Nursing Fundamentals: 28% Medical 23% Surgical 20% Pediatric 16% Community 13%

1 !"e nurse is teac"ing a mot"er #"ose daug"ter "as iron de$iciency anemia !"e nurse determines t"e %arent understood t"e dietary modi$ications& i$ s"e selects' a( *( c( d( )read and co$$ee Fis" and Por+ meat Coo+ies and mil+ ,ranges and green lea$y -egeta*les

2 ."ic" o$ t"e $ollo#ing is t"e most common clinical mani$estation o$ /6P0 $ollo#ing ingestion o$ as%irin' a( *( c( d( 1idney $ailure 2cute "emolytic anemia 3emo%"ilia 2 !"alassemia

3 !"e nurse assesses a client #it" an ileostomy $or %ossi*le de-elo%ment o$ #"ic" o$ t"e $ollo#ing acid4*ase im*alances' a( *( c( d( 5es%iratory acidosis Meta*olic acidosis Meta*olic al+alosis 5es%iratory al+alosis

6 !"e nurse antici%ates #"ic" o$ t"e $ollo#ing res%onses in a client #"o de-elo%s meta*olic acidosis

a( 3eart rate o$ 107 *%m *( 8rinary out%ut o$ 17 ml c( 5es%iratory rate o$ 30 c%m d( !em%erature o$ 39 degree Celsius 7 2 client "as a %"os%"orus le-el o$ 5.0mg/dL. !"e nurse closely monitors t"e client $or' a( *( c( d( Signs o$ tetany :le-ated *lood glucose Cardiac dysr"yt"mias 3y%oglycemia

6 2 nurse is caring $or a c"ild #it" %yloric stenosis !"e nurse #ould #atc" out $or sym%toms o$' a( *( c( d( ;omiting large amounts .atery stool Pro<ectile -omiting 0ar+4colored stool

= !"e nurse res%onder $inds a %atient unres%onsi-e in "is "ouse 2rrange ste%s $or adult CP5 a( *( c( d( e( $( 2ssess consciousness /i-e 2 *reat"s Per$orm c"est com%ression C"ec+ $or serious *leeding and s"oc+ ,%en %atient>s air#ay C"ec+ *reat"ing

???& ???& ???& ???& ???& ??? 8 ."ic" o$ t"e $ollo#ing "as mostly li+ely occurred #"en t"ere is continuous *u**ling in t"e #ater seal c"am*er o$ t"e closed c"est drainage system' a( *( c( d( !"e connection "as *een ta%ed too tig"tly !"e connection tu*es are +in+ed @ung eA%ansion 2ir lea+ in t"e system

9 ."ic" i$ t"e $ollo#ing young adolescent and adult male clients are at most ris+ $or testicular cancer' a( *( c( d( )as+et*all %layer #"o #ears su%%orti-e gear during *as+et*all games !eenager #"o s#ims on a -arsity s#im team 204year4old #it" undescended testis Patient #it" a $amily "istory o$ colon cancer

10 !"e nurse %lans to $reBuently assess a %ost4t"yroidectomy %atient $or' a( *( c( d( Polyuria 3y%oacti-e dee% tendon re$leA 3y%ertension @aryngos%asm

11 2n 184mont"4old *a*y a%%ears to "a-e a rounded *elly& *o#legs and slig"tly large "ead !"e nurse concludes' a( *( c( d( !"e c"ild a%%ears to *e a normal toddler !"e c"ild is de-elo%mentally delayed !"e c"ild is malnouris"ed !"e c"ild>s large "ead may "a-e neurological %ro*lems

12 2 nurse is going to administer 700mg ca%sule to a %atient ."ic" is t"e correct route'

2(

)(

C(

0(

13 2n a%%ro%riate instruction to *e included in t"e disc"arge teac"ing o$ a %atient $ollo#ing a s%inal $usion is' a( *( c( d( 0on>t use t"e stairs 0on>t *end at t"e #aist 0on>t #al+ $or long "ours S#imming s"ould *e a-oided

16 2 nurse is %re%aring to gi-e an CM in<ection o$ Cron 0eAtran t"at is irritating to t"e su*cutaneous tissue !o %re-ent irritation to t"e tissue& #"at is t"e *est action to *e ta+en' a( *( c( d( 2%%ly ice o-er t"e in<ection site 2dminister drug at a 67 degree angle 8se a 264gauge4needle 8se t"e D4trac+ tec"niBue

17 ."at s"ould a nurse do %rior to ta+ing t"e %atient>s "istory' a( *( c( d( ,$$er t"e %atient a glass o$ #ater :sta*lis" ra%%ort 2s+ t"e %atient to disro*e and %ut on go#n 2s+ %ertinent in$ormation $or insurance %ur%oses

16 2 %regnant #oman is admitted $or %re4eclam%sia !"e nurse #ould include in t"e "ealt" teac"ing t"at magnesium #ill *e %art o$ t"e medical management to accom%lis" t"e $ollo#ing'

a( *( c( d(

Control seiDures %romote renal %er$usion !o decrease sustained contractions Maintain intrauterine "omeostasis

1= 2 nurse is going to administer ear dro%s to a 64year4old c"ild ."at is t"e correct #ay o$ instilling t"e medicine a$ter tilting t"e %atient>s "ead side#ards' a( *( c( d( Pull t"e %inna *ac+ t"en do#n#ards Pull t"e %inna *ac+ t"en u%#ards Pull t"e %inna u% t"en *ac+#ards Pull t"e %inna do#n t"en *ac+#ards

18 2 nursing student #as inter-ened *y t"e clinical instructor i$ #"ic" o$ t"e $ollo#ing is o*ser-ed' a( *( c( d( Cnserting a nasogastric tu*e Positioning t"e in$ant in a Esni$$ing E%osition Suctioning $irst t"e mout"& t"en t"e nose SBueeDing t"e *ul* syringe to suction mout"

