MIND’S NEST REVIEW CENTER BY: DOC ARCE

(NURSES’ EDUCATION SPECIALIST TRAINER)

DAVAO CITY HEAD OFFICE **

GRAND COACHING
Medical Surgical Nursing
Prepared by: Dr. Nestor S. Arce, Jr,RN,USRN
Sit. 1: Nurses base their decisions on many different bodies of information in order to arrive at a course of action.
Among the basic guidelines to apply in nursing practice are the nursing process and other bodies of knowledge.

1. The nurse knows in the PACU that the most accurate way to determine a patient is breathing is to
a. Place her palm over patient’s nose and mouth
b. Auscultate for breath sounds
c. Inspect for diaphragmatic movement
d. Palpate for thoracic changes

2. Susan is diagnosed with congestive heart failure who is currently complaining of dyspnea. Which intervention should
the nurse implement first?
a. Administer furosemide a loop diuretic
b. Check the patient’s for adventitious lung sounds
c. Request the respiratory therapist to administer treatment
d. Notify the doctor for the problem of the patient

3. Mr. Cruz diagnosed with peptic ulcer has a blood pressure of 88/50 and an apical pulse of 132. The nurse writes the
nursing diagnoses altered tissue perfusion. Which intervention should the nurse implement first
a. Check the patient’s pulse oximeter reading
b. Notify the laboratory to draw a type and crossmatch
c. Assess the patient’s abdomen for tenderness
d. Insert an 18 gauge catheter and infuse lactated Ringers per doctor’s order

4. Which of these actions would be most appropriate for the nurse to take while providing care to help prevent the
spread of infection?
a. Sterilizing hands with a germicide once a day c. Washing hands before and after patient’s contact
b. Washing hands at the beginning of patient’s rounds d. Wearing gloves for all patient care

5. Seizure can occur without any warning and it compromises the patient’s safety. You should be able to provide care
needed to ensure safety. A critical nursing intervention for a patient with status epilepticus is:
a. Padding the bedrails c. Restraining the patient
b. Protecting the airway d. Providing privacy

IMMUNOLOGICAL CONCEPTS

Antibody mediated immunity Cellular mediated immunity

* Predominantly B lymphocytes * Predominantly T lymphocytes

* Plasma cell: produces immunoglobulin * Enhances immunity by cytokines
* Memory cell with faster reaction * Destroys non self, fungal infection
* Produces active and passive immunity * Graft rejection

Sit. 2: Clinical excellence in nursing remains to be the goal of every nurse to keep them motivated and ensure quality
nursing care in all aspects of their works. Nurse Kevin is caring several patients with immunological problems

6. One function of the cellular mediated immunity is

a. Surveillance for malignant cell changes c. Formation of antibodies
b. Activation of the complement system d. Opsonization of antigens to allow phagocytosis

7. The reason newborns are protected for the 6 months of life from bacterial infection is because of maternal
transmission of
a. Ig G b. IgM
b. Ig A d. Ig E

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 8. In type 1 hypersensitivity reaction, the primary immunologic disorders appear to be
a. Binding of Ig G to an antigen on the cell surface
c. Deposit of antigen-antibody complexes in a small vessel
d. Release of cytokines to interact with specific antigen
e. Release of mediators from mast cells and basophils

9. Nurse Pamela accidentally transfused a mismatch blood on a patient causing hemolysis and hematuria. This is
exemplified by what type of hypersensitivity reaction?
a. Type 1 c. Type 3
b. Type 2 d. Type 4

10. Ricardo is a child who was seen at the emergency department for fever, periorbital edema and tea colored urine,
The nurse is aware that the patient develops an acute glomerulonephritis and is what type of hypersensitivity reaction?
a. Type 1 c. Type 3
b. Type 2 d. Type 4

Sit. 3: Lea was 40 years old when she was admitted to the hospital for the treatment of acute arthritis. The present
attack of acute joint pain and swelling had begun suddenly and was related to the fact that she had been working
unusually long hours in the restaurant

11. The nurse assesses Lea with rheumatoid arthritis for which characteristics joint changes?
a. Swan-neck deformity c. Tophi
b. Heberden’s and Bouchard’s nodes d. Charcot’s joints

12. Which of the following devices should the nurse use in preparing Lea’s bed on admission?
a. Overhead frame c. Side rails
b. Rubber pillow d. Bed board

13. The swelling of Lea’s finger joints is probably due to

a. Infiltration of pus into the fibrous tissue surrounding the joints
b. Extravasation of blood from the skin capillaries into the subcutaneous tissue
c. Formation of bony spurs on the edges of articulating surfaces in the joint
d. Distention of joint capsule by an increased amount of synovial fluid

14. Rheumatoid arthritis is thought to be which of the following type of disease?

a. Malignant c. Nutritional
b. Collagen d, Metabolic

15. In establishing a plan care to manage pain for a client with rheumatoid arthritis (RA), what intervention would the
nurse use to increase the patient’s mobility?
a. Have the client work through pain by continuing exercise in order to established endurance.
b. Have the client use pain medication only when pain is present.
c. Teach the client that both heat and cold applications may help to relieve pain.
d. Teach the client to flex muscle groups when pain is felt in an extremit

GOUTY RHEUMATOID OSTEOARTHRITIS

J: Joint Etiology

O: Osteo involved

I: Investigation Arthrocentesis ESR Bone scan

ASO titer
N: Nursing Care

T: Therapeutics Colchicine ASA, NSAIDS Liniments

Probenecid DMARDS
Allopurinol Steroids
S: Surgery

Sit. 4: Adora was admitted to the hospital with malaise, fever, chest pain and polyarthralgia. An erythematous rash
over her nose and malar eminences was seen by the nurse at the ER and she suspects of SLE.

16. Systemic lupus erythematosus may produce changes in which of the following organs?
a. Epithelial tissues c. Connective tissues
b. Muscular tissues d. Nervous tissues

17. In taking Adora’s history, the nurse should know that which of the following symptoms frequently antedate the
diagnosis of SLE by several years?

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 a. Episodes of severe, painless bleeding on urination
b. Painful ischemia on fingers upon exposure to cold
c. Occurrence of leg cramps following exercise
d. Delayed healing of skin and mucosal lesions

18. Which of the following often trigger acute exacerbations of SLE?

a. Exposure to sunlight c. Pregnancy
b. Severe trauma d. Operative procedures

19. During the acute exacerbation of her SLE, Adora was treated with steroids. The nurse would expect the drug to
begin to be tapered when which serum laboratory results are evident?
a. Decreased anti-DNA c. Increased red blood cells
b. Increased complement factors d. Reduction of erythrocyte sedimentation rate

20. What is an ominous sign of advanced SLE disease?

a. Proteinuria from early glomerulonephritis
b. Dysrhytmia from fibrosis of the AV node
c. Anemia from antibodies against blood cells
d. Cognitive dysfunction from immune complex deposit in brain

Sit. 5: Diether Rosales, 35 years old is HIV positive. Aside from fatigue, Diether has no other complaints.

