rse '!dek is doin5 a alori testin5 to his %atient1 Aida1 a 33 year old !niversity %rofessor who re ently went into o$a after bein5 $a!led by her dis5r!ntled 6rd year n!rsin5 st!dents who$ she 5ave a failin5 $ark" After instillin5 a war$ water in the ear1 '!dek noti ed a rotary nysta5$!s towards the irri5ated ear" ?hat does this $eansG <2= A" Indi ates a CN /III Dysf!n tion '" Abnor$al '. /ormal D" In on l!sive @ Rotary nysta5$!s towards the ear < if war$ = or away fro$ it < if ool = is a nor$al res%onse" It indi ates that the CN /III /estib!lar bran h is still inta t" 36" Ear dro%s are %res ribed to an infant1 +he $ost a%%ro%riate $ethod to ad$inister the ear dro%s is <2= A" #!ll the %inna !% and ba k and dire t the sol!tion towards the eardr!$ B. &ull the pinna do$n and "ac3 and direct the solution onto the $all of the canal C" #!ll the %inna down and ba k and dire t the sol!tion towards the eardr!$ D" #!ll the %inna !% and ba k and dire t the sol!tion onto the wall of the anal @ Instillation for hildren !nder a5e 6 is C7ILD : D(?N AND 'ACL" Dire tin5 the sol!tion towards the eardr!$ $i5ht %erforate or da$a5e the infants fra5ile ty$%ani $e$brane" 3-" N!rse '!dek is develo%in5 a %lan of are for a %atient with Menieres disease" ?hat is the %riority n!rsin5 intervention in the %lan of are for this %arti !lar %atientG <:=

A" Air1 'reathin51 Cir !lation '" Love and 'elon5in5ness C" )ood1 Diet and N!trition D. Safety @ Altho!5h A is %riority a ordin5 to $aslow1 it is not s%e ifi in lients with $enieres disease" +he lient has an atta k of in a%a itatin5 verti5o and lient is hi5h risk for inI!ry d!e to falls" +he lient will %er eive the environ$ent $ovin5 d!e to disr!%tion of the vestib!lar syste$ of the earMs nor$al f!n tion"

33" After $astoide to$y1 N!rse '!dek sho!ld be aware that the ranial nerve that is !s!ally da$a5e after this %ro ed!re is <6= A" CN I '" CN II '. '/ <II D" CN /I @ +he fa ial nerve bran hes fro$ the ba k of the ear and s%read towards the $o!th1 heeks1 eyelids and al$ost all over the fa e" In $astoide to$y1 In ision is $ade at the ba k of the ears to lear the $astoid air ells of the $astoid bone that is infe ted" Clients are at very hi5h risk for CN /II inI!ry be a!se of this" (bservation d!rin5 the %ost o% after $astoide to$y sho!ld revolve aro!nd assessin5 the lientMs CN /II inte5rity" 3J" +he %hysi ian orders the followin5 for the lient with Menieres disease" ?hi h of the followin5 sho!ld the n!rse 0!estionG <:= A" Di%enhydra$ine <'enadryl= '" Atro%ine s!lfate '. !ut of "ed activities and am"ulation D" Dia>e%a$ </ali!$= @ Clients with a !te atta k of Menieres are re0!ired to have bed rest with side rails !% to %revent inI!ry" D!rin5 %eriods of in a%a itatin5 verti5o1 %atientMs eyes will have rotary nysta5$!s be a!se of the %er e%tion that the environ$ent is $ovin5" #atients are also observed to hold the side rails so hard be a!se they tho!5ht they are 5oin5 to fall" 'enadryl is !sed in $enieres d!e to its anti hista$ine effe ts" ' and D are !sed to allay lients anBiety and a%%rehension" 39" N!rse '!dek is 5ivin5 dietary instr! tion to a lient with Menieres disease" ?hi h state$ent if $ade by the lient indi ates that the tea hin5 has been s! essf!lG <:= A. I $ill try to eat foods that are lo$ in sodium and limit my fluid inta3e '" I $!st drink atleast 61888 $l of fl!ids %er day