19 C"oose amongst t"e o%tions illustrated *elo# t"at *est descri*es t"e angle $or an intradermal in<ection'

2(

)(

C(

0(

20 0uring a *asic li$e su%%ort class& t"e instructor said t"at *lind $inger s#ee%ing is not ad-isa*le $or in$ants ."ic" among t"e $ollo#ing could *e t"e reason' a( *( c( d( !"e mout" is still too small !"e o*<ect may *e %us"ed dee%er into t"e t"roat S"ar% $ingernails mig"t in<ure t"e -ictim !"e in$ant mig"t *ite

21 2 nurse enters a room and $inds a %atient lying on t"e $loor ."ic" o$ t"e $ollo#ing actions s"ould t"e nurse %er$orm $irst' a( *( c( d( Call $or "el% :sta*lis" res%onsi-eness o$ %atient 2s+ t"e %atient #"at "a%%ened 2ssess -ital signs

22 2 %atient #it" com%laints o$ c"est %ain #as rus"ed to t"e emergency de%artment ."ic" %riority action s"ould t"e nurse do $irst' a( *( c( d( 2dminister mor%"ine sul$ate intra-enously Cnitiate -enous access *y %er$orming -eni%unture 2dminister oAygen -ia nasal cannula Com%lete %"ysical assessment and %atient "istory

23 2 re"a* nurse re-ie#s a %ost4stro+e %atient>s immuniDation "istory ."ic" immuniDation is a %riority $or a =24year4old %atient' a( *( c( d( 3e%atitis 2 -accine 3e%atitis ) -accine 5ota-irus ;accine Pneumococcal ;accine

26 Se-eral %atients $rom a re%orted condominium $ire incident #ere rus"ed to t"e emergency room ."ic" s"ould t"e nurse attend to $irst' a( *( c( d( 2 174year4old girl& #it" *urns on t"e $ace and c"est& re%orts "oarseness o$ t"e -oice 2 284year4old man #it" *urns on all eAtremities 2 64year4old c"ild #"o is crying inconsola*ly and re%orts se-ere "eadac"e 2 604year4old #oman #it" com%laints o$ se-ere %ain on t"e le$t t"ig"

27 !"e doctor ordered 1 %ac+ o$ red *lood cells FP5)C( to *e trans$used to a %atient !"e nurse %re%ares t"e %ro%er C; tu*ing !"e C; tu*ing a%%ro%riate $or *lood trans$usion comes #it"' a( *( c( d( 2ir -ent Microdri% c"am*er Cn4line $ilter Soluset

26 !"e eA%ected yet negative F"arm$ul ( result $or %ost"emodialysis is a decrease in' a( *( c( d( Creatinine )8N P"os%"orus 5ed *lood cell count

2= 2 %atient #as *roug"t to t"e emergency room a$ter s"e $ell do#n t"e stairs ."ic" o$ t"e $ollo#ing is t"e *est indicator $or increased intracranial %ressure in "ead and s%inal in<ury' a( *( c( d( Cna*ility to mo-e eAtremities 0ecreased res%iratory rate Cncrease in %ulse and *lood %ressure 0ecrease le-el o$ consciousness

28 2 ne# nurse is administering an enema to a %atient !"e senior nurse s"ould inter-ene i$ t"e ne# nurse' a( *( c( d( 3angs t"e enema *ag 18 inc"es a*o-e t"e anus Positions t"e client on t"e rig"t side 2d-ances t"e cat"eter 6 inc"es into t"e anal canal @u*ricates 6 inc"es o$ t"e cat"eter ti%

29 !"e medication nurse is going to gi-e a %atient "is morning medications ."at is t"e %rimary action a nurse s"ould do *e$ore administering t"e medications' a( *( c( d( Pro-ide %ri-acy 5aise "ead o$ t"e *ed /i-e distilled #ater C"ec+ client>s identi$ication *racelet

30 2 304year4old client is admitted #it" in$lammatory *o#el syndrome FCro"n>s disease( ."ic" o$ t"e $ollo#ing instructions s"ould t"e nurse include in t"e "ealt" teac"ing' Select all that apply a( *( c( d( Corticosteroid medication is %art o$ t"e treatment Cnclude mil+ in t"e diet 2s%irin s"ould *e administered 2ntidiarr"eal medication can "el%

1.) Answer: D 0ar+ green lea$y -egeta*les are good sources o$ iron ,ranges are good sources o$ -itamin C t"at en"ances iron a*sor%tion in t"e small intestines 2.) Answer: B Cndi-iduals #it" /6P0 may eA"i*it "emolytic anemia #"en eA%osed to in$ection& certain medications or c"emicals Salicylates suc" as 2s%irin damages %lasma mem*ranes o$ eryt"rocytes& leading to "emolytic anemia 3.) Answer: B @o#er /C $luids are al+aline in nature and can *e lost -ia ileostomy !"us& loss o$ 3C,3& results to meta*olic acidosis 4.) Answer: Cnitially& res%iratory system #ill try to com%ensate meta*olic acidosis Patients #it" meta*olic acidosis "a-e "ig" res%iratory rate