21. Transmission of HIV from an infected individual to another occurs

a. Whenever drug users share injection equipment
b. Most commonly as a result of sexual contact
c. In all infants born to women with HIV infection
d. Only when there is a large amount of virus in the blood

22. Following infection with HIV,

a. Virus replicates mainly in B lymphocyte before spreading to CD4 cells
b. Immune system is impaired by the eventual destruction of CD4 cells
c. Infection of monocytes may occur and are quickly destroyed by antibodies
d. Long period of dormancy develops during which HIV cannot be found in blood

23. Screening for HIV infection generally involves

a. Laboratory analysis of blood to detect HIV antigens
b. Analysis of lymph tissues for the presence of HIV RNA
c. Laboratory analysis of blood to detect HIV antibody
d. Electrophoretic analysis for HIV antigen in the plasma

24. The use of HAART (Highly active ntiretroviral therapy) are used to
a. Cure acute HIV infection c. Treat opportunistic disease
b. Decrease pain and symptoms d.Decrease viral RNA levels

25. Which of the following HAART drugs are incorrectly pair ?

a. Nevirapine- NNRTI c. Zidovudine- NRTI
b. Indinavir- Protease inhibitor d. Maraviroc- Integrase inhibitot

HYPERSENSITIVITY REACTION AUTOIMMUNITY

Type 1: Ig E mediated to antibody
Type 2: Cytotoxic (IgM mediated) Failure to identify self,seen in women
Type 3: Immune complex mediated SLE: malar rashes
Type 4: Delayed reaction Sjogren’s syndrome: dry eyes,dry mucus membrane,joint
pains
Histamine: major substance causing narrowed airways Psoriasis: silverlike lesions
DOC: Epinephrine Reiter’s syndrome: joint pains. Urethritis, conjunctivitis
Use of medical alert bracelet Mainstay of treatment: Steroids
Plasmapheresis
Latex allergy: be wary with avocado, banana, kiwi

IMMUNODEFICIENCIES GAMMOPATHIES
Reduction in the protection Presence of abnormal plasma cells
HIV infection: retrovirus Multiple myeloma: plenty immature plasma cells with few

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Opportunistic infection is seen late RBC
PCP, Kaposi sarcoma, TB, Candidaiasis “Punched out” lesion, renal failure and
Prevention: Safe sex, Monogamous rel Bence Jones protein
Needs pre and post counselling when being tested
ELISA test remains accurate and cheap
Treatment is “cocktail” (HAART)
Highest priority: Protect from infection

Sit. 6: Patricia works with the Department of Health and was not surprised of the doubling of sexually transmitted
infections among young professionals. She had been working as a nurse educator on Adolescent Health for the past
few years. She was invited to be a speaker on STI in one of the call centers in Davao.

26.. The patient at the out patient clinic is reluctant to identify her sexual contacts. The nurse explains that the
reporting of contacts is essential to
a. Slow transmission and spread c. Increase funding for treatment
b. Increase public awareness d. Collect data for research

27. A patient with syphilis is seen at the clinic and complains of body aches, pustules, fever, and sore throat. The nurse
recognizes that these are symptoms of syphilis at which stage?
a. Primary c. Latent
b. Secondary d. Tertiary

28. The nurse, completing a history of present illnesses for a young woman who suspects she may have a STI, will ask
specifically about whether the patient has experienced:
a. Lethargy and fatigue c. Genital discharges
b. Heavy menses d. Abdominal cramps.

29. The causative organism for various STIs must be identified for appropriate treatment. The method used to identify
organisms is known as:
a. Smears and cultures c. Serologic tests
b. Antibody screening d. Sensitivity testing

30. The nurse should emphasize the importance of annual Papanicolaou’s smears to the patient with genital warts
(condylomata) because there is an association between human papilloma virus (HPV) and the eventual development of
a. Chronic vaginitis c. Premature menopause
b. Uterine fibroids d. Cervical cancer

SEX TRIPS
Gonorrhea N. gonnorhea Bacteria Gram staining Ceftriaxone
Syphilis T. pallidun Spirochete FTA-Abs Penicillin
Trichomonas T. vaginalis Protozoan Wet smear Metronidazole
Herpes Herpes virus 2 Virus Tzanck test Acyclovir
Chlamydia C. trachomatis Bacteria Culture Doxycycline

Sit. 7: Joshua noticed significant weight loss over the pass two months which he attributed to his busy work in the
office. He smokes occasionally and lead a very successful life. One morning he noticed blood in his stool prompting
consultation in the clinic.

31 During a routine health examination, Joshua, a 30-year-old patient tells the nurse about a family history of colon
cancer. The nurse will plan to
a. Teach him about the need for colonoscopy at the age of 50
b. Ask him to bring a specimen to test for ocult blood test
c. Have him ask the doctor about the specific tests for colon cancer
d. Schedule him for sigmoidoscopy to provide baseline data about patient

32. Joshua who has been told by the Dr. Garovillo that the cells in a bowel tumor are poorly differentiated asks the
nurse what is meant by “poorly differentiated.” Which response should the nurse make
a. Cells in the tumor do not look different from the normal bowel cells
b. Tumor cells have a DNA that is different from your normal bowel cells

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 c. Looks like immature fetal cell than normal bowel cell
d. Cells in your tumor had mutated from the normal bowel cells

33. Joshua was found to have a large tumor that is attached to the liver is scheduled to have a debulking procedure.
The nurse explains that the expected outcome of the surgery is to

a. Reduction of tumor burden to enhance adjuvant therapy

b. Control of tumor growth by removal of malignant
c. Promotion of better nutrition by relieving pressure
d. Relief of pain by cutting sensory nerve in the intestine

34. Joshua is receiving chemotherapy and is experiencing mucositis. The nurse advises the patient to use which of the
following as the best substance to rinse the mouth?
a. Hydrogen peroxide mixture c. Lemon flavored mouthwash
b. Alcohol based mouthwash d. Weak salt and bicarbonate mouth rinse

35. As part of his chemotherapy. Methotrexate and Cyclophosphamide were given to Joshua The nurse is aware that in
case of toxicity, the antidote for Methotrexate is
a. Leucovinphenylate c. Folic acid
b. Protamine sulfate d. Activated charcoal

Radiation Therapy

Teletherapy Brachytherapy

* Avoid sun exposure Sealed source Unsealed source

* Wash area with water (Implanted near tumor) ( Given by IV or oral )
*No powders, ointments, lotion
* Wear soft cloth over the area
* Do not remove the markings * Isolate the patient * Isolate the patient
* Avoid friction/pressure on skin * CBR, do not touch *All body fluids danger
* No pregnant nurse * Flushing concern
*Diet: Low residue
*Room: Away from station

SUPERIOR VENA CAVA SYNDROME:

- most often associated with lung cancer (bronchogenic)
- dyspnea- initial feature
- dilated tortuous vein on chest
- edema of face
- PEMBERTON’s Sign: facial flushing with elevated JVP and
distended vein in the chest
TX:
Steroids
Furosemide
Radiation therapy

TUMOR LYSIS SYNDROME

- breakdown of the cellular components of dying
cancer cells after treatment
- common in leukemia and lymphoma
*Hyperkalemia
*Hyperphosphatemia
*Hyperuricemia
*Hypocalcemia

CHEMOTHERAPY
A. Alkylating agent Damage The DNA Cyclophosphamide
Chlorambucil
B. Platinum drugs Binds to DNA Cisplatin

C. Antibiotics Inhibit synthesis of DNA Bleomycin

Doxorubicin (Adriamycin)
D. Mitotic inhibitor Interfere with mitosis Paclitaxel

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 E. Antimetabolites Blocks purine metabolism Methotrexate
5- FU
Vesicant: causes tissue necrosis and breakdown if extravasated
Irritants: causes sclerosis and inflammation of vein but no necrosis if extravasated

Sit. 8: Donna a 40 year old patient was diagnosed with breast cancer and is undergoing various treatment for her
condition.

