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Medical Surgical Nursing Examination: 100 Item Question Pool with Answers and Rationales, Exams of Nursing

A comprehensive set of 100 multiple-choice questions covering various aspects of medical-surgical nursing. Each question includes the correct answer and a detailed rationale explaining the reasoning behind the choice. The questions are designed to test knowledge and understanding of key concepts in medical-surgical nursing, making it a valuable resource for students and professionals seeking to enhance their understanding of the subject.

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2024/2025

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100 Item MEDICAL SURGICAL Nursing Examination
Correct Answers and Rationales
Question Pool
MEDICAL SURGICAL NURSING
DISCLAIMER: Care has been taken to verify that all answers and rationale below are
accurate. Please comment up if you noticed any errors or contradictions to maintain
accuracy and precision of the answers as not to mislead the readers.
SITUATION: Dervid, A registered nurse, witnessed an old woman hit by a motorcycle
while crossing a train railway. The old woman fell at the railway. Dervid Rushed at the
scene.
1. As a registered nurse, Dervid knew that the first thing that he will do at the scene is [3]
A. Stay with the person, Encourage her to remain still and Immobilize the leg
while While waiting for the ambulance.
B. Leave the person for a few moments to call for help.
C. Reduce the fracture manually.
D. Move the person to a safer place.
* The old woman is in the middle of a train railway. It is very unsafe to immobilize here
legs and remain still at the middle of a railway considering that a train might come
anytime while waiting for an ambulance. Safety is the utmost importance at this point.
If letter D is not among the choices and the situation is a little less dangerous, the
answer will be A. Remember that in all cases of emergencies, removing the victim from
the scene to a much safer place is a priority.
2. Dervid suspects a hip fracture when he noticed that the old woman’s leg is [4]
A. Lengthened, Abducted and Internally Rotated.
B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated.
* SADDER should be your keyword. A hip fracture will produce a SHORTENED,
ADDUCTED AND EXTERNALLY ROTATED extremity. Treatment will evolve in
casting the leg and putting it in an EXTENSION, NEUTRALLY POSITIONED and
SLIGHT INTERNAL ROTATION. In Hip prosthesis, The nurse should maintain the
client’s leg in FLEXION, EXTERNAL ROTATION and ABDUCTION to prevent the
dislocation of the prosthesis from the acetabulum. Take note of the difference because I
mistakenly answered the LATTER in casting a hip fracture thinking that it is similar to a
the leg positioning in hip dislocation. Just imagine a patient with a cast that has his leg
in
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16
pf17
pf18
pf19
pf1a
pf1b
pf1c
pf1d
pf1e

Partial preview of the text

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100 Item MEDICAL SURGICAL Nursing Examination

Correct Answers and Rationales

Question Pool MEDICAL SURGICAL NURSING DISCLAIMER: Care has been taken to verify that all answers and rationale below are accurate. Please comment up if you noticed any errors or contradictions to maintain accuracy and precision of the answers as not to mislead the readers. SITUATION: Dervid, A registered nurse, witnessed an old woman hit by a motorcycle while crossing a train railway. The old woman fell at the railway. Dervid Rushed at the scene.

  1. As a registered nurse, Dervid knew that the first thing that he will do at the scene is [3] A. Stay with the person, Encourage her to remain still and Immobilize the leg while While waiting for the ambulance. B. Leave the person for a few moments to call for help. C. Reduce the fracture manually. D. Move the person to a safer place.
  • The old woman is in the middle of a train railway. It is very unsafe to immobilize here legs and remain still at the middle of a railway considering that a train might come anytime while waiting for an ambulance. Safety is the utmost importance at this point. If letter D is not among the choices and the situation is a little less dangerous, the answer will be A. Remember that in all cases of emergencies, removing the victim from the scene to a much safer place is a priority.
  1. Dervid suspects a hip fracture when he noticed that the old woman’s leg is [4] A. Lengthened, Abducted and Internally Rotated. B. Shortened, Abducted and Externally Rotated. C. Shortened, Adducted and Internally Rotated. D. Shortened, Adducted and Externally Rotated.
  • SADDER should be your keyword. A hip fracture will produce a SHORTENED, ADDUCTED AND EXTERNALLY ROTATED extremity. Treatment will evolve in casting the leg and putting it in an EXTENSION, NEUTRALLY POSITIONED and SLIGHT INTERNAL ROTATION. In Hip prosthesis, The nurse should maintain the client’s leg in FLEXION, EXTERNAL ROTATION and ABDUCTION to prevent the dislocation of the prosthesis from the acetabulum. Take note of the difference because I mistakenly answered the LATTER in casting a hip fracture thinking that it is similar to a the leg positioning in hip dislocation. Just imagine a patient with a cast that has his leg in