5.) Answer: A Normal %"os%"orus le-el is 2 7 6 7 mgGd@ !"e le-el re$lects "y%er%"os%"atemia #"ic" is in-ersely %ro%ortional to calcium Client s"ould *e assessed $or tetany #"ic" is a %rominent sym%tom o$ "y%ocalcemia !.) Answer: Clinical mani$estations o$ %yloric stenosis include %ro<ectile -omiting& irrita*ility& consti%ation& and signs o$ de"ydration& including a decrease in urine out%ut ".) Answer: A# $# %# # B# D Cn accordance #it" t"e ne# guidelines& remem*er AB& ABS A4air#ay B4*reat"ing normally' H 4c"est com%ression A4air#ay o%en B4*reat"ing $or %atient S4serious *leeding& s"oc+& s%inal in<ury !"e nurse s"ould $irst assess consciousness o$ t"e %atient NeAt& o%en %atient>s air#ay to c"ec+ $or *reat"ing ."en t"ere is no *reat"ing& immediately %er$orm c"est com%ression t"en gi-e 2 *reat"s& do t"e cycle o$ care o-er Finally& c"ec+ $or serious *leeding& s"oc+& and s%inal in<ury '.) Answer: D Continuous *u**ling seen in #ater4seal *ottleG c"am*er indicates an air lea+ or loose connection& and air is suc+ed continuously into t"e closed c"est drainage system (.) Answer: !esticular cancer is most li+ely to a$$ect males in late adolescence 8ndescended testis is also one ma<or ris+ $or testicular cancer 10.) Answer: D 3y%ocalcemia occurs #"en t"ere is accidental remo-al or destruction o$ %arat"yroid tissue during surgical remo-al o$ t"e t"yroid gland @aryngos%asm is one o$ t"e clinical mani$estations o$ tetany& an indicator o$ "y%ocalcemia 11.) Answer: A Ct>s normal $or a toddler to "a-e *o#legs and a %rotruding *elly !"e "ead still a%%ears some#"at large in %ro%ortion $rom t"e rest o$ t"e *ody 12.) Answer: D 13.) Answer: B

!"ere is 648 mont"s acti-ity restriction $ollo#ing a s%inal $usion Sitting& lying& standing& normal stair clim*ing& #al+ing& and gentle s#imming is allo#ed )ending and t#isting at t"e #aist s"ould *e a-oided& along #it" li$ting more t"an 10 l*s 14.) Answer: D I4trac+ tec"niBue is used to administer drugs es%ecially irritating to t"e su*cutaneous tissue !"is met"od %romotes a*sor%tion o$ t"e drug *y %re-enting drug lea+age into t"e su*cutaneous layer 15.) Answer: B :sta*lis"ing ra%%ort is a #ay to gain trust t"at #ill lead $or a %atient to relaA Jou can get more insig"ts and in$ormation $rom a %atient #"en ra%%ort is esta*lis"ed 1!.) Answer: A @o# magnesium F"y%omagnesemia( %roduces clinical mani$estations li+e increased re$leAes& tremors& and seiDures Magnesium Sul$ate is t"e drug o$ c"oice to %re-ent seiDures in %re4 eclam%sia and eclam%sia 1".) Answer: :ar canal o$ c"ildren ages 3years and a*o-e can *e straig"tened *y %ulling t"e %inna u% t"en *ac+#ards For c"ildren *elo# 3 years o$ age& t"e ear canal can *e straig"tened *y %ulling t"e %inna do#n t"en *ac+#ards 1'.) Answer: A Cn$ants are nose *reat"ers 2 gastric tu*e may *e inserted to $acilitate lung eA%ansion and stomac" decom%ression& *ut not a nasogastric tu*e as it can occlude t"e nare& t"us& ma+ing *reat"ing di$$icult $or t"e in$ant 1(.) Answer: B 20.) Answer: B )lind $inger s#ee%s are not recommended in all CP5 cases es%ecially $or in$ants and c"ildren *ecause t"e $oreign o*<ect may *e %us"ed *ac+ into t"e air#ay 21.) Answer: B First ste% in cardio%ulmonary resuscitation FCP5( is assessing res%onsi-eness o$ t"e %atient 22.) Answer:

Priority nursing action is to administer oAygen to %atients #it" c"est %ain C"est %ain is caused *y insu$$icient myocardial oAygenation 23.) Answer: D Pneumococcal ;accine is a %riority immuniDation $or t"e elderly Seniors& ages 67 years old and a*o-e& "a-e "ig"er ris+ $or serious %neumococcal in$ection and li+ely "a-e lo# immunity !"is is administered e-ery 7 years 24.) Answer: A )urns on t"e $ace and nec+ can cause s#elling o$ t"e res%iratory mucosa t"at can lead to air#ay o*struction mani$ested *y "oarseness o$ -oice and di$$iculty in *reat"ing Maintaining an air#ay %atency is t"e main concern 25.) Answer: 2n in4line $ilter is reBuired $or *lood trans$usions 2!.) Answer: D Negati-e outcome: 3emodialysis decreases red *lood cell count #"ic" #orsens anemia& *ecause 5)Cs are lost in dialysis $rom anticoagulation during t"e %rocedure& and $rom residual *lood t"at is le$t in t"e dialyDer 2".) Answer: D 0ecrease in le-el o$ consciousness and "eadac"e are early signs o$ increase in intracranial %ressure FCCP( 2ltered le-el o$ consciousness is t"e most common sym%tom t"at indicates a de$icit in *rain $unction 2'.) Answer: B 5ecall t"e anatomy o$ t"e colon !"e a%%ro%riate %osition is le$t lateral to $acilitate $lo# o$ enema *y gra-ity into t"e colon 2(.) Answer: D 5ecall t"e 12 5ig"ts o$ administration C"ec+ing t"e %atient>s name is critical $or client4sa$ety 30.) Answer: A # D Cro"n>s disease is a c"ronic in$lammation o$ t"e colon #it" sym%toms o$ diarr"ea& a*dominal %ain& and #eig"t loss Corticosteroid is a treatment $or Cro"n>s disease 2ntidiarr"eal can gi-e relie$ to diarr"eal e%isodes 2s%irin s"ould *e a-oided as it can #orsen in$lammation !"ose #it" Cro"n>s disease are mostly lactose intolerant& so c"oice no F2( is incorrect