36. The nurse is teaching self breast examination and puts a folded towel under the left shoulder of the patient to be
examined for the procedure for the reason of
a. To make the left shoulder nearer to the hands of the examiner for palpation
b. To make the pectoralis muscle prominent toning the breast tissue for better palpation
c. To put the breast in a more lateral position to better ease the palpation
d. To balance and spread the breast tissue thus easing palpation

37. The nurse is teaching the sisters of Donna about mammography, the nurse tells them correctly that
a. The examination will takes about 1 hour
b. Avoid the use of deodorant and powders on day of the test
c. There is no discomfort associated with the procedure
d. Maintain an NPO status 6 hours prior to the procedure

38. Donna’s tumor is said to be estrogen receptor positive (ERP). The nurse knows that ERP tumor is
a. Good indicator of the possibility of breast reconstruction
b.Good indicator in giving estrogen replacement therapy to reduce tumor size
c. Indicator that patient might respond to Tamoxifen
d. Indicator that metastasis has already occurred

39. Donna is taking Adriamycin together with Tamoxifen. The nurse knows that Tamoxifen works by
a. Inhibiting DNA syntesis c. Preventing folic acid synthesis
b. Changing osmotic gradient of cell d. Increases cell wall permeability

40. Donna underwent mastectomy and 3 weeks after surgery on follow up the nurse found out that she loves
gardening. You should discourage her of handling:
a. Roses b. Chrysanthemum c. Orchid d. Dahlia

Sit. 9: Mr. Ferrero is a 57 year old patient is admitted to the medical unit for progressive symptoms of dyspnea on
exertion and decreased appetite, and is scheduled for pulmonary function testing. The nurse is caring for him and
prepares him for the examination.

41. The result showed non small cancer of the lungs and has a small pleural effusion that affects his respiratory
function. The doctor performs a thoracentesis in the patient’s room. Which post-procedure symptom will the nurse
report immediately to the doctor?
a. Complaint of productive cough ` c. Chest tightness
b. Heart rate of 73 beats/min d. Respiratory rate at 16 breaths/min

42. External radiation to the chest following surgery was done for Mr. Ferrero. he tells the nurse that he is so tired he
can hardly get up in the morning. Which of the following intervention is an appropriate goal for the patient?
a. Eliminate all unnecessary activities until radiation is completed
b. Establish a daily walking program
c. Consult with the doctor regarding situational depression
d. Begin rigorous aerobic exercise several times a week

43. In preparing for Mr. Ferrero for external beam radiation, the nurse should instruct him
a. Not to wash away any marks that the radiologist makes on his skin
b. About all the side effects he might experience
c. That he must stay in his own room after the treatment has begun
d. How to keep a bandage on the irradiation site

44. The nurse is monitoring Mr. Ferrero for signs and symptoms related to superior vena cava syndrome. Which of the
following is an early sign of this oncological emergency?
a. Cyanosis c. Arm edema
b. Periorbital edema d. Change in mental status

45. Mr. Ferrero with carcinoma of the lungs develops SIADH as a complication of the cancer. The nurse will anticipates
which of the following will be prescribed?
1. Chemotherapy 3. Radiation
2. Increase fluid intake 4. Serum sodium levels
a. 1 and 3 b. 1,2 and 3 c. 1,3 and 4 d. 1,2,3 and 4

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Sit. 10: Ambrosia, 50 years old was transported to the Operating Room for Total Abdominal Hysterectomy after
having profuse vaginal bleeding for the past three weeks. She was diagnosed to have dysfunctional uterine bleeding.

46. Appropriate preoperative teaching for a patient scheduled for abdominal surgery includes
a. Care for the surgical incision c. Methods for deep breathing and coughing.
b. Medications used during surgery d. Ccmplete all ordered antibiotics after surgery

47. The surgeon uses electrosurgical equipment to cauterize blood vessels. Which of the following nursing activity
should have been done by the circulating nurse to ensure safety?
a. Correctly drape electrocautery cable and cord
b. Electrocautery equipment is placed appropriately at the back of surgeon
c. Grounding pad is connected to grounding cable properly place under buttock of patient
d. Electrocautery pencil is made easily available each time the surgeon uses it

48. The surgeon passed the specimen to the scrub nurse. Which of the following is the correct action of the scrub
nurse?
a. Place specimen in basin moistened with saline solution c. Wrap specimen with surgical sponge
b. Wipe specimen with sponge d. Pass the specimen to the circulating nurse

49. The surgeon tells the scrub nurse that the procedure done was Total Abdominal Hysterectomy with bilateral
Salphingo-oophorectomy. The scrub nurse understands that the specimen she received would consist of which of the
following organs?
a. Right and left ovaries, uterus and fallopian tube
b. Uterus,fallopian tube, ovary and urinary bladder
c. Uterus, right and left fallopian tubes and ovaries
d. Uterus, urinary bladder, two ovaries, right and left fallopian tube

50. The surgeon asked for a suture to close the peritoneum. Which of the following should have been done by the
scrub nurse before suture is handed to the surgeon?
a. Specimen passed to the circulating nurse c. Needle mounted on the needle holder
b. Needle holder passed to the surgeon d. Surgical count completed

Sit. 11: Anne, age 34, is in excellent health and is scheduled for an open reduction of a fractured femur. The general
anesthetic drugs to be used include Enflurane and Nitrous oxide.

51. Which of the following part of the central nervous system is depressed first by anesthetic agents?
a. Cerebellum c. Cerebrum
b. Medulla oblongata d. Hypothalamu

52. The circulating nurse was asked to get more instrument while the surgery was on going. Which of the following
areas in the surgical suite will the nurse be going for more instruments?
a. Central supply room c. Unrestricted area
b. Semi restricted area d. Restricted area

53. The nurse will most likely provide which of the following nursing intervention as a priority in the first stage of
anesthesia?
a. Maintain a patent airway c. Maintain a quiet environment
b. Assure sterility of the materials d. Protect patient from injury

54. Which of the following is the most dangerous complication during induction of spinal anesthesia?
a. Hyperthermia b. Tachycardia c. Hypotension d. Bradypnea

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 AREAS IN THE OR:
UNRESTRICTED: area for communication between OR personnel and families of patient
STREET CLOTHES
SEMI-RESTRICTED: area inside with access to preparation area, corridor, procedure room
SCRUBS, HEADGEAR,OR SHOES
RESTRICTED AREA: operating room located
SCRUBS and MASK

SURGICAL CONSCIENCE: an act of mental discipline built on the principles of asepsis which involved regulation of one’s
practice during surgery

Aseptic technique: prevents contamination of microorganism through the principle of contain and control

Sterile technique: comprises method by which contamination of an item is prevented by maintaining sterility

8 PRINCIPLES OF ASEPTIC TECHNIQUE

1.All items used within a sterile field must be sterile Sterile tissue CRITICAL Sterile
2. A sterile barrier that has been permeated must be or vascular
contaminated system
3. The edge of sterile wrapper are considered unsterile once

55. Which of the following characterizes the excitement phase of surgical anesthesia?
a. Occurs from administration of anesthesia to loss of consciousness
b. Loss of consciousness to the loss of lid reflex
c. Loss of lid reflex to the loss of many reflexes
d. Loss of many reflexes until respiratory collapse

ANESTHESIA Team for Intra-operative nursing

Scrub nurse:
General Anesthesia Regional anesthesia S: __Service the surgeon
C: __ Calculate instrument
INHALATION IV EPIDURAL SPINAL LOCAL R: __ Restore order at surgical field
U:__ Uses instrument with care
Stage of Analgesia: B:__ Brings and prepares instrument

Stage of Excitement Circulating Nurse

C: __ Coordinates with the OR team
Stage of Surgical anesthesia: I: __ Inspect all equipments
R:__ Records at the nurses notes
Stage of Medullary Response C:__ Counts the instrument with the nurse
L:__ Linkage with the family
E:__Ensure positioning

Sit. 12: Leah was rushed to the emergency room with extensive burns due to accidental industrial spill on her leg and
trunk.