ABDUCTION, EXTERNAL ROTATION AND FLEXION. It will cause flexion contractures.

  1. The old woman complains of pain. John noticed that the knee is reddened, warm to touch and swollen. John interprets that this signs and symptoms are likely related to [2] A. Infection C. Thrombophlebitis B. Inflammation D. Degenerative disease
  • After a trauma, Inflammation will start almost instantly. Infection occurs 24-48 hours after bone fracture and not immediately. Thrombophlebitis occurs within 4 to 7 days of hospitalization after prolonged immobilization. There is no evidence that the client has a degenerative disease and degenerative diseases will manifest in variety of ways and not after a trauma.
  1. The old woman told John that she has osteoporosis; Dervid knew that all of the following factors would contribute to osteoporosis except [4] A. Hypothyroidism B. End stage renal disease C. Cushing’s Disease D. Taking Furosemide and Phenytoin.
  • B,C,D all contributes to bone deminiralization except HYPOTHYROIDISM. Hyperthyroidism will contribute to bone deminiralization as well as Hyperparathyroidism due to the increase in PTH, It will cause the movement of calcium from the bone to the blood causing HYPERCALCEMIA. ESRD will cause increase in PHOPHSATE due to its poor excretion. The amount of phosphate is inversely proportional to the amount of calcium. Cushing disease promotes bone demineralization as well as medications like diuretics and anti convulsants.
  1. Martha, The old woman was now Immobilized and brought to the emergency room. The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor Martha for which of the following sign and symptoms? [3] A. Tachycardia and Hypotension B. Fever and Bradycardia C. Bradycardia and Hypertension D. Fever and Hypertension
  • hemorrhage results in severing of the vascular supply of the bone of the femur and the pelvis due to the fracture leading to bleeding causing the s/s of tachycardia and hypotension. SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.

RIGHT. Imagine if the client moves his RIGHT LEG together witht the RIGHT CANE, it already violated the LAW OF RECIPROCAL MOTION. Moving the right leg will require Mr. Rojas to move his left arm and not the cane, which is on his right. SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood

