Medical Surgical Nursing
What is the nursing priority for a patient with epiglottitis?
B.assist in endotracheal intubation
C.assist in tracheostomy
D.apply warm moist pack
Correct Answer C. Epiglottitis is an emergency situation requiring immediate intervention: the inflamed epiglottis is blocking the entrance to the trachea, therefore clearing the patient’s AIRWAY is the priority nursing action (eliminate options A and D).Option C is better than Option B; endotracheal intubation will be difficult because theinflamed epiglottis will not permit the insertion of a laryngoscope.
The following are clinical manifestations of nontoxic goiter (hypothyroidism) EXCEPT:
D.sensitivity to cold
Correct Answer C. Hypothyroidism causes a decrease in thyroid hormones, which in turn causes decreased metabolism. Options A, B and D are all consistent with decreased metabolism. Option C is a symptom of increased metabolism found in hyperthyroidism.
What is the best way to prevent the spread of STDs?
D.Practice Safe Sex
Correct Answer B. TEST-TAKING TIP: Pick the conservative answer. Remember the Board of Nursing is composed of older women with traditional values who do not approve of promiscuity (implied in options A and D). Telling the patient to abstain from sex (Option C) is not an acceptable response from the nurse.
What is the nursing priority if the client is suffering from 1st, 2nd, 3rd or 4th degree burns?
A.fluid and electrolyte balance
Correct Answer B. Infection is a priority for all types of burns. Airway is a priority only for burns to the face and neck. Pain is a second priority for 1st and 2nd degree burns. Fluid and electrolyte balance is a second priority for 3rd and 4th degree burns [no pain because nerve endings are damaged].
What is a normal physical finding of the thyroid gland?
A. nodular consistency
D. palpable upon swallowing
The correct answer is A. The thyroid gland is symmetrical, non-tender, and palpable only if the patient has goiter. The palpable mass on the neck is the thyroid cartilage. It is present in both males and females but is larger in males; it develops during puberty.
What food is most appropriate for a toddler?
Correct Answer is D. Toddlers need a high-carb diet to sustain their active play lifestyle. Toddlers are also at risk for aspiration, therefore eliminate foods that are choking hazards (options A and B). Milk is not the best food for toddlers because of its low IRON content; Milk is the primary cause of Iron-deficiency Anemia in children.
TEST-TAKING TIP: `Di ba may hotdog ang spaghetti? No, no, no… DO NOT ADD DETAILS TO THE QUESTION. Do not justify a wrong answer.
What would the nurse include in the teaching plan for a paraplegic client?
B. assisted coughing
C.adapted feeding techniques
Correct Answer A. A paraplegic patient has lower extremity paralysis (paralyzed bladder and bowel). Therefore the nursing priority is ELIMINATION.
Review the following terms:
Monoplegia — 1 limb paralysis
Hemiplegia — Right or Left side paralysis
Paraplegia – Lower extremity paralysis (note: there is no such thing as upper extremity paralysis)
Quadriplegia/Tetraplegia – Paralysis from the neck down. The priority for a quadriplegic patient is AIRWAY.
CNS: brain and spinal cord
PNS: 12 cranial nerves + 31 spinal nerves
8 cervical nerves (C1 to C8)
12 thoracic nerves (T1 to T12)
5 lumbar nerves (L1 to L5)
5 sacral nerves (S1 to S5)
1 coccygeal nerve (Co)
The spinal cord terminates at L1 to L2, therefore a LUMBAR TAP is performed at L3 ,L4 or L5
(no risk of paralysis from spinal cord damage).
Autonomic Nervous System
Drug Effects of Autonomic Nervous System
The nurse admits a patient with COPD. For the management of hypertension, the doctor prescribes Inderal 40 mg P.O. What is the appropriate nursing action?
A. administer Inderal 1 hour before or 2 hours after meals
B. withhold Inderal if the pulse is less than 60 bpm
C. question the physician regarding the order
D. monitor BP prior to administration
Correct Answer is C. A patient with COPD has decreased respiration. Propranolol [Inderal] is contraindicated for patients with COPD because of its PNS effects (it will aggravate the patient’s respiratory depression).
3 characteristics of neurons:
1. Excitability – Neurons are affected by changes in the environment
2. Conductivity – Neurons transmit wave of excitations
3. Permanent cells – Once neurons are destroyed, they are not capable of regeneration.