56. The nurse assesses the patient for fluid shifting. Fluid shift that occurs during the emergent phase of a burn injury
are caused by fluid moving from
a. Vascular to the interstitital space c. interstitial to the vascular space
b. extracellular to the interstitial space d. extracellular to the intracellular space

57. Which of the following electrolyte imbalances is expected during the acute phase of burns?
a. Hyperkalemia b. Hypernatremia c. Hyponatremia d. Hypocalcemia

58. Which of the following activities should the nurse include in the plan of care for Leah with burn injuries to be
carried out about thirty minutes before the daily whirlpool bath and dressing changes?
a. Remove the dressing c. Soak the dressing
b. Administer an analgesic d. Slit the dressing with blunt scissors

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 59. Leah asks the nurse what the word eschar means. Which of the following description by the nurse defines an
eschar?
a. Scar tissue in a developmental stage c. Visible living tissue with a rich blood suppl
b. Burned tissue that has become infected d. Crust formation without blood supply

60. After the initial phase of the burn injury, the patient’s plan of care will focus primarily on
a. Maintain positive self-concept c. Preventing infection
b. Promoting hygiene d. Care on the skin grafting

Emergent Phase Acute Phase Rehabilitation

Fluid shift
BP
Hematocrit
Urine output
Blood pH
Serum Na
Serum K

61. Frank has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this patient?
a. Do not allow the client to ingest fluids.
b. Encourage the client to drink at least 500 ml of water each hour.
c. Request the central supply department to send supplies for straining urine.
d. Administer an opioid analgesic as prescribed

62. In addition to nausea and severe flank pain, Frank with renal calculi complains of pain in groin and bladder. The
nurse should determine that these symptoms most likely result from which of the following?
a. Nephritis c. Urine retention
b. Referred pain. d. Additional stone formation.

63. After an intravenous pyelogram (IVP), the nurse should anticipate incorporating which of the following measures
into the client's plan of care?
a. Maintaining bed rest. c. Assessing for hematuria.
b. Encouraging adequate fluid intake. d. Administering a laxative.

64. The nurse teaches the patient who has cystitis methods to relieve his discomfort until the antibiotic takes effect.
Which of the following responses by the client would indicate that she understands the nurse's instructions?
a. I will place ice packs on my perineum. c. I will drink a cup of warm tea every hour
b. I will take hit tub baths d. I will void every 5 to 6 hours.

65. . Veronica with cystitis is given a prescription for Phenazopyridine hydrochloride (Pyridium). The nurse should teach
the client that this drug is used to treat urinary tract infections by:
a. Releasing formaldehyde and providing bacteriostatic action.
b. Potentiating the action of antibiotic.
c. Providing an analgesic effect on the bladder mucosa.
d. Preventing the crystallization that can occur with sulfa drugs

66. Jodi was admitted to the hospital because of decrease urine output and peri-orbital edema is diagnosed with acute
poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority?
a. Assessing vital signs every 4 hours. c. Obtaining daily weight measurements.
b. Monitoring intake and output every 12 hours d. Obtaining serum electrolyte levels daily.

67. When developing the plan of care for Jodi with acute glomerulonephritis who has a fluid restriction of 1,000
ml/day, which of the following fluids should the nurse consider as most appropriate for the client's condition and
effective for preventing excessive thirst?
a. Diet cola b. Ice chips c. Lemonade d. Tap water

68. The urinalysis of Mang Ruben’s son diagnosed with nephrotic syndrome reveals +4 for protein. The nurse interprets
this result as indicating which of the following?
a. Decreased secretion of aldosterone.
b. Increased glomerular permeability to albumin.
c. Inhibited tubular reabsorption of sodium and water.
d. Loss of red blood cells in the urine.

69. Mang Ruben asks the nurse what can be done about the child's swollen eyes. Which measure should the nurse
suggest?
a. Applying cool compresses to child's eyes. c. Applying eye drops every 8 hours.
b. Elevating the head of the child's bed. d. Limiting the child's television watching.

70. . Which of the following urinary symptoms is the most common initial manifestation of acute renal failure?

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a. Dysuria b. Anuria c. Hematuria d. Oliguria

71. Mr. Garduque’s serum potassium level is elevated in acute renal failure, and the nurse administers sodium
polystreyene sulfate (Kayexalate). This drug acts to:
a. Increase potassium excretion from the colon. c. Increase calcium absorption in the colon.
b. Release hydrogen ions for sodium ions. d. Exchange sodium for potassium ions in the colon.

72. In the oliguric phase of acute renal failure, the nurse would anticipate the development of which of the following
complications?
a. Pulmonary edema. b. Metabolic alkalosis c. Hypotension d. Hypokalemia

73. JC was scheduled on peritoneal dialysis. The dialysis solution is warmed before use in peritoneal dialysis primarily
to:
a. Encourage the removal serum urea c. Add extra warmth to the body
b. Force potassium back into the cells d. Promote abdominal muscle relaxation

74. The nurse is aware that the dialysate for peritoneal dialysis contains
a. Electrolytes in equal concentration to blood
b. Glucose in higher concentration with blood
c. Sodium in a higher concentration with blood
d. Potassium in lower concentration with blood

Inflammatory Glomerulonepritis ___________________ ____________________

Nephrotic syndrome ____________________ _____________________
Cystitis ____________________
_____________________

KIDNEY Obstructive Nephrolithiasis __________________ ____________________

Hydronephrosis

Functional RENAL FAILURE Diet: Low protein diet

Electrolyte control
Fluid control
Dialysis

75. The patient underwent transurethral resection of the prostate (TURP), and a large three-way indwelling urinary
catheter was inserted in the bladder with continuous bladder irrigation. In which of the following circumstances should
the nurse increased the flow rate of the continuous bladder irrigation?
a. When drainage is continuous but slow
b. When drainage appears cloudy and dark yellow
c. When drainage becomes bright red.
d. When there is no drainage of urine and irrigating solution

DISABILITY/IMMOBILITY
Illness itself
Adverse effect of treatment
General effect of deconditioning

CVS effect Respiratory effect Skin Musculoskeletal

-Increase workload of heart -Impaired lung expansion- Pressure ulcers - Muscle atrophy
-Orthostatic hypotension - Stasis of secretions - Demineralization
-Thrombus formation - Oxygen and CO2 imbalance - Contractures

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 Fracture: a break in the continuity of the bone

Open Fracture Close Fracture

I:
________________________________________________________________
_
C:
________________________________________________________________
E:_______________________________________________________________
__
T:_______________________________________________________________
__
E:_______________________________________________________________
__
A:_______________________________________________________________
__

Sit. 13: Martin had never been seriously ill in his life when he fell on ice and broke his leg. He was in great pain when
he was brought to the hospital.

76. Which of the following nursing measures should be carried out before moving Martin to the orthopedic ward from
the emergency room?
a. The splint should be reapplied to his right leg
b. Tourniquet should be place under his leg
c. An ace bandage should be applied to reduce swelling
d. Ice bag should be applied to the fracture site

77. In the ward, a Buck’s extension traction was applied and the doctor would provide countertraction by
a. Applying head halter and attached weight c. Placing sandbags across the upper thigh
b. Suspending the hips in a pelvic sling d. Elevating the foot of the bed on blocks

78. Which of the following is most apt to predispose Martin to peripheral vascular problems while on traction?
a. Circulation in the blood of toxins released from necrotic tissues
b. Increased deposition of fatty substance between the vessel lining
c. Decreased formation of blood cells due to bone marrow destruction
d. Stasis of blood in the legs due to lack of muscular contraction

79. While talking to the nurse, Martin asks certain stuffs on healing. Based on the nurse’s understanding of the
physiology of bone and cartilage, the injury that the nurse would expect to heal most rapidly is
a. Fracture of the midhumerus c. Fractured nose
b. Torn knee cruciate ligament d. Severely sprained ankle

80. Martin develops compartment syndrome. When caring for him the nurse would be alert for which of the following
signs of organ failure?
a. Rales c. Jaundice
b. Dark scanty urine d. Generalized edema

Sit. 14: Jigs had sustained fracture of the femur and the bone fragments were immobilized with a Smith Peterson nail
and attached plate. After the operative incision, the doctor applied a light weight boot cast to both lower legs and
connected the cast at the ankle with a horizontal bar.