  1. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also known as [1] A. PPD B. PDP C. PDD D. DPP
  • PPD stands for purified protein derivative. It is used to check for TB exposure. All clients who had BCG need not perform this test because they will always be +.
  1. The nurse would inject the solution in what route? [1] A. IM B. IV C. ID D. SC
  • A Wheal is created intradermally and then it is marked and timed. reading will be done within 2 to 3 days.
  1. The nurse notes that a positive result for Alfred is [2] A. 5 mm wheal B. 5 mm Induration C. 10 mm Wheal D. 10 mm Induration
  • 10 mm Induration [ redness ] is considered positive for individuals with competitive immune response. Wheals are not measured, they will not anymore enlarge. A 5 mm induration is considered positive for patients with AIDS or immunocompromised.
  1. The nurse told Alfred to come back after [2] A. a week B. 48 hours C. 1 day D. 4 days
  • Clients are asked to comeback within 2 to 3 days for the reading.
  1. Mang Alfred returns after the Mantoux Test. The test result read POSITIVE. What should be the nurse’s next action? [3] A. Call the Physician B. Notify the radiology dept. for CXR evaluation C. Isolate the patient D. Order for a sputum exam
  • The nurse has no authority order the radiology department for a chest x ray evaluation nor order for a sputum exam. The client need not be isolated because Mantoux test do not determine the activeness of the disease.
  1. Why is Mantoux test not routinely done in the Philippines? [2] A. It requires a highly skilled nurse to perform a Mantoux test B. The sputum culture is the gold standard of PTB Diagnosis and it will definitively determine the extent of the cavitary lesions C. Chest X Ray Can diagnose the specific microorganism responsible for the lesions D. Almost all Filipinos will test positive for Mantoux Test
  • almost all filipinos tests positive for mantoux test due to the fact that BCG are required and TB exposure in the country is fullminant. All individuals vaccinated with BCG will test POSITIVE for mantoux test all their lives.
  1. Mang Alfred is now a new TB patient with an active disease. What is his category according to the DOH? [1] A. I B. II C. III D. IV
  • Category I patients are those with a newly diagnosed TB whose sputum culture are positive. II are for those who have relapses while III are those with negative sputum culture but positive chest x ray, or PTB Minimal.
  1. How long is the duration of the maintenance phase of his treatment? [2] A. 2 months B. 3 months C. 4 months D. 5 months
  • Clients in category I will have 2 months INTENSIVE and 4 months maintenance treatment.
  1. Which of the following drugs is UNLIKELY given to Mang Alfred during the
  1. Direct sputum examination and Chest X ray of TB symptomatic is in what level of prevention? [1] A. Primary B. Secondary C. Tertiary D. Quarterly
  • National board exam loves asking about level of prevention. Mastery with the primary, secondary and tertiary levels of prevention is a must. All diagnostic, case finding and treatment belongs to the secondary level of prevention. SITUATION: Michiel, A male patient diagnosed with colon cancer was newly put in colostomy.
  1. Michiel shows the BEST adaptation with the new colostomy if he shows which of the following? [2] A. Look at the ostomy site B. Participate with the nurse in his daily ostomy care C. Ask for leaflets and contact numbers of ostomy support groups D. Talk about his ostomy openly to the nurse and friends
  • Actual participation conveys positive acceptance and adjustment to the altered body image. Although looking at the ostomy site also conveys acceptance and adjustment, Participating with the nurse to his daily ostomy care is the BEST adaptation a client can make during the first few days after colostomy creation.
  1. The nurse plans to teach Michiel about colostomy irrigation. As the nurse prepares the materials needed, which of the following item indicates that the nurse needs further instruction? [3] A. Plain NSS / Normal Saline B. K-Y Jelly C. Tap water D. Irrigation sleeve
  • The colon is not sterile, nor the stomach. Tap water is used in enema irrigation and not NSS. Although some clients would prefer a distilled, mineral or filtered water, NSS is not always necessary. KY Jelly is used as the lubricant for the irrigation tube and is inserted 3-4 inches into the colostomy pointing towards the RIGHT. Irrigation sleeve is use to direct the flow of the irrigated solution out of the stomach and into the bedpan or toilet.
  1. The nurse should insert the colostomy tube for irrigation at approximately [3] A. 1-2 inches B. 3-4 inches