C" I will try to follow a 384 arbohydrate1 684 fat and 284 %rotein diet D" I will not eat t!rni%s1 red $eat and raddish @ Clients are advised to li$ite fl!id and sodi!$ intake as not to f!rther a!se a !$!lation of fl!ids in the endoly$%h" C is the diabeti diet" D are the foods not eaten when lients are abo!t to have a 5!aia test" 3E" #ea hy was r!shed by his father1 Steven into the hos%ital ad$ission" #ea hy is o$%lainin5 of so$ethin5 b!>>in5 into her ears" N!rse '!dek assessed %ea hy and fo!nd o!t It was an inse t" ?hat sho!ld be the first thin5 that N!rse '!dek sho!ld try to re$ove the inse t o!t fro$ %ea hyAs earG <6= A. =se a flashli%ht to coax the insect out of peachy8s ear '" Instill an antibioti ear dro%s C" Irri5ate the ear D" #i k o!t the inse t !sin5 a sterile lean for e%s @ Li5hts an oaB the inse t o!t of the hildMs ear" +his is the first $eas!re e$%loyed in re$ovin5 a live inse t fro$ the hilds ear" Inse ts are not re$oved ALI/E1 therfore1 C and D are both wron5" Antibioti s has no effe ts sin e the hild do not have any infe tion" If the inse t did not o$e o!t after oaBin5 it with li5ht1 2nd $eas!re e$%loys instillation of dil!ted al ohol or a $ineral oil to kill the inse t whi h is then re$oved !sin5 letter D" 3;" )ollowin5 an ear s!r5ery1 whi h state$ent if heard by N!rse '!dek fro$ the %atient indi ates a orre t !nderstandin5 of the %ost o%erative instr! tionsG <2= A" A tivities are res!$ed within 3 days '" I will $ake s!re that I will lean $y hair and fa e to %revent infe tion C" I will !se straw for drinkin5 D. I should avoid air travel for a $hile @ After ear s!r5ery1 Air travel is halted for a while" +here is no need to restri t a tivities" +he lient is not allowed to shower for 9 days1 #atient an lean hi$self !sin5 a s%on5e bath b!t avoids to sha$%oo or wet the fa e and hair" Straws are not !sed after ear s!r5ery be a!se si%s in reases %ress!re in the ear" J8" N!rse '!dek will do a alori testin5 to a lient who s!stained a bl!nt inI!ry in the head" 7e instilled a old water in the lientAs ri5ht ear and he noti ed that nysta5$!s o !rred towards the left ear" ?hat does this findin5 indi atesG <2= A" Indi atin5 a Cranial Nerve /III Dysf!n tion '" +he test sho!ld be re%eated a5ain be a!se the res!lt is va5!e C" +his is Grossly abnor$al and sho!ld be re%orted to the ne!ros!r5eon D. his indicates an intact and $or3in% vesti"ular "ranch of '/ <III @ Refer to O32

J:" A lient with Catara t is abo!t to !nder5o s!r5ery" N!rse '!dek is %re%arin5 %lan of are" ?hi h of the followin5 n!rsin5 dia5nosis is $ost a%%ro%riate to address the lon5 ter$ need of this ty%e of %atientG <:= A" AnBiety RH+ to the o%eration and its o!t o$e B. Sensory perceptual alteration R2 >ens extraction and replacement C" Lnowled5e defi it RH+ the %re o%erative and %ost o%erative self are D" 'ody I$a5e dist!rban e RH+ the eye %a kin5 after s!r5ery @ #atient do not have si5ns of anBiety1 knowled5e defi it or body i$a5e dist!rban e" +he safest answer is ' be a!se before atara t s!r5ery1 lient has a bl!rry vision that alters his sensory %er e%tion" After s!r5ery lient will be A#7ALIC and a5ain1 will have an alteration in %er e%tion !ntil the a%haki 5lass is available" J2" N!rse '!dek is %erfor$in5 a ?E'ERS +ES+" 7e %la ed the t!nin5 fork in the %atients forehead after ta%%in5 it onto his knee" +he lient states that the fork is lo!der in the LE)+ EAR" ?hi h of the followin5 is a orre t on l!sion for n!rse '!dek to $akeG <-= A" 7e $i5ht have a sensory hearin5 loss in the left ear '" Cond! tive hearin5 loss is %ossible in the ri5ht ear '. He mi%ht have a sensory hearin% loss in the ri%ht hear, and2or a conductive hearin% loss in the left ear. D" 7e $i5ht have a ond! tive hearin5 loss in the ri5ht ear1 andHor a sensory hearin5 loss in the left ear" @ ?ebers test assesses both air and bone ond! tion b!t is not de isive eno!5h to I!d5e whi h is whi h" ?hen the t!nin5 fork is ta%%ed on the eBa$iners knee1 it is %la ed in the forehead or above the lients to% li%" If the so!nd laterali>es towards the left ear1 its either1 the lient has ond! tive hearin5 loss towards the left (R a sensory hearin5 loss in the ri5ht ear" ?hy does ond! tive hearin5 %rod! es a lo!der so!nd G Cond! tive hearin5 loss is a ty%e of hearin5 loss where in1 the ossi les hy%ertro%hies1 as in (+(SCLER(SIS" +he sta%e is %er$anently atta hed to the oval window and it wo!ld not b!l5e a!sin5 a %er$anent L(UD ond! tion of so!nd !sin5 the bone be a!se the sta%es is already atta hed %er$anently into the inner ear" In a nor$al sta%e1 It will not to! h the oval window !nless a so!nd is trans$itted" < refer to the ear anato$y and %hysiolo5y = J6" Alin5 $yrna has Menieres disease" ?hat ty%i al dietary %res ri%tion wo!ld n!rse '!dek eB%e t the do tor to %res ribeG <2= A" A low sodi!$ 1 hi5h fl!id intake