81. Meticulous care should be taken that the skin is not cut during Jig’s preoperative skin preparation, as such injury
would increase his chances of post op
a. Osteomyelitis c. Thrombophlebitis
b. Scarring d. Itchiness

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 T ____________________________________________________

R ____________________________________________________

A ____________________________________________________

C ____________________________________________________

T ____________________________________________________

I ____________________________________________________

O _____________________________________________________

N ____________________________________________________

82. How much time is required for plaster of Paris to set?

a. 15 minutes c. 24 hours
b. 8 hours d. 1 hour

83. Immediately after Jig has been returned to his room, the nurse should make sure that
a. Cast edges are bound with adhesive
b. All toes on both feet are visible
c. Caked plaster is washed off his skin
d. Cast is immobilized with sand bags

84. A client with a fracture tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse
indicates an understanding of a plaster-of-Paris cast? The nurse:
a. Handles the cast with fingertips c. Petal the casr
b. Dries cast with hair dryer d. Bear weight after 24 hours

85. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which
response would be best?
a. It is all right for your friends to sign the cast
b. It can weaken the cast because it is made of plaster
c. If they don’t use chalk to autograph, it is okey
d. Writing in any form on the cast can be damaging

Sit. 15: Jaime is a 43 year old man who has been rushed to the ER with an acute attack of gouty arthritis. He had
admitted to the nurse of having a drinking spree with his officemates the night before the admission.

86. Jaime was in severe pain because of sudden onset of severe pain and inflammation of great toe. A definitive
diagnosis of gouty arthritis is made on the basis of what?
a. Family history of gout c. Elevated serum uric acid
b. Urate crystals in synovial fluid d. Elevated uric acid level

87. On assessment which of the following findings is expected for Jaime with gouty arthritis?
a. Unilateral swelling and involvement c. Symmetrical affectation of joints
b. Atrophic nails and fingers d. Tenderness on weight bearing joints

88. To limit painful attacks, which food should the nurse teach Jaime to avoid?
a. Milk and cheese c. Hard boiled eggs
b. Salmon and milkfish d. Pancakes and spring roll

89. Which of the following medications should Alfredo with gout be encouraged to avoid to prevent gouty attacks?
a. Acetaminophen c. NSAID
b. Aspirin d. Narcotics

90. Upon discharge, the doctor prescribed Alfredo with Allopurinol to lower his blood uric acid level. While taking the
drugs which of the following measures by the nurse will be questionable?
a. Taking the activities of daily living in slow progression
b. Encouraged daily exercise and swimming
c. Check the skin for any tophaceous growth
d. Ensure adequate intake of fruits such as mango and guavas

Sit. 16: Miho is a 60 year old post menopausal woman who has pain in motion in her fingers and asks the nurse
whether this is just the result of aging process.

91. What is most likely the cause of pain experienced in the later stage of osteoarthritis?

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a. Bouchard’s node c. Heberden’s node
b. Crepitation d. Surfaces of bone rubbing together

92. Which description is most characteristic of osteoarthritis when compared to other arthritis syndrome?
a. Not systemic or symmetrical c. Most common in women
b. RF factor is positive d. Morning stiffness lasts for several hours

93. Miho was scheduled for a bone density scan. To plan for the patient’s test, the nurse should tell the patient
a. Tell Miho to report any significant pain to her doctor two days before the exam
b. Request to remove all metal objects on the day of the scan
c. Instruct to have a high calcium diet few days before the exam
d. Infrom Miho she will need to ingest 500 mg of calcium for two weeks

94. To preserve function and the ability to perform activities of daily living (ADLs) what should the nurse teach the
patient with OA?
a. Avoid exercise that involves the effected joints
b. Plan and organize task performance to be less stressful to joints
c. Maintain normal activities during an acute episode to prevent loss of function
d. Use mild analgesics to control symptoms when performing tasks that cause pain

95. Miho underwent knee replacement surgery when her osteoarthritis becomes severe. Post operatively, which of the
following intervention will the nurse include in her plan of care?
a. Immobilize the affective leg c. Begin passive range of motion exercises
b. Avoid placing leg in flexion d. Monitor for paresthesia and pallor

Sit. 17:Nurse Carlo was immediately hired as an ER nurse in a tertiary facility of Danao City and was immediately
placed on orientation for the first weeks. He was assigned to do assessment of several patients with neurological
problems.

96. While Nurse Carlo is performing an admission assessment on a newly admitted patient, the patient states “I am
very unsteady on my feet”. Which of the following will Nurse Carlo perform to evaluate patient’s statement?
a. Perform assessment to evaluate cerebellar function
b. Test the patient’s intellectual functioning by asking general knowledge questions
c. Assess the patient for two point discrimination
d. Test ocular fields to confirm any visual problems

97. Nurse Carlo is testing the patient’s ability to recognize familiar objects. When the nurse place a coin in the patient’s
hands, the patient correctly identifies the object. How would Nurse Carlo document this finding?
a. Hyperesthesia b. Stereognosis c. Astereognosis d. Apraxia

98. Nurse Carlo is aware that a positive triceps reflex when he describes this as which of the following?
a. Fanning of the fingers c. Adduction of the arm
b. Adduction of the arm d. Extension of the forearm

99. To test the seventh cranial nerve, what is the most appropriate assessment for Nurse Carlo to conduct?
a. Direct and consensual pupillary reaction to light
b. Corneal reflex by touching cornea with wisp of cotton
c. Having patient clenched teeth
d. Vision by using a Snellen’s chart

100. Nurse Carlo has just assessed a patient who has Glasgow coma scale score of 7. He will conclude that the patient
has which status?
a. Awake and oriented c. Arousable
b. Lethargic d. Unresponsive

Sit. 18: An unknown truck driver sustained an acute head injury while traversing Highway 54 towards the province of
Camarines. He was brought unconscious at the emergency room and was monitored for possible herniation of the
brain

101. On admission, the Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse will
anticipate the need to
a. Type and crossmatch blood for transfusion c. Administer IV furosemide
b. Immediate surgery d. Giving of barbiturates for pain

102. The nurse is aware for potential for seizure for the patient with increased intracranial pressure. The best nursing
measure that a nurse could do will be
a. Admistering pain medication for relief fo head ache
b. Maintain patient on strict bed rest with head elevated
c. Keeping the room quiet and darkened to minimize stimulation

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d. Controlling fever with prescribed cooling techniques

103. Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a
head injury. To evaluate the effectiveness of therapy, the nurse should
a. Monitor oxygen saturation c. Monitor intracranial pressure (ICP)
b. Check arterial blood gases d. Assess patient breath sounds

104. The doctor prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine that the
medication is effective
a. Seizure behavior is reduced c. Increase in urine output
b. Increase level of consciousness d. Abnormal EEG readings

105. Patient’s condition did not improve hence a supratentorial craniotomy was done for decompression. The nurse
should provide which of the following in the unit after returning from surgery?
1. Bed with side rails 3. Tracheostomy set 5. Hypothermia blanket
2. Suction machine 4. Canvas restraint

a. 1,2,3 b. 1,3,5 c. 2,4,5 d. 2,3,5

Head Injury:
Assessment: “change in the LOC”
otorrhea, rhinorrhea
Skull fracture: Battle’s sign, raccoon’s eye
Epidural hematoma ________________________
Subdural hematoma ________________________
Subarachnoid bleed ________________________

Best Position: Elevate the head

Neuro check for ICP signs
Avoid injury
Mannitol
Dexamethasone

Sit. 19 A 17 year old nursing student was admitted in the hospital because of convulsion 6 hours ago. A week ago
the child had been having on and off cough and low grade fever. On examination, nurse observes nucchal rigidity.