C. 6-8 inches D. 12-18 inches

  • Remember 3-4 inches. They are both used in the rectal tube and colostomy irrigation tube insertion. 1 to 2 inches is too short and may spill out the irrigant out of the stoma. Starting from 6 inches, it would be too long already and may perforate the bowel.
  1. The maximum height of irrigation solution for colostomy is [3] A. 5 inches B. 12 inches C. 18 inches D. 24 inches
  • If you will answer in the CGFNS and NCLEX, C will be the correct answer. According to BRUNNER AND SUDDARTHS and Saunders, The height of the colostomy irrigation bag should be hanging above the clients shoulder at around 18 inches. According to MOSBY, 12 inches should be the maximum height. According to Lippinncots, 18 inches is the maximum height. According the the board of examiners, 12 inches should be the maximum height and an 18 inches irrigant height would cause rapid flow of the irrigant towards the colostomy. Therefore, answer in the local board should only be at 12 inches.
  1. Which of the following behavior of the client indicates the best initial step in learning to care for his colostomy? [1] A. Ask to defer colostomy care to another individual B. Promises he will begin to listen the next day C. Agrees to look at the colostomy D. States that colostomy care is the function of the nurse while he is in the hospital
  • The client made the best initial step in learning to care for his colostomy once he looks at the site. This is the start of the client's acceptance on his altered body image. A,B and D delays learning and shows the client's disintrest regarding colostomy care.
  1. While irrigating the client’s colostomy, Michiel suddenly complains of severe cramping. Initially, the nurse would [1] A. Stop the irrigation by clamping the tube B. Slow down the irrigation C. Tell the client that cramping will subside and is normal D. Notify the physician
  • Stopping the irrigation will also stop the cramping and pain. During the first few days of irrigation, The client will feel pain and cramping as soon as the irirgant touches the bowel. This will start to lessen once the client got accustomed to colostomy irrigation. Slowing down the irrigation will not stop the pain. Telling the client that it is normal and will subside eventually is not acceptable when a client experiences pain. Pain is all encompasing and always a priority over anything else in most situations. Notifying the

patients who lost a lot of blood after an operation. Blue stoma indicated cyanosis or alteration in perfusion. Stomas are not expected to be Gray. SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.

  1. Wilma, His sister and a nurse is suctioning the tracheostomy tube of James. Which of the following, if made by Wilma indicates that she is committing an error? [2] A. Hyperventilating James with 100% oxygen before and after suctioning B. Instilling 3 to 5 ml normal saline to loosen up secretion C. Applying suction during catheter withdrawal D. Suction the client every hour
  • This is unecessary. Suctioning is done on PRN basis and not every hour. A,B and C are all correct processes of suctioning a tracheostomy.
  1. What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs? [2] A. Fr. 5 B. Fr. 10 C. Fr. 12 D. Fr. 18
  • The height is given and it looks like james is a very tall individual. The maximum height of suction tube is used. fr 12-18 are used for adults while 6-8 are used in children.
  1. Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit? [4] A. 2-5 mmHg B. 5-10 mmHg C. 10-15 mmHg D. 20-25 mmHg
  • A is used in pediatric clients. B is for children and C is for adults. 20-25 mmHg is too much for a portable suction unit and is not recommended.
  1. If a Wall unit is used, What should be the suctioning pressure required by James? [4] A. 50-95 mmHg B. 95-110 mmHg C. 100-120 mmHg D. 155-175 mmHg
  • A is used in pediatric clients. B is for children and C is for adults. 155-175 mmHg is too

much for a wall suction unit and is not recommended.

  1. Wilma was shocked to see that the Tracheostomy was dislodged. Both the inner and outer cannulas was removed and left hanging on James’ neck. What are the 2 equipment’s at james’ bedside that could help Wilma deal with this situation? [3] A. New set of tracheostomy tubes and Oxygen tank B. Theophylline and Epinephrine C. Obturator and Kelly clamp D. Sterile saline dressing
  • In an emergency like this, The first thing the nurse should do is maintaining the airway patency. With the cannunlas dislodged, The stoma will stenosed and narrows giving james an obstructed airway. The nurse would insert the kelly clamp to open the stoma and lock the clamp in place to maintain it open while she uses an obturator as to prevent further stenosis of the stoma. An obturator is a part of the NGT package included by most manufacturers to guide the physician or nurses in inserting the outer cannula.
  1. Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed? [2] A. Wilma places 2 fingers between the tie and neck B. The tracheotomy can be pulled slightly away from the neck C. James’ neck veins are not engorged D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process.
  • Wilma should place 2 fingers underneath the tie to ensure that it is not too tight nor too loose. Letter D is the measurement for NGT insertion and is unrelated to tracheostomy.
  1. Wilma knew that James have an adequate respiratory condition if she notices that [1] A. James’ respiratory rate is 18 B. James’ Oxygen saturation is 91% C. There are frank blood suction from the tube D. There are moderate amount of tracheobronchial secretions
  • an RR of 18 means that James is not tachypneic and has an adequate air exchange. Oxygen saturation should be more than 95%. Frank blood is not expected in the suction tube. A slight tinged of blood in the tube is acceptable and expected. Amount of secretion are not in anyway related in assessing the respiratory condition of a person and so is the amount of blood in the tube.
  1. Wilma knew that the maximum time when suctioning James is [1] A. 10 seconds B. 20 seconds C. 30 seconds