'" A hi5h alorie1 hi5h %rotein dietary intake C" low fat1 low sodi!$ and hi5h alorie intake D. lo$ sodium and restricted fluid inta3e @ Refer to O 39 SI+UA+I(N : < )ro$ DEC :;;: NLE = A -3 year old $ale onstr! tion worker was ad$itted to a tertiary hos%ital for in essant vo$itin5" Assess$ent dis losed: weak ra%id %!lse1 a !te wei5ht loss of "3k51 f!rrows in his ton5!e1 slow flattenin5 of the skin was noted when the n!rse released her %in h" +e$%erat!re: 63"E C 1 'UN Creatinine ratio : :8 : :1 7e also o$%lains for %ost!ral hy%otension" +here was no infe tion" J-" ?hi h of the followin5 is the a%%ro%riate n!rsin5 dia5nosisG <:= A" )l!id vol!$e defi it RH+ f!rrow ton5!e B. ,luid volume deficit R2 uncontrolled vomitin% C" Dehydration RH+ s!bnor$al body te$%erat!re D" Dehydration RH+ in essant vo$itin5 J3" A%%roBi$ately how $! h fl!id is lost in a !te wei5ht loss of "3k5G <:= A" 38 $l '" 938 $l '. 4)) ml D" 93 $l @ :L P :k5 JJ" #ost!ral 7y%otension is <:= A" A dro% in systoli %ress!re less than :8 $$75 when %atient han5es %osition fro$ lyin5 to sittin5" B. A drop in systolic pressure %reater than () mmH% $hen patient chan%es position from lyin% to sittin% C" A dro% in diastoli %ress!re less than :8 $$75 when %atient han5es %osition fro$ lyin5 to sittin5 D" A dro% in diastoli %ress!re 5reater than :8 $$75 when %atient han5es %osition fro$ lyin5 to sittin5 @ #ost!ral hy%otension is eBhibited by a dro% of systoli '# when lient han5es %osition fro$ lyin5 to sittin5 or standin5" J9" ?hi h of the followin5 $eas!res will not hel% orre t the %atientAs ondition <:=

A. !ffer lar%e amount of oral fluid inta3e to replace fluid lost '" Give enteral or %arenteral fl!id C" )re0!ent oral are D" Give s$all vol!$es of fl!id at fre0!ent interval @ +he %atient will not tolerate lar5e a$o!nt of oral fl!id d!e to in essant vo$itin5" JE" After n!rsin5 intervention1 yo! will eB%e t the %atient to have <:= :" 2" 6" -" Maintain body te$%erat!re at 6J"3 C EBhibit ret!rn of '# and #!lse to nor$al Manifest nor$al skin t!r5or of skin and ton5!e Drinks fl!ids as %res ribed

A" :16 '" 21C" :161D. .,0,* @ Client need not $aintain a te$%erat!re of 6J"3 C" As lon5 as the lient will eBhibit absen e of fever or hy%other$ia1 N!rsin5 interventions are s! essf!lly arried o!t" SI+UA+I(N: < )ro$ DUN 2883 NLE = A J3 year old wo$an was ad$itted for #arkinsonAs Disease" +he har5e n!rse is 5oin5 to $ake an initial assess$ent" J;" ?hi h of the followin5 is a hara teristi of a %atient with advan ed #arkinsonAs diseaseG <:= A" Dist!rbed vision '" )or5etf!lness '. Mas3 li3e facial expression D" M!s le atro%hy @ #arkinsonMs disease does not affe t the o5nitive ability of a %erson" It is a disorder d!e to the de%letion of the ne!rotrans$itter do%a$ine whi h is needed for inhibitory ontrol of $!s !lar ontra tions" Client will eBhibit $ask like fa ial eB%ression1 Co5 wheel ri5idity1 'radykinesia1 Sh!fflin5 5ait et " M!s le atro%hy does not o !r in %arkinsonMs disease nor vis!al dist!rban es" 98" +he onset of #arkinsonAs disease is between 38&J8 years old" +his disorder is a!sed by <:= A" InI!rio!s he$i al s!bstan es '" 7ereditary fa tors C" Death of brain ells d!e to old a5e D. Impairment of dopamine producin% cells in the "rain