106. In assessing a patient with suspected meningitis, the nurse is aware that nucchal rigidity as the hallmark sign of the
disease is due to
a. Virulence of the microorganism c. Irritation of the meninges
b. Infiltration of the brainstem d. Bacterial toxins released

107.If patients will be admitted the nurse is aware of possible means of preventing the spread of infection by wearing
which of the following
a. Gowns, mask and goggles c. Gowns and mask
b. Gloves, gowns and masks d. Masks and gowns

108. To confirm the diagnosis, the doctor performed lumbar puncture. The result that would indicate that the cause of
the disease is more of bacterial in origin would be
a. Increased pressure, glucose and protein
b. Increased pressure, protein and decreased glucose
c. Increased protein, low glucose and pressure
d. Cloudy CSF, increased protein and glucose

109.In managing the admission of the meningitic patient, the nurse will prepare which of the following rooms?
a. Private room near the station c. Private room with good ventilation
b. Private room with air filter d. Private room away from the station

110. Primary importance in the care of a meningitis patient is

a. Administration of antibiotic c. Institute seizure precaution
b. Reduction of environmental stimuli d. Nutritional support

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 Meningitis- most often due to bacteria
- hematogenous spread, adjacent spread (look at the ears)

Key Signs: Fever, altered LOC and signs of meningeal irritation

Brudzinski sign: neck sign Kernig’s sign: leg sign
Signs of increased ICP

Lumbar puncture: High opening pressure, Cloudy CSF and High protein
and low CSF
Nursing: Room- dimly lighted, quiet

Tx: Antibiotic

Sit. 20: Tirso accidentally fell during a rock climbing activity organized by his social club. He was immediately brought
to the hospital alert and conscious but unable to move his arm and legs on command. The nurse suspect of spinal
cord injury.

111. When planning to move a person with possible spinal cord injury,which of the following would be a priority
concern?
a. Wrapping and supporting the extremities which can be easily injured
b. Moving patient gently to help reduce pain
c. Immobilizing the head and neck to prevent further injury
d. Cushioning the back with pillows to ensure comfort

112. When Tirson has a cord transection at T4, which of the following is the primary focus of nursing assessment?
a. Vascular status c. Renal status
b.Gastrointestinal function d. Biliary function

113. The nurse is planning to teach Tirso with SCI and intermittent NGT suctioning about interventions to protect his
integumentary system. Which of the following should the nurse include?
a. Eat enough calories to maintain desired weight
b. Stay in cool environment to avoid sweating
c. Stay in warm environment to avoid chilling
d. Eat a low sodium food to avoid edema

114. Which of the following should the nurse use as the best method to assess for the development of deep vein
thrombosis in a patient with spinal cord injury?
a. Homan’s sign c. Tenderness
b. Pain d. Leg girth

115. During the period of spinal shock, the nurse would expect Tirso’s bladder function to be which of the following?
a. Spastic c. Atonic
b. Normal d. Uncontrolled
Spinal Cord Injury
Assessment: know the levels of injury
Cervical
Thoracic
Lumbar/Sacral

Spinal shock- loss of neurogenic tone

Myelogram- gold standard test Autonomic dysreflexia- excessive SNS stimulation

Oil based dye-
Water based dye-
Air-

Sit. 21: : A volunteer nurse from Red Cross finds a victim under a wreckage of a collapsed house in Marikina. The
patient is conscious and breathing satisfactorily and lying on back complaining of back pain.

116. On assessment the nurse observe inability to move the legs. Which of the following actions should the nurse take
first?
a. Leave him with instructions not to move and seek additional help
b. Roll the patient on his abdomen, place a pad under the head and cover him
c. Gently raised him to a sitting position to check whether the pain intensifies or diminish
d. Gently lift him and place on flat piece of lumber and bring to hospital

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 117. The patient was brought to the hospital and was noted to have paraplegia. The nurse assesses for which major
problem he may experience in the early recovery period?
a. Bladder control c. Quadriceps setting b. Nutritional intake d. Use of aids for ambulation

118. To prevent the development of contractures, what should the nurse include in the care plan for this patient?
a. Deep massage c. Use of tilt board
b. Active exercise d. Proper positioning

119. The patient underwent cervical laminectomy. When caring for him, the nurse should
a. Place head in flexed position
b. Added responsibility of removing oral secretions
c. Keep the patient’s bed at a 45 degree angle continuously
d. Turn the patient as a unit

120. What is the reason the nursing care plan should include turning the patient every 1-2 hours?
a. Prevent pressure ulcers c. Prevent flexion contractures
b. Keep patient comfortable d. Improve venous circulation on legs

SEIZURE DISORDERS HEADACHES

Priority: Safety of the patient Priority: Pain control
Test: EEG (Electroencephalography) A: Avoid foods that causes the attack
A: Avoid stress B: Bed rest
B: Blood levels C: Create a diary
C: Compliance D: Drug regimen
D: Drug regimen

Sit. 22: Mang Edgar has a history of hypertension for an unspecified number of years. He
doesn’t take any medication. A few days ago, he started to have some weakness on the right side of the body
prompting consult.

121. Mang Edgar who has weakness on the right side and impaired reasoning had most likely had the CVA in the
a. Left hemisphere of the cerebrum c. Left cerebellum
b. Right hemisphere of the cerebrum d. Right temporal lobe

122. The nurse is aware that pneumonia is the most frequent cause of death after a stroke. The intervention that would
be contraindicated in the acute care of a patient with hemorrhagic stroke is to
a. Thicken liquids to ease swallowing and prevent aspiration
b. Change position every 30 to 60 minutes
c. Maintain adequate fluid intake, orally or IV
d. Encourage forceful coughing to stimulate deep breathing

123. In assessing Mang Edgar’s affective domain, the nurse should ask questions about which of the following items?
a. Dietary preferences c. Preconceptions about stroke
b. Educational backgroundd. Religious affiliation

124. Mang Edgar who had a stroke needs to be fed. What instructions should you give to a nursing student who will
feed the patient?
a. Suction secretions between bites of food
b. Feed the patient quickly because there are more waiting
c. Check the patient’s gag and swallowing reflex
d. Position the patient sitting up in bed before feeding him

125. The nursing student caring for Mang Edgar ,who subsequently develops right hemisphere stroke, is giving physical
care. Which of the following requires intervention?
a. The student instructs Mang Edgar to sit up straight
b. The student moves the tray to the right side of overbed tray
c. The student assist Mang Edgar with passive range of motion
d. The student combs the left side of the hair when Mang Edgar combs only right side

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 Stroke – alteration in blood supply to the brain

TIA- may be due to clot or embolus < 24 hours

Hemorrhagic stroke- due to aneurysm rupture

Acute phase: ABC

Rehabilitation:
Hemiplegia- prevent flexion deformity
Homonymous hemianopsia- scanning
Anterior cerebral artery- anteromedial Aphasia- alternative form of communication
Middle cerebral artery- lateral Dysphagia- check the gag reflex
Posterior cerebral artery- posterior/inferior

Sit. 23: Mrs. Mryna a clinical instructor has cerebrovascular accident. Upon admission in the medical ward, she is
unconscious with left-sided paralysis.