A. IRIS

B. PUPIL

c. RODS [RETINA] D. CONES [RETINA]

  • CO NES Are responsible for CO LOR VISION and DAY VISION, they are very sensitive to RED LIGHT that is why red lights are use to guide the elderly towards the bathroom when they wake up to urinate. Rods are responsible for night vision. They are sensitive to blue and green lights.
  1. Nurse Jet knows that Aqueous Humor is produce where? [4] A. In the sub arachnoid space of the meninges B. In the Lateral ventricles C. In the Choroids D. In the Ciliary Body
  • AH is produced in the CILIARY BODY. It is filtered by the trabecular meshwork into the canal of schlemm.
  1. Nurse Jet knows that the normal IOP is [2] A. 8-21 mmHg B. 2-7 mmHg c. 31-35 mmHg D. 15-30 mmHg
  2. Nurse Jet wants to measure Mr. Batumbakal’s CN II Function. What test would Nurse Jet implement to measure CN II’s Acuity? [1] A. Slit lamp B. Snellen’s Chart C. Wood’s light D. Gonioscopy
  • CN II is the optic nerve. To assess its acuity, Snellen's chart is used. Slit lamp is the one you see in the usual Eye glasses shop where in, you need to look into its binocular- like holes and the optometrist is on the other side to magnify the structures of the eye to assess gross damage and structure. Woods light is a BLUE LIGHT used in dermatology. It is use to mark lesions usually caused skin infection. Gonioscopy is the angle measurement of the eye.
  1. The Doctor orders pilocarpine. Nurse jet knows that the action of this drug is to [4] A. Contract the Ciliary muscle B. Relax the Ciliary muscle C. Dilate the pupils D. Decrease production of Aqueous Humor
  • When the ciliary muscles contract, pupils constrict and the angle widens causing an increase AH outflow and decrease IOP. Relaxing the ciliary muscle will cause mydriasis or dilation, it is used as a pre op meds for cataract surgery and eye examination to better visualize the structures behind the iris. A and C are the same. Other drugs like betaxolol, Azetazolamide and epinephrine are the drugs used to decrease AH production.
  1. The doctor orders timolol [timoptic]. Nurse jet knows that the action of this drug is [4] A. Reduce production of CSF B. Reduce production of Aqueous Humor C. Constrict the pupil D. Relaxes the Ciliary muscle
  • All the eye drops the ends in OLOL decreases AH production. They are BETA BLOCKERS. Watch out for the S/S of congestive heart failure, bradycardia, hypotension and arrythmias.
  1. When caring for Mr. Batumbakal, Jet teaches the client to avoid [1] A. Watching large screen TVs B. Bending at the waist C. Reading books D. Going out in the sun
  • Bending at the waist increase IOP and should be avoided by patients with glaucoma. Treatment for glaucoma is usually for life. Patients are given laxatives to avoid stratining at the stool. They should avoid all activities that will lead to sudden IOP increase like bending at the waist. Clients should bend at the knees.
  1. Mr. Batumbakal has undergone eye angiography using an Intravenous dye and fluoroscopy. What activity is contraindicated immediately after procedure? [4] A. Reading newsprint B. Lying down C. Watching TV D. Listening to the music
  • The client had an eye angiography. Eye angiography requires the use MYDRIATICS pre-procedure. It is done by injecting an Intravenous dye and visualizes the flow of the dye throught the fluoroscopy along the vessels of the eye. This is to assess macular degeneration or neovascularizations [ proliferation of new vessels to compensate for continuous rupture and aneurysms of the existing vessels ] Mydratics usually takes 6 hours to a day to wear off. If client uses a mydratic, his pupil wil dilate making it UNABLE to focus on closer objects. Only A necessitates the constriction of the pupil to focus on a near object, which Mr.Batumbakals eye cannot perform at this time.
  • Although A is priority according to maslow, it is not specific in clients with menieres disease. The client has an attack of incapacitating vertigo and client is high risk for injury due to falls. The client will perceive the environment moving due to disruption of the vestibular system of the ear's normal function.
  1. After mastoidectomy, Nurse Budek should be aware that the cranial nerve that is usually damage after this procedure is [3] A. CN I B. CN II C. CN VII D. CN VI
  • The facial nerve branches from the back of the ear and spread towards the mouth, cheeks, eyelids and almost all over the face. In mastoidectomy, Incision is made at the back of the ears to clear the mastoid air cells of the mastoid bone that is infected. Clients are at very high risk for CN VII injury because of this. Observation during the post op after mastoidectomy should revolve around assessing the client's CN VII integrity.
  1. The physician orders the following for the client with Menieres disease. Which of the following should the nurse question? [1] A. Dipenhydramine [Benadryl] B. Atropine sulfate C. Out of bed activities and ambulation D. Diazepam [Valium]
  • Clients with acute attack of Menieres are required to have bed rest with side rails up to prevent injury. During periods of incapacitating vertigo, patient's eyes will have rotary nystagmus because of the perception that the environment is moving. Patients are also observed to hold the side rails so hard because they thought they are going to fall. Benadryl is used in menieres due to its anti histamine effects. B and D are used to allay clients anxiety and apprehension.
  1. Nurse Budek is giving dietary instruction to a client with Menieres disease. Which statement if made by the client indicates that the teaching has been successful? [1] A. I will try to eat foods that are low in sodium and limit my fluid intake B. I must drink atleast 3,000 ml of fluids per day C. I will try to follow a 50% carbohydrate, 30% fat and 20% protein diet D. I will not eat turnips, red meat and raddish
  • Clients are advised to limite fluid and sodium intake as not to further cause accumulation of fluids in the endolymph. C is the diabetic diet. D are the foods not eaten when clients are about to have a guaiac test.
  1. Peachy was rushed by his father, Steven into the hospital admission. Peachy is