@ Do%a$ine %rod! in5 ells in the basal 5an5lia $ysterio!sly deteriorates d!e to !nknown a!se" 9:" +he %atient was %res ribed with levodo%a" ?hat is the a tion of this dr!5G <:= A. Increase dopamine availa"ility '" A tivates do%a$iner5i re e%tors in the basal 5an5lia C" De rease a etyl holine availability D" Release do%a$ine and other ate hola$ine fro$ ne!rolo5i al stora5e sites @ Levodo%a is an altered for$ of do%a$ine" It is $etaboli>ed by the body and then onverted into do%a$ine for brainMs !se th!s in reasin5 do%a$ine availability" Do%a$ine is not 5iven dire tly be a!se of its inability to ross the '''" 92" ,o! are dis !ssin5 with the dieti ian what food to avoid with %atients takin5 levodo%aG <6= A" /ita$in C ri h food '" /ita$in E ri h food C" +hia$ine ri h food D. <itamin B# rich food @ /ita$in bJ or %yridoBine is avoided in %atients takin5 levodo%a be a!se levodo%a in reases vita$in bJ availability leadin5 to toBi ity" 96" (ne day1 the %atient o$%lained of diffi !lty in walkin5" ,o!r res%onse wo!ld be <2= A. 1ou $ill need a cane for support '" ?alk ere t with eyes on hori>on C" IAll 5et yo! a wheel hair D" DonAt for e yo!rself to walk @ +ellin5 the lient to walk ere t ne5le ts the lients o$%lain of diffi !lty walkin5" ?heel hair is as $! h as %ossible not !sed to still enhan e the lientMs $otor f!n tion !sin5 a ane" +ellin5 the lient not to for e hi$self walk is non thera%e!ti " +he lient wants to talk and we sho!ld hel% her walk !sin5 devi es s! h as ane to %rovide s!%%ort and %revent inI!ries" SI+UA+I(N: < )ro$ DUN 2883 NLE = Mr" Dela Isla1 a lient with early De$entia eBhibits tho!5ht %ro ess dist!rban es" 9-" +he n!rse will assess a loss of ability in whi h of the followin5 areasG <2= A. Balance

B. 7ud%ment '. Speech D" End!ran e @ #erha%s this 0!estion fro$ the DUN 2883 NLE is findin5 what sho!ld the n!rse N(+ assess be a!se A1' and C are all affe ted by de$entia eB e%t ENDURANCE1 whi h is nor$ally lost as a %erson a5es" +here will be alteration in balan e be a!se oordination and s%atial ability 5rad!ally deteriorates" D!d5e$ent is also i$%aired as the lient eBhibits %oor $e$ory and on entration" S%ee h is severely altered" Client develo%s a%hasia1 a5nosia and in at end1 will lose all the ability to s%eak witho!t any $anifestation of $otor %roble$" 93" Mr" Dela Isla said he annot o$%rehend what the n!rse was sayin5" 7e s!ffers fro$: <:= A" Inso$nia '" A%hraBia C" A5nosia D. Aphasia @ +his 0!estion was REC,CLED d!rin5 the last 288J NLE" A%hasia is the INA'ILI+, to s%eak or !nderstand" A%hraBia is the inability to arry o!t %!r%osef!l tasks" A5nosia is the inability to re o5ni>e fa$iliar obIe ts" Inso$nia is the inability to fall aslee%" 9J" +he n!rse is aware that in o$$!ni atin5 with an elderly lient1 the n!rse will <:= A" Lean and sho!t at the ear of the lient '" (%en $o!th wide while talkin5 to the lient C" Use a low&%it hed voi e D. =se a medium-pitched voice @ +alk as nor$ally as %ossible" +he lient has de$entia and is not deaf1 altho!5h hearin5 $i5ht be i$%aired %ro5ressively as the lient a5es1 the n!rse sho!ld not alter his voi e1 sho!t or over en!n iate the words" Client will %re eive this thin5s as belittlin5 and dires%e tf!l" 99" As the n!rse talks to the da!5hter of Mr" Dela Isla1 whi h of the followin5 state$ent of the da!5hter will re0!ire the n!rse to 5ive f!rther tea hin5G <:= A" I know the hall! inations are %arts of the disease B. I told her she is $ron% and I explained to her $hat is ri%ht C" I hel% her do so$e tasks he annot do for hi$self D" Ill t!rn off the +/ when we 5o to another roo$ @ 7all! inations and del!sions are %art of DEMEN+IA and is ter$ed as (RGANIC