126. In assessing the level of her consciousness, the nurse should determine the:
a. Degree of paresis c. Response to stimuli
b. Extent of paralysis d. Reaction to light

127. When you took the blood pressure, petechiae was noted on Myrna’s skin. This is a manifestation of which possible
deficiency:
a. Niacin b. Iron c. Vit. B6d. Vit. C

128. If Myrna’s condition resulted to aphasia, one of the following would be your appropriate nursing care:
a. Try to anticipate her needs
b. Limit verbal communication
c. Wait for her to verbalize what she need
d. Encourage her to accept her present situation

129. Initially, heparin rather than dicumarol is ordered because heparin:

a. Is much cheaper when purchase
b. Has a slow rapid onset of action
c. Has a more rapid onset of action
d. Does not interfere with prothrombin formation

130. As her condition deteriorates, she becomes more irritable and unpleasant everyday. Your appropriate nursing
action is to:
a. Provide her conducive environment with less noise and activity
b. Allow her to express her hostility
c. Provide diversional activities
d. Allow her to socialize with other patients, so she will forget her ailment

Sit. 24: Phillip is a newly registered nurse who was hired to work in a nursing home in their area. He was assigned to
take care several patients with problems on the peripheral nervous system.

131. Phillip is aware that which of the following symptoms is associated with Guillain Barre syndrome?
a. Tinnitus c. Diplopia
b. Vertigo d. Nausea

132. The procedure used in the management of patient with GBS that could reduce length of hospitalization is
a. Electrophoresis c. Diaphoresis
b. Plasmapheresis d. Diapedesis

133. Phillip is caring for a patient with myasthenia gravis. Which of the following is a significant finding he would expect
from the patient?
a. Decreased DTR in lower extremities
b. Decrease ability to discern the colors red and green
c. Voice become softer with conversation
d. Able to sit in chair with safety belt applied

134. Which of the following interventions for a patient with myasthenia gravis may be included by Phillip in his care
plan?
a. Discourage independence in ADL c. Patching eye alternately everyday
b. Provide assistance to reduce frustration d. Asking the patient to repeat when not understood

135. Which of the following findings is associated with Bell’s palsy?

a. Face mask like and sagging on one side c. Eyes close tightly agains resistance
b. Excessive tearing of the eyes d. Oral mucous membrane dry

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Disease Parkinson’s Multiple Sclerosis Myasthenia gravis Guillain Barre syndrome
Defect Lack of dopamine Demyelination Low acetylcholine Demyelination
Earliest/Hallmark Penmanship changes Ptosis Clumsiness

Test Clinical LP and EMG Tensilon test Clinical

Drugs Levodopa Steroids Anticholinesterase Supportive
Carbidopa Interferon

Sit. 26: Ayn is working in a n ambulatory clinic who caters to patients with visual and auditory problems. She had
been working in the area for almost three years.

135. Part of her job is teaching patients on prevention of accidental eye injuries in the community setting. Which of the
following is the most important thing to stress?
a. Follow workplace policies in handling chemicals
b. Children and parents should be cautious about aggressive play
c. Wear protective eyewear during sports and hazardous work
d. Establish emergency eyewash station in any workplace

137. During teaching session, an old woman asked about information regarding stye or hordeolum on the right upper
eyelid. Ayn tells her it is best to manage it first by
a. Apply warm compress c. Obtain prescription of antibiotic drops
b. Gentle hygienic eyelid scrubs d. Call the doctor immediately

138. In eyedrop administration, Ayn teaches them to perform the following steps in which correct order?
1. Have client gently close eyes and move it around
2. Gently press lacrimal duct for a minute
3. Expose lower conjunctiva by pulling gently downward
4. Have the client look up while giving the drops
a. 3,1,2, 4 b. 3,1,4, 2 c. 2,4,1,3 d. 1,2,3,4

139. Which physical assessment findings should be reported by Ayn to the doctor?
a. A cone of light in the innermost part of the tympanic membrane
b. Bulging red or blue tympanic membrane
c. Dense whitish ring at the circumference of the tympanum
d. Pearly gray tympanic membrane

140. Ayn is reviewing understanding of a patient who underwent stapedectomy few days ago. Which comment
concerns you the most?
a. “ I will have swimming lessons in a couple of months”
b. “ I have to take overseas flight next week to visit my son”
c. “I have been coughing a lot with open mouth”
d. “ I turn down the volume of radio and TV in the house”

1. Blepharitis Eyelid inflammation Warm moist compress

2. Hordeolum Sweat gland swelling Warm compress with antibiotics
3. Conjunctivitis Swollen conjunctiva Hygiene and antibiotics
4. Cataract Progressive blurred vision Surgery, Mydriatics
5. Glaucoma Eye pain with halos Acetazolamide,BB, Surgery, Miotics
6. Retinal detachment Loss of vision Scleral buckling
7. Macular degeneration Central blindness Supportive, LASIK
8. Meniere’s disease Tinnitus,Hearing loss,Vertigo Low salt, anti vertigo
9. Otosclerosis hearing loss Stapedectomy

TESTING visual ACuity:

Snellen Chart
PIn hole test
Counting fingers test
Hand movement
Light perception

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Sit. 26:Communication is the fundamental element of nurse-patient relationship. It is a mechanism for
demonstrating compassion and caring. The nurse must be able to communicate clearly and accurately in order for
the patient’s needs to be met, hence an intact sensori-neural functioning is a must.

141. Mr. Wency 67 years old had been admitted due to detached retina. He asks Nurse Roselle what may have
contributed to the development of his detached retina. The nurse most apt reply is due to
a. Cranial tumors c. Excess blowing of nose from sinusitis
b. Nearsightedness d. Hypertension

142. Nurse Betty is caring for Mr. Dan who has eye patches on both eyes following surgery. To avoid startling the
patient, which of the following interventions should the nurse do when entering the room during treatment and
medication?
a. Proceed to the bedside and speak louder
b. Quietly enter the room and greet the patient
c. Knock at the door and introduce yourself
d. Announce presence before entering the room

143. Lola Marta is scheduled for removal of cataract at the left eye. Before surgery the nurse is to instill drops of
Phenylyphrine into his right eye. This preparation acts in the eye to produce
a. Pupillary dilation and constriction of vessels
b. Pupillary constriction and dilation of vessels
c. Pupillary dilation and dilation of vessels
d. Pupillary dilation and congestion on the vessels

144. Which of the following should the nurse provide a part of information to prepare a patient for tonometry?
a. Medication will be given to dilate the pupils before the procedure
b. It is a painless of procedure with no adverse effect
c. Blurring of vision may occur after the procedure
d. Oral pain medication will be given before the procedure

145. Nurse Sherill is working with a patient with a moderate hearing impairment. Which of the following nursing
approaches should the nurse follow to promote communication?
a. Invite the patient in the room for privacy c. Speak louder
b. Quietly slip from behind and speak softly d. Use visible expression

Sit. 27: Mrs. Dominador developed blurring of vision and pain in the eyes. He went to her oculist to have her glasses
changed and she was diagnosed with glaucoma.

