exam Flashcards
Urinary retention is:
a condition where your bladder doesn’t empty all the way or at all when you urinate
The patient is an 86-year-old male who is incontinent at night. An appropriate
alternative to catheterisation for this patient would be:
uridome at night
The mechanism of action of the oral laxative docusate sodium (coloxyl) is:
helps stimulate movement and soften stools
The nurse begins to suspect faecal impaction in a patient who has not passed a stool in
10 days when the patient
ado pain
- liquid stool - overflow
- malaise
- persistent urge
- bleeding-
- absent bowel sounds in LLQ
- distended lower abdomen
- tenderness on palpation
- dull sound on percussion
An elderly patient states that she is worried because she has not had a bowel movement
each day. The nurse’s best response concerning defecation patterns for elderly people
would be:
ask what usual patterns are
Ascites is defined as:
abnormal accumulation of fluid within the peritoneal cavity/ abdomen
causes swelling
What is a normal finding on palpation of the abdomen?
the abdomen is non-tender and soft with no guarding, no palpable masses felt
When inspecting a client’s abdominal contour, the nurse observes the abdomen to be
sunken with the lower edges of the ribs visible. The nurse describes and documents
this as:
concave
scaphoid
A nurse asks a patient to turn their palm down with the elbows straight. The specific
joint movement the nurse is testing for is:
pronation of the elbow
A client who presents in the medical centre with lower limb pain following a motor vehicle
accident requires a musculoskeletal assessment. When completing the assessment,
the nurse should apply all of the following principles except:
asking the client to move the joint quickly whilst applying pressure
The nurse is examining the ROM of a client’s shoulder. Which of the following is a
normal finding?
full active and painless ROM with no crepitus
bilateral equal muscle strength
You are caring for Mr Smith who has been admitted following a mechanical fall. You
are reviewing his nursing care plan. Which component of the care plan indicates that
the patient’s problems have been appropriately described?
nursing diagnosis
When using a mobile hoist with a dependent patient, identify the correct rule:
how many assist
- lite assessment
brakes off on hoist
The older person’s tendency to take smaller steps with feet close together will mostly
likely result in:
- falls risk
- tripping hazard
To ensure safe administration of medications the nurse must be aware of the seven
rights of medication administration. These are the right:
- medication
- patient
- dose
- time
- reason
- route
- documentation
A person with a normal gait should demonstrate all of the below actions, except:
- coordinated movements, able to maintain balance [posture and body alignment during moving
(pick one that isnt these)
A nurse administers medication to a patient. Who has the ultimate responsibility for the
medication to be administered correctly?
the nurse
While the nurse is administering medication, the patient states, “This pill looks different
to what I usually take.” What is the correct practice in this situation?
identification of the patient, check correct medication
A nurse administering medications has many responsibilities including knowledge of
pharmacodynamics. Pharmacodynamics is best described as:
what the drug does to the body
A nurse needs to document that a medication has been administered under the tongue.
What term would they use?
sublingual
The prescription for a patient instructs the nurse to administer flucloxacillin 250mg po
QID. How and when is the medication administered?
orally 4 x daily
Three common complications of diabetes mellitus are:
- decreased sensation in the peripheries
- poorly controlled BGL
- changes in weight
- changes in appetite
- frequency of urination
- frequency of thirst
- glaucoma
Mary Brown is 17 years old and presents with a diagnosis of Type 1 Diabetes Mellitus.
Clinical manifestations associated with T1D include all the following except:
Clinical manifestation symptoms are things like frequency of urination ect… looking for answer like …….
hyponatraemia
John Smith has a history of Type 2 Diabetes Mellitus. As the nurse, you are performing
a risk assessment. Identify a modifiable risk factor for John:
insufficient exercise/ sedentary lifestyle
Microvascular complications of diabetes mellitus include damage to the kidney. This is
called:
nephropathy
Three common complications of diabetes mellitus are:
- decreased sensation in the peripheries
- poorly controlled BGL
- changes in weight
- changes in appetite
- frequency of urination
- frequency of thirst
- glaucoma
Measures of glycosylated haemoglobin, such as HbA1c, monitor glucose control over a
period of time, relative to the average life span of a red blood cell. This is normally:
3 months 90 days
Which of the following statements, regarding T1D, is true:
total inability to produce insulin
You are working in a family planning centre and providing an education session on
genital warts. Information you provide includes:
HPV vaccine
- personal hygiene
- STI checks
- contraception/ protection
- frequency of tests
Which of the following is NOT a bacterial sexually transmitted infection?
genital warts
An early sign/symptom of syphilis is:
a painless sore on the genitals
You are providing education to a women’s group on breast cancer. Identify the factor
below that is incorrect:
- men cannot get breast cancer
- always hereditary
- healthy people don’t get it
- wearing a bra can cause it
Folate is a particularly important nutrient for which patient group?
- pregnant women
- expectant mothers
- trying to conceive
Which age and gender are MOST at risk of developing an iron deficiency?
- women of childbearing age.
- pregnant women.
Foods permitted on a clear, liquid diet include all the following except:
anything you can’t see through
What type of diet is most likely to prevent constipation?
high fibre
A patient who has had a stroke is assessed by the nurse. The nursing diagnosis
identified for the patient is: risk of aspiration related to dysphagia and left sided facial
weakness. An appropriate technique for the nurse to use when assisting the patient to
eat is to:
- pureed diet
- sit up 90 degrees
- assisted feeding
- small spoon
- double swallow
- thickened fluids
- supervision
Identify the condition that is not an abnormality of the nose:
epistaxis - deviation of the septum - cleft palate - rhino rhinosinusitis - sinusitis (nasal obstruction) - Nasalpolyips
An elderly patient, who has recently had a stroke, is assessed by the nurse as having a
reddened area over the coccyx. To prevent this from progressing the nurse decides to:
- apply barrier cream
- 2 hourly turns
- air mattress
- mobilising
- incontinence tests
- pressure cushion
- no wrinkles in sheets
- keep dry
The tissue surfaces of an incision that are brought together are described as:
- primary intention healing
- stitches
There are several instruments for assessing patients who are at risk of developing a
pressure injury. The Braden Scale is commonly used. What risk factors are assessed
using the Braden Scale?
sensory perception activity mobility nutrition moisture level and friction/shear
The haemostasis phase of wound healing is characterised by:
coagulation
slowing of blood loss
clotting
The nurse observes that the client has a pressure injury on their right heel. There is full
thickness loss of the dermis. The nurse can see subcutaneous fat, but no muscle or
bone. Classify the stage of the pressure injury as:
stage 3
An effective question to assess orientation in a mental health assessment may include:
- what day/ month/ time
- what is your name?
- who am i?
time place person and location
The nurse uses a surgical aseptic technique when:
procedures are technically complex and invasive
Delirium is characterised by:
- confusion
- disorientation
- restlessness
- acute or sudden onset of confusion, agitation, decrease in cognition and awareness/ orientation
- is treatable
The nurse is performing a lymph node assessment on a client who has been
complaining of a sore throat. In palpating for the occipital lymph nodes, the nurse must
position the pads of their fingers in which position?
- base of the skull
- top of spine
- occipital bone
Which symptoms are commonly associated with enlarged head and neck lymph nodes?
headache
malaise
difficulty swallowing sore throat
flu-like symptoms
You are inspecting your clients spinal symmetry and assessing their posture. you identify that the client has kyphosis. This is
outward curve of spine in upper back
dorsally exaggerated thoracic curve
what is the term given to an unexpected effect of a medication
adverse effect