1 Cn %er$orming a *acterial #ound s#a*& #"y is it necessary to co-er t"e #ound #it" a%%ro%riate dressing' a * c d Ct reduces t"e transmission o$ microorganisms Promotes %atient>s com$ort Facilitates #ound "ealing& a*sor*s eAudate& and reduces ris+ o$ *acterial coloniDation Ct decreases trauma to t"e tissue

2 ."ic" o$ t"e $ollo#ing ty%es o$ *urn in<ury is more $reBuent' a * c d !"ermal *urns C"emical *urns :lectrical *urns 5adiation related *urns

3 ."at +ind o$ tec"niBue used $or assessing t"e eAtent o$ *urn t"at gi-es re%roduci*le accuracy es%ecially age4related cases' a * c d .allace>s Erule o$ ninesK tool @und and )ro#der c"art FitD%atric+>s Scale )ot" 2 and )

6 ."ic" o$ t"e $ollo#ing classi$ication o$ *urn in<ury t"at in-ol-es t"e muscle& *one& tendon and interstitial tissue' a * c d Full t"ic+ness *urn Su%er$icial %artial t"ic+ness *urn Su%er$icial *urn Su*dermal *urn

7 ."ic" o$ t"e $ollo#ing clearly descri*es a stage 3 %ressure in<ury' a Ct includes a $ull t"ic+ness tissue loss #it" eA%osed *one& tendon& and muscle * Ct includes a %artial t"ic+ness loss o$ dermis and s"allo# o%en ulcers c Ct includes a $ull t"ic+ness s+in lossL su*cutaneous $at may *e -isi*le d Ct is %resent on areas o$ %ersistent& non4*lanc"a*le redness #"en com%ared #it" t"e surrounding s+in 6 ."ic" o$ t"e $ollo#ing is considered as a ma<or $actor in determining %ressure in<uries to %atients' a * c d 5edness 2*scess :dema Pain

= ."ic" o$ t"e $ollo#ing strategy is not essential in %re-enting %ressure in<uries' a * c d Promote ru**ing and massaging t"e *ony %rominences Monitor %atient>s nutrition and "ydration Maintain good s+in "ygiene Pre-ent s"ear and $riction

8 ."ic" o$ t"e $ollo#ing ty%es o$ leg ulcer #"ic" is o$ten %ainless' a * c d ;enous 8lcer 2rterial leg ulcer 0ia*etic leg ulcer )ot" 2 and )

9 2ll o$ t"e $ollo#ing descri*es t"e im%ortance o$ using critical t"in+ing eAce%t: a * c d Nurses do not in-ol-e t"emsel-es in ma+ing im%ortant decisions Nurses use +no#ledge in a -arious $ield o$ study and su*<ects Nurses deal #it" c"ange in a -ery demanding and stress$ul en-ironment Nurses s"ould use it to sol-e client %ro*lems and ma+e a reasona*le solution

10 Nurses use t"e nursing %rocess systematically in order to %lan and %ro-ide t"e a%%ro%riate nursing care ."ic" o$ t"e $ollo#ing ste% in t"e nursing %rocess #"ere a nurse #ill continue& modi$y& or terminate t"e client>s %lan *ased on t"e outcomes gat"ered' a * c d 0iagnosing :-aluating 2ssessing Cm%lementing

11 !"ere are -arious ty%es o$ assessment use *y a nurse #"ic" de%ends on t"e situation ."ic" o$ t"e $ollo#ing is %er$ormed during any %"ysiologic or %syc"ological crisis o$ t"e %atient' a * c d !ime4@a%sed 5eassessment Cnitial 2ssessment Pro*lem4Focused 2ssessment :mergency 2ssessment

12 ,*taining data is a -ery crucial %art in %lanning %atient>s care ."ic" o$ t"e $ollo#ing ty%es o$ data is also re$erred as t"e o-ert data' a * c d Su*<ecti-e data Constant data ,*<ecti-e data Cn"erent data

13 !"ere are di$$erent ty%es o$ nursing diagnosis t"at a nurse can c"oose $rom ."ic" o$ t"e $ollo#ing ty%es is considered as a client %ro*lem #"ic" is %resent at t"e time o$ assessing t"e %atient' a * c d 2ctual diagnosis .ellness diagnosis 5is+ nursing diagnosis Syndrome diagnosis

16 Maslo#>s "ierarc"y o$ needs clearly de%icts t"e "uman needs as it is ran+ed *ased on "o# essential it is $or our sur-i-al ."ic" o$ t"e $ollo#ing is not a c"aracteristic o$ Maslo#>s "ierarc"y o$ needs' a * c d Ct is realistic& sees li$e clearly& and is su*<ecti-e a*out "is or "er o*ser-ations 3as su%erior %erce%tion& is more decisi-e Ct is sel$4centered rat"er t"an %ro*lem centered Ct is "ig"ly e$$ecti-e& $leAi*le& s%ontaneous& courageous& #illing to ma+e mista+es

17 2side $rom Maslo#& 1alis" also %resented a "ierarc"y o$ needs ."ic" o$ t"e $ollo#ing needs "e incor%orated or added to t"e $i-e le-els o$ needs *y Maslo#' a * c d 2$$ection needs Stimulation needs Cnde%endence needs 5ecognition needs

16 ."ic" o$ t"e $ollo#ing descri*es a secondary le-el o$ %re-ention' a * c d Family %lanning ser-ices 5e$erring a client to a su%%ort grou% 3e%atitis ) CmmuniDation 0en-er 0e-elo%mental Screening !est