#S,C7(SES" +he da!5hter needs f!rther tea hin5 when she try to bar5ain1 eB%lain1 diss%rove or advi e a lient with de$entia" the lient has an i$%aired I!d5e$ent1 on entration1 thinkin51 reasonin5 and $e$ory and has inability to learn that is why instit!tional are for lients with de$entia is always re0!ired" +he disease is %ro5ressive and is not %reventable" 9E" ?hi h of the followin5 is $ost i$%ortant dis har5e tea hin5 for Mr" Dela Isla <2= A" E$er5en y N!$bers B. Dru% 'ompliance C" RelaBation te hni0!e D" Dietary %res ri%tion @ Dr!5 o$%lian e is the $ost i$%ortant tea hin5 for Mr" Dela Isla to %revent the sy$%to$s of %sy hoses and to ontrol behavioral sy$%to$s" SI+UA+I(N : Lnowled5e of the dr!5 #R(#AN+7ELINE 'R(MIDE <#robanthine= Is ne essary in treat$ent of vario!s disorders" 9;" ?hat is the a tion of this dr!5G <-= A" In reases 5land!lar se retion for lients affe ted with ysti fibrosis '" Dissolve blo ka5e of the !rinary tra t d!e to obstr! tion of ystine stones '. Reduces secretion of the %landular or%an of the "ody D" Sti$!late %eristalsis for treat$ent of onsti%ation and obstr! tion @ #robanthine red! es 5land!lar se retion of the different or5ans of the body" It is an anti& holiner5i H anti s%as$odi dr!5 and still1 not a%%roved by the )DA for treat$ent with vario!s disorders" #robanthine eBerts benifits for treat$ent of severe dia%horesis1 Ul ers d!e to over se retion of 7Cl1 S%as$s1 &A/'REA I S < #lease take note = and other onditions of over se retion" E8" ?hat sho!ld the n!rse a!tion the lient when !sin5 this $edi ation <-= A. Avoid ha?ardous activities li3e drivin%, operatin% machineries etc. '" +ake the dr!5 on e$%ty sto$a h C" +ake with a f!ll 5lass of water in treat$ent of Ul erative olitis D" I $!st take do!ble dose if I $issed the %revio!s dose @ Like other anti holiner5i sH anti s%as$odi s1 #robanthine a!ses di>>iness1 bl!rred vision and drowsiness" #atients are advised not to drive1 o%erate heavy $a hineries et " #robanthine sho!ld be taken with a f!ll 5lass of water b!t is ontraindi ated with infla$$atory bowel diseases like !l erative olitis and hrons disease" Dr!5 is taken with $eals to %revent irritation of the 5astri $! osa and lient is advised not to take do!ble dose in ase the %revio!s dose is $issed"

E:" ?hi h of the followin5 dr!5s are not o$%atible when takin5 #robanthineG <-= A" Caffeine '" NSAID C" A eta$ino%hen D. Alcohol @ #robanthine on its own already a!se severe di>>iness and drowsiness" Addition of al ohol will f!rther de%ress the CNS and $i5ht lead to %otentiation of the side effe ts of %robanthine" A1'1C are not ontraindi ated when takin5 %robanthine ECCE#+ when the disease entity itself do not %er$it intake of s! h dr!5s like in #an reatitis1 NSAID is not !se" #ain is ontrolled !sin5 %robanthine and $e%eridine < de$erol = in ases of a !te %an reatitis" E2" ?hat sho!ld the n!rse tell lients when takin5 #robanthineG <-= A. Avoid hot $eathers to prevent heat stro3es '" Never swi$ on a hlorinated %ool C" Make s!re yo! li$it yo!r fl!id intake to :L a day D" Avoid old weathers to %revent hy%other$ia @ #robanthine alters the ability of the body to se rete sweat" +ellin5 the lient to avoid hot weathers to %revent heat stroke is a%%ro%riate" Chlorinated %ool is dis o!ra5ed for %atients !nder5oin5 skin radiation for skin an er to %revent breakdown" Li$itin5 fl!id intake and avoidin5 old weather are !ne essary tea hin5s" E6" ?hi h of the followin5 disease wo!ld #robanthine eBert the $! h needed a tion for ontrol or treat$ent of the disorderG <-= A" Urinary retention B. &eptic =lcer Disease C" Ul erative Colitis D" Gla! o$a @ #robanthine is !se in #UD to de rease 5astri a id se retion" It is also !sed in #an reatitis to rest the %an reas fro$ over se retion of %an reati en>y$e and to %revent %ain and s%as$" #robanthine is ontraindi ated in lients with UC1 Gla! o$a" Sin e this is an anti s%as$odi dr!51 Urinary retention will be a side effe t" SI+UA+I(N : < )ro$ DEC 2888 NLE = Mr" )ran o1 98 years old1 s!ddenly o!ld not lift his s%oons nor s%eak at breakfast" 7e was r!shed to the hos%ital !n ons io!s" 7is dia5nosis was C/A" E-" ?hi h of the followin5 is the $ost i$%ortant assess$ent d!rin5 the a !te sta5e