complaining of something buzzing into her ears. Nurse Budek assessed peachy and found out It was an insect. What should be the first thing that Nurse Budek should try to remove the insect out from peachy’s ear? [3] A. Use a flashlight to coax the insect out of peachy’s ear B. Instill an antibiotic ear drops C. Irrigate the ear D. Pick out the insect using a sterile clean forceps

  • Lights can coax the insect out of the child's ear. This is the first measure employed in removing a live insect from the childs ear. Insects are not removed ALIVE, therfore, C and D are both wrong. Antibiotics has no effects since the child do not have any infection. If the insect did not come out after coaxing it with light, 2nd measure employs instillation of diluted alcohol or a mineral oil to kill the insect which is then removed using letter D.
  1. Following an ear surgery, which statement if heard by Nurse Budek from the patient indicates a correct understanding of the post operative instructions? [2] A. Activities are resumed within 5 days B. I will make sure that I will clean my hair and face to prevent infection C. I will use straw for drinking D. I should avoid air travel for a while
  • After ear surgery, Air travel is halted for a while. There is no need to restrict activities. The client is not allowed to shower for 7 days, Patient can clean himself using a sponge bath but avoids to shampoo or wet the face and hair. Straws are not used after ear surgery because sips increases pressure in the ear.
  1. Nurse Budek will do a caloric testing to a client who sustained a blunt injury in the head. He instilled a cold water in the client’s right ear and he noticed that nystagmus occurred towards the left ear. What does this finding indicates? [2] A. Indicating a Cranial Nerve VIII Dysfunction B. The test should be repeated again because the result is vague C. This is Grossly abnormal and should be reported to the neurosurgeon D. This indicates an intact and working vestibular branch of CN VIII
  • Refer to #
  1. A client with Cataract is about to undergo surgery. Nurse Budek is preparing plan of care. Which of the following nursing diagnosis is most appropriate to address the long term need of this type of patient? [1] A. Anxiety R/T to the operation and its outcome B. Sensory perceptual alteration R/T Lens extraction and replacement C. Knowledge deficit R/T the pre operative and post operative self care D. Body Image disturbance R/T the eye packing after surgery