1= 3ealt" *e"a-ior c"ange is a cyclical %rocess #"ere a %atient %rogress in a series num*er o$ ste%s ."ic" o$ t"e $ollo#ing correctly descri*es t"e contem%lation stage' a Ct is t"e stage #"ere t"e %atient ac+no#ledges t"at "e "as a %ro*lem and considers c"anging t"at *e"a-ior $or t"e $uture * Ct is t"e stage #"ere t"e %atient %lans to ma+e actions in t"e immediate $uture Fe g #it"in neAt t#o #ee+s( c Ct is t"e stage #"ere t"e %erson acti-ely %artici%ates in t"e course o$ %rogram designed $or "im d Ct is t"e stage #"ere t"e %erson stri-es to %re-ent rela%se *y integrating actions into "is li$e 18 !"e de$inition o$ "ealt" is -ery com%leA and may consider a lot o$ $actors ."ic" o$ t"e $ollo#ing models o$ "ealt" and #ellness descri*es t"at a %erson is considered "ealt"y as long as t"ey can %er$orm t"eir roles in t"e society'

a * c d

2da%ti-e Model 5ole Consistency Model 5ole Status Model 5ole Per$ormance model

19 2gent4"ost4en-ironment model *y @ea-ell and Clar+ is one o$ t"e t"eories #"ic" is #idely use in determining illness rat"er t"an %romoting #ellness Ct is *ased on t"e interaction o$ t"ree $actors: agent& "ost and en-ironment ."ic" o$ t"e $ollo#ing deals #it" t"e agent $actor' a * c d Climate :conomic le-el @ac+ o$ *ody nutrients Family "istory

20 Sociologists use t"e term illness *e"a-ior to descri*e "o# an indi-idual deals #it" "is signs& sym%toms& and medical regimen at t"e time o$ "is illness or disease ."ic" o$ t"e $ollo#ing is not included in t"e $our as%ects o$ t"e sic+ role %ro-ided *y Parsons' a * c d Clients are "eld res%onsi*le $or t"eir condition Clients are o*liged to try to get #ell as Buic+ly as %ossi*le Clients are eAcused $rom certain social roles and tas+s Clients or t"eir $amilies are o*liged to see+ com%etent "el%

21 /ro#t" is t"e %"ysical c"ange and increase in siDe 0e-elo%ment on t"e ot"er "and is an increase in t"e $unction and s+ill %rogression ."ic" o$ t"e $ollo#ing correctly descri*e t"e %rinci%le a*out gro#t" and de-elo%ment' a * c d !"e %ace o$ gro#t" and de-elo%ment is e-en Certain stages o$ gro#t" and de-elo%ment are more critical t"an t"e ot"ers 0e-elo%ment *ecomes increasingly undi$$erentiated 0e-elo%ment %roceeds $rom sim%le to com%leA or $rom integrated acts to single acts

22 ,ne o$ t"e signi$icant c"aracteristics during t"e toddler"ood stage is t"e increase in %syc"osocial s+ills and motor de-elo%ment ."ic" o$ t"e $ollo#ing nursing im%lications is -ery im%ortant during t"is stage' a * c d !"e nurse s"ould assist in de-elo%ing co%ing *e"a-iors !"e nurse s"ould assist t"e %arents to identi$y and meet t"e unmet needs !"e nurse s"ould %ro-ide o%%ortunities $or %lay and social acti-ity !"e nurse s"ould *alance *et#een sa$ety and ris+4ta+ing strategies to %ermit gro#t"

23 Freud identi$ied $i-e stages o$ de-elo%ment ."ic" o$ t"e $ollo#ing correctly "a%%ens during t"e anal stage' a 6 years to %u*erty * 1 M to 3 years old

c 1 to 3 years old d 6 to 6 years old 26 :ri+son identi$ied eig"t stages o$ de-elo%ment 3e %ointed out t"at during t"e early c"ild"ood& t"e central tas+ s"ould *e autonomy -ersus s"ame and dou*t ."ic" o$ t"e $ollo#ing is an indicator o$ negati-e resolution to t"is stage' a * c d Com%ulsi-e sel$4restraint Mistrust :strangement @ac+ o$ sel$4con$idence

27 Cogniti-e de-elo%ment deals on #ays in #"ic" a %erson learn to t"in+& reason out& and use language !"e cogniti-e t"eory *y Piaget %ointed out t"ree %rimary a*ilities #"ic" are %resent in eac" %"ase ."ic" o$ t"e $ollo#ing deals #it" t"e %rocess #"ere an indi-idual encounters and reacts to#ards ne# situation and using t"e mec"anisms t"at t"ey already "a-e' a * c d 2ccommodation 2da%tation 2ssimilation Co%ing *e"a-ior

26 ."ic" o$ t"e $ollo#ing maternal $actors does not contri*ute to t"e "ig"er ris+ o$ lo# *irt" #eig"t *a*ies' a * c d @o# stress le-els& including %"ysical or emotional a*use 8se o$ addicti-e drugs or alco"ol during %regnancy Com%lications during %regnancy& %oor "ealt" status& eA%osure to in$ections Poor nutrition during %regnancy

2= 5e$leAes are normal to ne#*ornL t"ey are unconscious and in-oluntary res%onses ."ic" o$ t"e $ollo#ing in$ant re$leAes is also +no#n as t"e $encing re$leA' a * c d )a*ins+i re$leA Ste%%ing re$leA !onic nec+ re$leA Palmar re$leA

28 ."ic" o$ t"e $ollo#ing %syc"osocial de-elo%ment stages is considered as t"e crucial crisis according to :ri+son' a * c d 2utonomy -ersus s"ame and dou*t Cnitiati-e -ersus guilt Cdentity -ersus role con$usion !rust -ersus mistrust

29 Nurses use di$$erent ty%es o$ t"era%eutic communication tec"niBues in order to *uild an e$$ecti-e relations"i% to#ards t"eir %atients ."ic" o$ t"e $ollo#ing tec"niBues illustrates ac+no#ledging t"e %atient' a * c d EJou trimmed your nails today and #as"ed your "ands K EJour *oo+ is "ere in t"e dra#er Ct is not stolen K EC>ll stay #it" you until your mot"er arri-es K E!ell me a*outNK