of an !n ons io!s %atient like Mr" )ran oG <:= A" Level of awareness and res%onse to %ain '" #a%illary refleBes and res%onse to sensory sti$!li C" Coheren e and sense of hearin5 D. &atency of air$ay and ade;uacy of respiration @ Airway is always a %riority in an !n ons io!s lient" Refer to $aslows hierar hy of needs for %rioriti>ation" Altho!5h this is not absol!te1 knowled5e with %atho%hysiolo5y will best lead yo! to the orre t o%tion" E3" Considerin5 Mr" )ran oAs onditions1 whi h of the followin5 is $ost i$%ortant to in l!de in %re%arin5 )ran oAs bedside e0!i%$entG <:= A" 7and bell and eBtra bed linen '" Sandba5 and tro hanter rolls C" )ootboard and s%lint D. Suction machine and %loves @ C/A %atients has i$%aired swallowin5 ability and if not absent1 de%ressed 5a5 refleB" Client is at the hi5hest risk for as%iration when eatin5 or drinkin5 that is why NG+ is initiated early in the hos%itali>ation" ' %revent EC+ERNAL R(+A+I(N in hi% or le5 fra t!re" )ootboards and s%lint %revents )((+DR(# seen in lients that has a severed %eroneal nerve or %rolon5ed i$$obili>ation !s!ally d!e to fra t!res that event!ally %!ts %ress!re on the %eroneal nerve" A is not s%e ifi to lients with C/A" EJ" ?hat is the rationale for 5ivin5 Mr" )ran o fre0!ent $o!th areG <:= A" 7e will be thirsty onsiderin5 that he is doesnAt drink eno!5h fl!ids '" +o re$ove dried blood when ton5!e is bitten d!rin5 a sei>!re C" +he ta tile sti$!lation d!rin5 $o!th are will hasten ret!rn to ons io!sness D. Mouth "reathin% is used "y comatose patient and it8ll cause oral mucosa dyin% and crac3in%. @ Client will be on NG+ on e o$atose1 A is re$oved first" Client with C/A MA, have sei>!res1 b!t it is RARE eno!5h that it $!st re0!ire a fre0!ent $o!th are1 ' is eli$inated neBt" Lnowin5 that ta tile sti$!lation is done by to! hin5 the %atient and not by %efor$in5 $o!th are will lead yo! to letter D" Co$atose %atient !ses the $o!th to breathe %redis%osin5 hi$self to dryin51 ra kin5 and infe tions" E9" (ne of the o$%li ations of %rolon5ed bed rest is de !bit!s !l er" ?hi h of the followin5 an best %revent its o !rren eG <:= A" Massa5e reddened areas with lotion or oils B. urn fre;uently every . hours C" Use s%e ial water $attress

D" Lee% skin lean and dry @ )re0!ent t!rnin5 and %ositionin5 is the sin5le $ost i$%ortant n!rsin5 intervention to %revent !l er for$ation" Skins are $assa5ed b!t on e the areas are reddened already < CLASS I Ul er =1 It is not any$ore $assa5ed as not to %revent f!rther breakdown" Lotions and (ils are not !se in lients skin be a!se it will f!rther enhan e skin breakdown" ?ater $atress are !sed in 'URN %atients to li$it the %ress!re on the skin by his own body wei5ht" An alternatin5&inflatable air $atress is $! h $ore o$%atible in %eriodi distrib!tion of %ress!re in lients with %rolon5 i$$obility" Lee%in5 skin lean and dry is i$%ortant b!t not as i$%ortant as fre0!ent t!rnin5 and %ositionin5" EE" If Mr" )ran oAs Ri5ht side is weak1 ?hat sho!ld be the $ost a the n!rseG <-= !rate analysis by