hypotension. There was no infection.

  1. Which of the following is the appropriate nursing diagnosis? [1] A. Fluid volume deficit R/T furrow tongue B. Fluid volume deficit R/T uncontrolled vomiting C. Dehydration R/T subnormal body temperature D. Dehydration R/T incessant vomiting
  2. Approximately how much fluid is lost in acute weight loss of .5kg? [1] A. 50 ml B. 750 ml C. 500 ml D. 75 ml
  • 1L = 1kg
  1. Postural Hypotension is [1] A. A drop in systolic pressure less than 10 mmHg when patient changes position from lying to sitting. B. A drop in systolic pressure greater than 10 mmHg when patient changes position from lying to sitting C. A drop in diastolic pressure less than 10 mmHg when patient changes position from lying to sitting D. A drop in diastolic pressure greater than 10 mmHg when patient changes position from lying to sitting
  • Postural hypotension is exhibited by a drop of systolic BP when client changes position from lying to sitting or standing.
  1. Which of the following measures will not help correct the patient’s condition [1] A. Offer large amount of oral fluid intake to replace fluid lost B. Give enteral or parenteral fluid C. Frequent oral care D. Give small volumes of fluid at frequent interval
  • The patient will not tolerate large amount of oral fluid due to incessant vomiting.
  1. After nursing intervention, you will expect the patient to have [1]
  2. Maintain body temperature at 36.5 C
  3. Exhibit return of BP and Pulse to normal
  4. Manifest normal skin turgor of skin and tongue
  5. Drinks fluids as prescribed

A. 1,

B. 2,

C. 1,3,

D. 2,3,

  • Client need not maintain a temperature of 36.5 C. As long as the client will exhibit absence of fever or hypothermia, Nursing interventions are successfully carried out. SITUATION: [ From JUN 2005 NLE ] A 65 year old woman was admitted for Parkinson’s Disease. The charge nurse is going to make an initial assessment.
  1. Which of the following is a characteristic of a patient with advanced Parkinson’s disease? [1] A. Disturbed vision B. Forgetfulness C. Mask like facial expression D. Muscle atrophy
  • Parkinson's disease does not affect the cognitive ability of a person. It is a disorder due to the depletion of the neurotransmitter dopamine which is needed for inhibitory control of muscular contractions. Client will exhibit mask like facial expression, Cog wheel rigidity, Bradykinesia, Shuffling gait etc. Muscle atrophy does not occur in parkinson's disease nor visual disturbances.
  1. The onset of Parkinson’s disease is between 50-60 years old. This disorder is caused by [1] A. Injurious chemical substances B. Hereditary factors C. Death of brain cells due to old age D. Impairment of dopamine producing cells in the brain
  • Dopamine producing cells in the basal ganglia mysteriously deteriorates due to unknown cause.
  1. The patient was prescribed with levodopa. What is the action of this drug? [1] A. Increase dopamine availability B. Activates dopaminergic receptors in the basal ganglia C. Decrease acetylcholine availability D. Release dopamine and other catecholamine from neurological storage sites
  • Levodopa is an altered form of dopamine. It is metabolized by the body and then converted into dopamine for brain's use thus increasing dopamine availability. Dopamine is not given directly because of its inability to cross the BBB.
  1. You are discussing with the dietician what food to avoid with patients taking