30 @earning is re%resented *y a c"ange o$ *e"a-ior ."ic" o$ t"e $ollo#ing learning t"eories #"ere a nurse is seen a%%lying a "umanistic t"eory' a * c d !"e nurse #ill %ro-ide an enoug" time $or "is %atient to sol-e %ro*lems t"roug" trial and error !"e nurse #ill ac+no#ledge t"e %atient $or correct *e"a-ior !"e nurse #ill encourage acti-e learning *y *eing t"e $acilitator andGor mentor !"e nurse #ill assess a %erson>s de-elo%mental and indi-idual readiness

31 2ndragogy is de$ined as t"e art and science use in teac"ing adults ."ic" o$ t"e $ollo#ing conce%ts can *e used as a guide $or client teac"ing' a * c d 2n adult>s %re-ious eA%eriences can *e used as a resource $or learning 2s %eo%le mature& t"ey mo-e $rom inde%endence to de%endence 2n adult>s readiness to learn is o$ten not related to a de-elo%mental tas+ or social role 2n adult is more oriented in learning #"en material is use sometime in t"e $uture

32 Nurses as %art o$ t"e "ealt" care team can contri*ute largely on t"e "ealt" literacy o$ %atients ."ic" o$ t"e $ollo#ing client *e"a-iors #ill a nurse sus%ects t"at a %atient "as a %ro*lem in terms o$ "ealt" literacy' a * c d No %resence o$ %attern o$ eAcuses $or not reading t"e instruction materials !"e %atient #ill read t"e instructions instead o$ $amily mem*ers Pattern o$ com%liance Patient #ill insist t"at t"ey already understand t"e in$ormation gi-en to t"em

33 2 leader is someone #"o can in$luence ot"ers to accom%lis" a s%eci$ic goal ."ic" o$ t"e $ollo#ing leaders"i% styles t"at "as a minimal leader acti-ity le-el' a * c d 2ut"oritarian @eaders"i% Style 0emocratic @eaders"i% Style @aisseD4Faire @eaders"i% Style 2 and )

36 0elegation is t"e trans$er o$ res%onsi*ility and aut"ority to a com%etent %erson Ct is a tool t"at a nurse can use in order to im%ro-e %roducti-ity ."ic" o$ t"e $ollo#ing tas+s t"at s"ould not *e delegated to unlicensed assisti-e %ersonnel'

a * c d

!a+ing -ital signs :-aluation o$ care e$$ecti-eness Postmortem care Suctioning o$ c"ronic trac"eostomies

37 ."ic" o$ t"e $ollo#ing inter-entions t"at a nurse s"ould not %er$orm in %atients su$$ering $rom "y%ot"ermia' a * c d Co-er t"e client>s scal% #it" a ca% or tur*an 2%%ly #arm *lan+ets Pro-ide a #arm en-ironment 1ee% lim*s $ar $rom t"e *ody

1. )at*+nale: is t"e correct ans#er *ecause it %ro-ides a moist en-ironment $or t"e #ound t"us %romotes "ealing as it reduces *acterial coloniDation !"e ot"er c"oices t"oug" correct *ut t"ey cannot eA%lain clearly t"e im%ortance o$ #ound dressing 2 is #rong *ecause it tal+s a*out a-oiding to touc" t"e #ound ) is #rong *ecause it is more on assisting %atient>s com$orta*le %osition 0 is #rong *ecause it is more on t"e remo-al o$ t"e dressing and c"ec+ing t"e condition o$ #ound 2. )at*+nale: A is t"e correct ans#er *ecause t"e cause o$ t"ermal *urns "a%%ens usually in t"e "ouse Fe g +itc"en( #"ic" ma+es a %erson more %rone to "ot liBuids or $lames )& C& and 0 are not considered as more $reBuent ty%es t"oug" t"ey may "a%%en at #or+%lace 3. )at*+nale: B is t"e correct ans#er *ecause it uses age4de%endent gra%"s #"ic" are most %re$erred $or c"ildren and neonates 2 is incorrect *ecause it is more a%%lica*le to adults C"ildren "a-e di$$erent *ody %ro%ortions com%ared to c"ildren C is incorrect *ecause t"is scale is use to determine t"e color o$ t"e s+in to determine t"e res%onse to t"e 8; lig"t 4. )at*+nale: D is t"e correct ans#er *ecause it correctly de$ines t"e ty%e o$ *urn classi$ication Su*dermal *urn a%%ears as #"ite& *ro#n& or dee% red #it" no *listers /ra$ting is reBuired and scarring #ill occur 2 is #rong *ecause it only in-ol-es e%idermis& dermis& and su*cutaneous tissueL it a%%ears as #it" or #it"out *listers ) is #rong *ecause it only in-ol-es e%idermis and eAtends into t"e %a%illary or su%er$icial layer o$ t"e dermisL t"ere are small *listers C is #rong *ecause it in-ol-es only t"e e%idermis and no *listers 5. )at*+nale: is t"e correct ans#er *ecause it correctly de$ines a stage 3 %ressure in<ury 2 is #rong *ecause it is a stage 6 %ressure in<ury ) is #rong *ecause it is a stage 2 %ressure in<ury 0 is #rong *ecause it is a stage 1 %ressure in<ury !"is stage may *e di$$icult to assess es%ecially to indi-iduals #"o "a-e dar+ s+in tones !. )at*+nale: 0 is t"e correct ans#er *ecause it signi$ies t"at %ain o-er t"e site is a %recursor to tissue *rea+do#n 2& )& C& are #rong *ecause t"ey are secondarily c"ec+ during assessment o$ t"e s+in and t"eir %resence may mean ot"er s+in condition