A. Expressive aphasia is prominent on clients $ith ri%ht sided $ea3ness '" +he affe ted lobe in the %atient is the Ri5ht lobe C" +he lient will have %roble$s in I!d5in5 distan e and %ro%rio e%tion D" Clients orientation to ti$e and s%a e will be $! h affe ted @ If the lientMs ri5ht side is weak1 the affe ted lobe is the LE)+ L('E whi h is where the bro aMs area is lo ated" Client will eBhibit eB%ressive a%hasia1 aref!l and slow $ove$ents and ri5ht sided weakness" D!d5in5 distan e and %ro%rio e%tion is !s!ally i$%aired in lients with RIG7+ sided stroke" +ellin5 that the lients orientation to ti$e and s%a e will be $! h affe ted is a blind shot analysis" +his is seen on lients with severe and $assive he$orrha5i stroke with re overy fail!re related to ane!rys$s %rod! in5 lon5 ter$ and %er$anent o$a" Mr" )ran o ri5ht side is weak1 not %aralysed1 $eanin51 so$e f!n tions are still left inta t" SI+UA+I(N : < )ro$ DUN :;EE NLE = a 28 year old olle5e st!dent was r!shed to the ER of #G7 after he fainted d!rin5 their R(+C drill" Co$%lained of severe ri5ht ilia %ain" U%on %al%ation of his abdo$en1 Ernie Ierks even on sli5ht %ress!re" 'lood test was ordered" Dia5nosis is a !te a%%endi itis" E;" ?hi h res!lt of the lab test will be si5nifi ant to the dia5nosisG <:= A" R'C : -"3 +( 3 Million H !" $$" '" 75b : :6 to :- 5$Hdl" C" #latelets : 2381888 to 3881888 !"$$" D. 6B' @ (.,))) to (0,)))2cu.mm @ ?'C in reases with infla$$ation and infe tion" ;8" Stat a%%ende to$y was indi ated" #re o% are wo!ld in l!de all of the followin5 eB e%tG <:=

A" Consent si5ned by the father B. Enema S A C" Skin %re% of the area in l!din5 the %!bis D" Re$ove the Iewelries @ Refer to A'D(MINAL ASSESSMEN+ : S+(R, +(?ARDS MAS+ER, ;:" #re&anestheti $ed of De$erol and atro%hine s!lfate were ordered to : <6= A. Allay anxiety and apprehension '" Red! e %ain C" #revent vo$itin5 D" RelaB abdo$inal $!s le @ #ain is not red! ed in a%%endi its" Clients are not 5iven %ain $edi ation as to assess whether the a%%endiB r!%t!red" A s!dden relief of %ain indi ates the the a%%endiB has r!%t!red and lient will have an e$er5en y a%%ende to$y and %revent %eritonitis" De$erol and Atro%ine are !sed to allay lientMs anBiety %re o%eratively" ;2" Co$$on anesthesia for a%%ende to$y is <6= A. Spinal '" General C" Ca!dal D" 7y%nosis @ S%inal anesthesia is the $ost o$$on $ethod !sed in a%%ende to$y" Usin5 this $ethod1 (nly the area affe ted is anestheti>ed %reventin5 syste$i side effe ts of anestheti s like di>>iness1 hy%otension and RR de%ression" ;6" #ost o% are for a%%ende to$y in l!de the followin5 eB e%t <:= A" Early a$b!lation B. Diet as tolerated after fully conscious C" Naso5astri t!be onne t to s! tion D" Dee% breathin5 and le5 eBer ise @ ClientMs %eristalsis will ret!rn in -E to 92 ho!rs %ost&o% therefore1 )l!id and food are witheld !ntil the bowel so!nds ret!rns" Re$e$ber that ALL #R(CUDURES re0!irin5 GENERAL and S#INAL anesthesia above the nerves that s!%%ly the intestines will a!se te$%orary %aralysis of the bowel" S%e ially when the bowels are tra!$ati>ed d!rin5 the %ro ed!re1 it $ay take lon5er for the intestinal %eristalsis to res!$e" ;-" #eritonitis $ay o whi h are <2= !r in r!%t!red a%%endiB and $ay a!se serio!s %roble$s

:" 2" 6" -"

7y%ovole$ia1 ele trolyte i$balan e Elevated te$%erat!re1 weakness and dia%horesis Na!sea and vo$itin51 ri5idity of the abdo$inal wall #allor and event!ally sho k