146. The nurse knows that intraocular pressure is determined by the

1. Rate of aqueous humor production by the ciliary bodies
2. Speed of blood flow through the retinal arteries and vein
3. Resistance to outflow of aqueous humor in the eye
4. Width of aperture through which optic nerve enters in the eye
a. 1 and 3 b. 1 and 4 c. 1 and 2 d. 1,2,3 and 4

147. The device used to measure intraocular pressure operates by determining the
a. Angle by which eye surface refracts light waves
b. Electrical potential of the epithelial covering of the cornea
c. Degree of corneal indentation produced by slight pressure
d. Surface tension of the fluid film covering the eye

148. In instilling medication into Mrs. Dominador’s eye, the most important precaution to be observed is to
a. Carefully check doctor’s order for medication and the label on the container
b. Maintain the sterility of the medication solution during instillation
c. Refrain from applying the solution to the central area of corneal surface
d. Ensure prolonged contact of the drug to the eye tissue by closing the lids

149. Mrs. Dominador is taking Pilocarpine a miotic agent. The nurse notes that the solution is cloudy, the nurse next
best nursing action is
a. Discard the drug it may have undergone chemical reaction
b. Advise to buy fresh container of pilocarpine solution
c. Observe the patient in administration of drug for possible source of contamination
d. Tell her to close tightly the container and protect from light

150. What should the nurse do in administering Pilocarpine?

a. Administer at bedtime to prevent night blindness
b. Apply pressure on the outer canthus of the eye to reduce adverse effects
c. Apply pressure on the inner canthus of the eye to reduce systemic effect
d. Flushing of eye to reduce the burning sensation from the drug

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 TIME OUT for some COMMUNICABLE DISEASESE

Disorder Other Name Hallmark Diagnostic test Drug of choice

Tuberculosis Koch’s disease Weight loss with hemoptysis Sputum exam RESPI
(Multidrug therapy)
Meningitis Spotted fever Brudzinski/Kernig’s sign
Scarlet fever Dick test
Measles Rubeola Clinical
German measles
Varicella Acyclovir
Herpes zoster
Diphtheria Klebs-Loeffler
Pertussis Cough and cyanosis
Isolation: Droplet and airborne precaution

CD on 5 F (FINGERS, FECES, FLY, FOOD, FOMITES)

Thyphoid fever Salmonella thypii Rose spots Widal test Chloramphenicol
Cholera Rice watery stool
Food poisoning Staph
Food poisoning Clostridium
Poliomyelitis
Amoebiasis
Bacillary dysentery
Ascariasis Intestinal Mebendazole
obstruction
Hookworm Anemia Mebendazole
Pinworm Rectal pruritus Mebendazole
Whipworm Rectal prolapse Mebendazole

BLOOD BORNE COMMUNICABLE DISORDER and its RELATIVES

Malaria Plasmodium mosquito Cold-hot-wet BSMP Chloroquine

stage
Tetanus Clostridium - Clinical
Schistosomiasis Schistososoma Snail Swimmer’s itch
japunicum
Rabies Rhabdovirus
Dengue fever Flavivirus
Leptospirosis Leptospira specie
Filiriasis Wuchereria bancrofti DEC

Leprosy Mycobacterium
leprae

BIOLOGIC DISASTERS

1. Anthrax – small black eschar leading to death

2. Botulinum- dyspnea, flaccid paralysis
3. Plague- from bite of rat causing hemoptysis, LAD
4. Smallpox- fever, pustules and scabs
5. Tularemia- non healing wound, pneumonia
6. Ebola virus- DIC
7. SARS- fever and respiratory arrest
8. MERS-CoV- exposure from camel

Key: know the antidote

PRACTICE MAKES PERFECT:

_____1. Spider Bite A. Use of tape to remove hair
_____2. Tick bite B. Remove it by tweezer
_____3. Snake bite C. Remove constrictive garments
_____4. Jellyfish sting D. Apply with acetic acid
_____5. Scorpion bite E. Monitor blood pressure

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 _____6. Bee sting F. Swipe with credit card

SUMMARY OF PEDIATRIC DISORDERS and Key POINTS

Disorder Assessment Key point

Hydrocephalus A- Anterio fontanelle bulging Assess for signs of increased ICP
B-big head circumference
C- cracked pot sound Prepare for VP shunt
Cry that is shrill
Meningitis Fever Isolation for 24 hours
Brudzinski sign Seizure precaution
Kernig’s sign Antibiotics
LP= Cloudy CSF,low glucose,high
protein
Spina bifida Protruding sac Cover sac with sterile moist dressing
Best position: Prone
Monitor early signs of infection
Cerebral palsy Stiff arms and legs Reducing deformity and protect from injury
Reye’s syndrome Viral illness + Aspirin use Seizure precaution and ICP monitoring
Kawasaki disease Red tongue, fever,conjunctivitis Monitor fever
Cracked lips Never give steroid
Immunoglobulin
Tetralogy of fallot Blue spells or tet spells Surgery
Clubbing of fingers
Squatting when hypoxic
Patent ductus arteriosus Machinery like murmur Indomethacin

Coarctation of aorta High BP in upper extremity, Surgery

weak pulses in lower extremity
Transposition of great vessels Cyanotic at birth Surgery
Laryngotracheobronchitis Seal bark or brassy cough Cool air vaporizer or cool night air
(CROUP) retractions Use of racemic epinephrine
Use of Heliox reduce work of breathing

Epiglottitis Drooling of saliva Avoid visualization of posterior pharynx or oral

Tripod position temp
Do not leave the child unattended
Cystic fibrosis Thick tenacious SWEAT chloride test
sputum,intestinal obstruction, Causes fertility problem
malabsorption Monitor respiratory status
Cleft lip/palate Separation of lip on the floor of Upright position on feeding with use of special
nose nipples
Elbow restraints after surgery
Tracheoesophageal fistula Coughing NPO
Choking Supine upright position
Cyanosis on feeding
Pyloric stenosis Projectile vomiting Aspiration precaution
Olive shaped mass in epigastric
area
Celiac disease Steatorrhea No BROW, with ADEK supplementation
Diarrhea Read food labels carefully
Hirschprung’s disease Ribbon like stools Surgery by colostomy
Abdominal distention
Intussusception Currant jelly stool Monitor for peritonitis
Sausage shaped mass on Surgery
abdomen
Hemophilia Hemarthrosis No contact sports
Prolonged bleeding on tooth Immobilization and ice pack
extraction Factor 8 administration
Sickle cell anemia Painful swelling of fingers Avoid high altitude area
pallor Hydration
Pain meds but no Demerol- seizure
Von Willebrands disease Epistaxis and gumm bleeding Wear Medic alert bracelet
Leukemia Pallor, fever and bleding Protect from infection

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Acute glomerulonephritis Tea colored urine Look for sorethroat
edema Antibiotic
Nephrotic syndrome Edema and elevated cholesterol Steroids
with proteinuria Diet- high protein diet
Impetigo Honey colored crusting Contact precaution
Eczema Redness and itchiness Avoid irritants
Burrow’s solution
Scabies Nightime pruritus Permethrin overnight
Contact precaution
Pediculosis capitis Scalp scratching Permethrin
Back of ears-most K location Check other playmates and siblings
Clubfoot Forefoot adduction Treat immediately with cast
Plantar flexion
Developmental dysplasia of hips Shortening of limb Pavlik harness- flexion and abduction
Unequal gluteal folds
Limited hip abduction
Scoliosis Assymetry of ribs and flank Use of braces for 16-23 hours/day
when bending forward Skin care

MONITORING

1. Glasgow coma scale - assess LOC and neurological status

2. Braden scale - risk for pressure ulcer
3. Silverman-Anderson scoring – assess respiratory status of premature baby
4. Ballard scoring - physical and neurological status of baby
5. Baker and Wong scoring - for pain assessment
6. Denver scoring - screening and cognitive problem in pre schoolers

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