". )at*+nale: A is correct ans#er *ecause massaging or ru**ing any *ony %rominences #ill only increase t"e c"ance o$ de-elo%ing a %ressure in<ury leading to tissue damage Pillo#s can *e used to a-oid %ressure in<ury es%ecially i$ t"e %atient is %ositioned %ro%erly ) is essential *ecause it allo#s t"e *ody to re%air itsel$ C is essential *ecause good s+in "ygiene %reser-es s+in integrity 0 eA%lains t"e im%ortance o$ %ro%er %ositioning in order to %re-ent s"ear and $riction '. )at*+nale: is correct ans#er *ecause it is associated #it" a loss o$ %rotecti-e sensation Fneuro%at"y( andGor t"e %resence o$ isc"emia #it" %atients "a-ing dia*etes 2 is #rong *ecause it ranges $rom no %ain to se-ere& constant %ain Ct is o$ten #orse a$ter standing $or long %eriods ) is #rong *ecause it is o$ten accom%anied *y se-ere cram%ing %ain in t"e $oot or cal$ muscle at rest #"en t"e legs are ele-ated (. )at*+nale: A is t"e correct ans#er *ecause it is not true t"at nurses don>t ma+e im%ortant decisions& rat"er t"ey are !"ese decisions o$ten include t"e total #ell4*eing o$ t"eir %atients )& C& and 0 are all o%tions #"ic" clearly descri*e t"e im%ortance o$ using critical t"in+ing *y t"e nurses in t"e #or+ $ield 10. )at*+nale: B is t"e correct ans#er *ecause it is in t"e e-aluating stage #"ere a nurse collects t"e data in order to determine t"e outcomes From t"e outcomes gat"ered& a nurse com%ares and relates it to t"e goals set or t"e %atient C$ c"anges need to *e done& it is "ere #"ere t"e nurse #ill continue& modi$y or terminate t"e client>s %lan 2 is #rong *ecause it is t"e ste% #"ere t"e nurse #ill analyDe t"e data and $ormulate diagnostic statements C is #rong *ecause it is a ste% #"ere a nurse collects& organiDe and -alidate t"e data 0 is #rong *ecause it is a ste% #"ere a nurse im%lements t"e inter-entions %lanned $or t"e %atient 11. )at*+nale: D is t"e correct ans#er *ecause it is t"e ty%e o$ assessment use in order to identi$y any li$e t"reatening %ro*lems andGor ne# or o-erloo+ed %ro*lems 2 is #rong *ecause it is done during se-eral mont"s a$ter initial assessment ) is #rong *ecause it is %er$ormed #it"in s%eci$ied time a$ter admission to a "ealt" care $acility C is #rong *ecause it is %er$ormed during t"e ongoing %rocess o$ nursing care 12. )at*+nale: is t"e correct ans#er *ecause an o*<ecti-e data are t"e ones #"ic" can *e detected *y someone else Fo*ser-er( and can *e measured using acce%ted standard %roceduresL t"is is t"e reason #"y it is also termed as signs or o-ert data 2 is #rong *ecause a su*<ecti-e data is also re$erred as sym%toms or co-ert dataL t"ese ty%e o$ data is t"e one t"at t"e %atient $eels ) is #rong *ecause a constant data are in$ormation #"ic" doesn>t c"ange o-er a %eriod o$ time Fe g *lood ty%e( 0 is com%letely #rong *ecause it is not included in t"e ty%es o$ data t"at a nurse acBuires 13. )at*+nale: A is t"e correct ans#er *ecause an actual diagnosis is made *ased on t"e signs and sym%toms %resent ) is #rong *ecause it Edescri*es "uman res%onses to le-els o$ #ellness in an indi-idual& $amily& or community t"at "a-e a readiness $or en"ancement: FN2N02 Cnternational& 2007& % 2==( C is #rong *ecause it is made *ased on t"e %resence o$ ris+ $actors t"at suggest t"at a %ro*lem #ill li+ely occur i$ it is le$t untreated andGor le$t unseen *y t"e "ealt"care team 0 is #rong *ecause it is a ty%e o$ diagnosis #"ic" is related to a num*er o$ ot"er diagnoses

14. )at*+nale: is t"e correct ans#er *ecause Maslo#>s "ierarc"y o$ needs is not sel$4centered rat"er it is %ro*lem centered 2& )& and 0 are all c"aracteristics o$ Maslo#>s "ierarc"y o$ needs 15. )at*+nale: B is t"e correct ans#er *ecause it is one o$ t"e needs t"at 1alis" added *et#een t"e %"ysiologic and sa$ety and security needs o$ Maslo# 2 is #rong *ecause a$$ection needs is under t"e lo-e and *elongingness needs o$ Maslo# C and 0 are #rong *ecause inde%endence needs and recognition are under t"e sel$4esteem needs o$ Maslo# 1!. )at*+nale: D is correct *ecause a 0en-er 0e-elo%mental Screening !est is an eAam%le o$ screening sur-ey andGor %rocedures 2 and C are #rong *ecause t"ey are *ot" %rimary le-el o$ %re-ention ) is #rong *ecause it is an eAam%le o$ a tertiary le-el o$ %re-ention 1". )at*+nale: A is correct *ecause it correctly de$ines t"e contem%lation stage ) is #rong *ecause it is t"e %re%aration stage C is #rong *ecause it is t"e action stage 0 is #rong *ecause it is t"e maintenance stage 1'. )at*+nale: D is correct *ecause t"is model considers t"at sic+ness is t"e ina*ility to $ul$ill one>s role 2 is #rong *ecause t"is model deals a*out "o# an indi-idual ada%ts #it" "is en-ironment to#ards to good "ealt" )ot" ) and C are #rong *ecause t"ey are not included in t"e acce%ted models o$ "ealt" and illness 1(. )at*+nale: is t"e correct ans#er *ecause lac+ o$ *ody nutrients %redis%oses a certain indi-idual in acBuiring a diseaseL ot"er eAam%le include en-ironmental $actor or stress $actor 2 and ) are *ot" #rong *ecause climate and economic le-el are all eAam%le o$ en-ironment $actor 0 is #rong *ecause $amily "istory is an eAam%le o$ "ost $actorL ot"er eAam%le includes age and li$estyle "a*its 20. )at*+nale: A is correct *ecause it is not included in t"e $our as%ectsL it is not true t"at clients are "eld res%onsi*le $or t"eir condition )& C& and 0 are all included in t"e $our as%ects o$ sic+ role 21. )at*+nale: B correctly descri*e t"e a*out gro#t" and de-elo%ment 2 is #rong *ecause t"e %ace o$ gro#t" and de-elo%ment is une-enL as suc"& gro#t" is greater during in$ancy com%ared to c"ild"ood C is #rong *ecause de-elo%ment *ecomes increasingly di$$erentiated& i e it starts in a generaliDed res%onse to a s+illed s%eci$ic res%onse 0 is #rong *ecause de-elo%ment %roceeds $rom single acts to integrated acts 22. )at*+nale: D is correct *ecause t"is nursing inter-ention is -ery im%ortant in toddler"ood stage 2 is #rong *ecause it is im%ortant during adolescence stage ) is #rong *ecause it is im%ortant during neonatal stage C is #rong *ecause it is im%ortant in t"e %resc"ool stage 23. )at*+nale: B is correct *ecause during t"is age t"at anal stage "a%%ens 2 is #rong *ecause it "a%%ens during latency stage C is #rong *ecause it is <ust a di-ersion to t"e c"oices 0 is #rong *ecause it "a%%ens during t"e %"allic stage