A" : and 2 '" 2 and 6 C" :1216 D. All of the a"ove @ #eritonitis will a!se all of the above sy$%to$s" +he %eritone!$ has a nat!ral tenden y to GUARD and be o$e RIGID as to li$it the infe tive eB!date eB han5e inside the abdo$inal avity" 7y%ovole$ia and )QE i$balan e are a!sed by severe na!sea and vo$itin5 in %atients with %eritonitis be a!se of a !te %ain" As infla$$ation and infe tion s%reads1 fever and hills will be o$e $ore a%%arent a!sin5 elevation in te$%erat!re1 weakness and sweatin5" If %eritonitis is left !ntreated1 Client will be o$e severely hy%otensive leadin5 to sho k and death" ;3" If after s!r5ery the %atientAs abdo$en be o$es distended and no bowel so!nds a%%re iated1 what wo!ld be the $ost s!s%e ted o$%li ationG <:= A" Int!ss!s e%tion B. &aralytic Ileus C" 7e$orrha5e D" R!%t!red olon @ #aralyti Ile!s is a $e hani al bowel obstr! tion where in1 the %atients intestine fails to re5ain its $otility" It is !s!ally a!sed by s!r5ery and anesthesia" Int!s!ss!s e%tion1 A%%endi itis and #eritonitis also a!ses %aralyti ile!s" ;J" NG+ was onne ted to s! tion" In arin5 for the %atient with NG+1 the n!rse $!st <2= A. Irri%ate the tu"e $ith saline as ordered '" Use sterile te hni0!e in irri5atin5 the t!be C" advan e the t!be every ho!r to avoid kinks D" (ffer so$e i e hi%s to wet li%s @ NG+ after a%%ende to$y is !sed not to deliver n!trients b!t to de o$%ress the GI tra t be a!se of the absen e of %eristalsis after a%%ende to$y" +he sto$a h and intestines are not sterile1 Clean te hni0!e is s!ffi ient d!rin5 irri5ation" NG+ is %la ed and not any$ore advan ed as lon5 as it already rea h the sto$a h" Naso enteri t!bes are the one that are advan ed %eriodi ally !ntil obstr! tion is rea hed in the intestine" +he lient still needs assess$ent and onfir$ation of the ret!rn of %eristalsis before anythin5 is 5iven %er ore$" Irri5ations are done to %revent

obstr! tion in the t!be" ;9" ?hen do yo! think the NG+ t!be be re$ovedG <:= A" ?hen %atient re0!ests for it '" Abdo$en is soft and %atient asks for water '. A"domen is soft and flatus has "een expelled D" ' and C only @ ?hen flat!s is eB%elled1 it $eans that %eristalsis has ret!rned and theres is no need for ontin!in5 the NG+" Sit!ation: A$anda is s!fferin5 fro$ hroni arterios lerosis 'rain syndro$e she fell while 5ettin5 o!t of the bed one $ornin5 and was bro!5ht to the hos%ital1 and she was dia5nosed to have erebrovas !lar thro$bosis th!s transferred to a n!rsin5 ho$e" ;E" ?hat do yo! all a S+R(LE that $anifests a bi>arre behaviorG <-= A" Inor5ani Stroke '" Inor5ani #sy hoses C" (r5ani Stroke D. !r%anic &sychoses @ (r5ani %sy hoses is a broad and olle tive ter$ !sed for %sy hoses and s hi>o%hrenia that has an or5ani a!se" < D!e to Cre!t>feldt Iakob disease1 h!ntin5ton1 hydro e%hal!s1 in rease IC#1 de$entia1 stroke et " = Manifestin5 si5ns and sy$%to$s like hall! ination1 del!stions1 ill!sion1 ideas of referen e et " that is si$ilar to s hi>o%hrenia and %sy hoses in absen e of or5ani a!ses" ;;" +he $ain differen e between hroni and or5ani brain syndro$e is that the for$er <2= A" ( !rs s!ddenly and reversible '" Is %ro5ressive and reversible '. tends to "e pro%ressive and irreversi"le D" ( !rs s!ddenly and irreversible @ Chroni brain syndro$e tends to be %ro5ressive and irreversible" (r5ani brain syndro$e is a !te and irreversible or reversible de%endin5 on the a!sative fa tor"

:88" ?hi h behavior res!lts fro$ or5ani %sy hosesG <-= A" Me$ory defi it B. Disorientation '. Impaired 7ud%ement D. Inappropriate affect @ '1 C and D are all behaviors that res!lts fro$ or5ani %sy hoses" +he 0!estions see$s to ask ECCE#+I(N whi h is A. MEM!R1 DE,I'I " (r5ani %sy hoses is the sa$e as the !s!al %sy hoses eB e%t that the a!sative fa tor of or5ani %sy hoses is evidently a!sed by a disease %ro ess of the brain or affe tin5 the brain" EBa$%le are %atients who s!ffer stroke s!ddenly eB%erien e hall! inations and del!sions" (r5ani %sy hoses is si$%ly a %sy hoses that has an IDEN+I)IED CAUSE" Lnowin5 this will lead yo! to !nderstand that %sy hoses is $anifested by '1C1 and D b!t N(+ MEM(R, DE)ICI+"