24. )at*+nale: A is correct *ecause it is t"e rig"t negati-e resolution during early c"ild"oodL ot"ers include com%ulsi-e com%liance and de$iance ) and C are *ot" #rong *ecause t"ey "a%%en during in$ancy stage 0 is #rong *ecause it "a%%ens during late c"ild"ood stage 25. )at*+nale: is t"e correct term $or t"e de$inition gi-en a*o-e 2 is #rong *ecause accommodation is de$ined as t"e %rocess o$ c"ange #"ere cogniti-e %rocesses mature su$$iciently to allo# an indi-idual to sol-e %ro*lems t"at #ere unsol-a*le *e$ore )ot" ) and 0 are #rong *ecause t"ey mean t"e same t"ingL it is t"e a*ility to deal #it" t"e demands in t"e en-ironment 2!. )at*+nale: A is correct *ecause a lo# stress le-el #ill result to a less ris+ o$ lo# *irt" #eig"t *a*y )& C& and 0 are all maternal $actors t"at contri*ute to t"e "ig"er ris+ o$ lo# *irt" #eig"t *a*ies 2". )at*+nale: is correct *ecause tonic nec+ re$leA is t"e ot"er term $or $encing re$leAL it is de$ined as t"e %ostural re$leA #"ic" disa%%ears a$ter 646 mont"s 2 is #rong *ecause )a*ins+i re$leA is c"aracteriDed as rising o$ t"e *ig toe and $anning out o$ ot"er toes #"en t"e sole o$ t"e $oot is *eing stro+ed ) is #rong *ecause it is also +no#n as t"e #al+ing or dancing re$leA #"ic" disa%%ears at a*out 2 mont"s 0 is #rong *ecause a %almar re$leA "a%%ens #"en a small o*<ect is %laced against t"e %alm o$ t"e "and causing t"e $ingers to curl on it 2'. )at*+nale: D is correct *ecause according to :ri+son t"e resolution o$ t"is stage #ill determine "o# a %erson #ill "andle to resol-e t"e neAt stages to come 2& )& and C are all di-ersion to t"e Buestion 2(. )at*+nale: A is correct *ecause t"e statement ac+no#ledges t"e %atient in a non<udgmental #ay ) is #rong *ecause it uses a %resenting reality tec"niBue C is #rong *ecause it uses an o$$ering sel$ tec"niBue 0 is #rong *ecause it uses an o%en4ended Buestions tec"niBue 30. )at*+nale: is correct *ecause it descri*es "o# a nurse clearly a%%lies t"e "umanistic t"eory to#ards "is %atient 0 is #rong *ecause t"e nurse a%%lies t"e cogniti-e t"eory 2 and ) are *ot" #rong *ecause t"ey descri*e a nurse #"o uses t"e *e"a-ioristic t"eory 31. )at*+nale: A is correct *ecause an adult #ill res%onse to eit"er ne# or same situations *ased on t"e %re-ious eA%eriences t"at t"ey encountered ) is #rong *ecause %eo%le #ill mature $rom de%endence to inde%endence C is #rong *ecause an adult>s readiness is related to de-elo%mental tas+ or social role 0 is #rong *ecause adult is more oriented in learning #"en t"e materials are %resented immediately and not in t"e $uture 32. )at*+nale: D is correct *ecause it indicates t"at a %atient may "a-e a %ro*lem #it" "is "ealt" literacy le-el 2& )& and C are not client *e"a-iors t"at #ill indicate a "ealt" literacy %ro*lem to a %atient 33. )at*+nale: is correct *ecause a minimal leader acti-ity le-el de%icts a laisseD4$aire style #"ic" is #"y it is considered as ine$$icient 2 and ) are *ot" #rong *ecause t"ey are *ot" "ig" in terms o$ leader acti-ity le-el

34. )at*+nale: B is correct *ecause e-aluation o$ care e$$ecti-eness s"ould *e done *y nursesL unlicensed assisti-e %ersonnel are not reBuired to create a nursing care %lan 2& C& and 0 are tas+s #"ic" can *e delegated to unlicensed assisti-e %ersonnel 35. )at*+nale: D is t"e ans#er *ecause t"e lim*s s"ould not *e $ar $rom t"e *ody *ut rat"er close to it 2& )& and C are all nursing inter-entions t"at can *e done to %atients #it" "y%ot"ermia