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Management of Nursing Care > MN multi-choice exam > Flashcards

MN multi-choice exam Flashcards

1
Q

Mrs Bago, 80 years old, is a resident of the rest home where you are on student placement. Whilst playing cards in the day room with a fellow resident she became unresponsive without warning for about 30 seconds. Five minutes have passed and she has now regained consciousness and is lying on her bed, after being taken there by her carer.

A

Complete the following questions

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2
Q

Which of the following would be the most appropriate for you as the student nurse to do next?

  • Leave Mrs Bago to go and talk to the other residents about what happened.
  • Perform a Glasgow Coma Score (GCS).
  • Refer the patient for immediate follow-up.
  • Ask if the patient has ever had a seizure
A

Perform a Glasgow Coma Score (GCS).

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3
Q

When performing a physical examination of Winnie which of the following would be most appropriate?

  • Allow Winnie to remain dressed.
  • Omit intrusive parts of the exam.
  • Dim the room light.
  • Try to minimise position changes for her.
A

Try to minimise position changes for her.

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4
Q

Which test would be most appropriate to perform when assessing Winnies eye muscle strength and cranial nerve function?

  • Visual fields test.
  • Cover test.
  • Corneal light reflex test.
  • Extra ocular movement test.
A

Extra ocular movement test.

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5
Q

Which of the following nursing assessments will give you objective data relating to the functioning of Winnies cerebellum?

  • Vital signs.
  • Coordination.
  • Glasgow Coma Score
  • Cardiac function.
A

Coordination

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6
Q

The registered nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have Winnie do?

  • Lock the fingers together and pull against each other.
  • Stretch the arms overhead.
  • Squeeze a thigh with the opposite hand.
  • Clench the jaw tightly.
A

Lock the fingers together and pull against each other.

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7
Q 
Winnies patellar reflex is normal.  Which of the following is the correct number to document this? 
2+ 
3+ 
4+ 
5+
A

2+

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8
Q

Which of the following would be the most likely sign of a frontal lobe contusion?

  • Inability to hear high-pitched sounds
  • Difficulty speaking
  • Blurred vision
  • Loss of tactile sensation
A

Difficulty speaking

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9
Q

For which patient condition would you most likely expect a capillary refill time longer than two seconds?

  • Malignant melanoma.
  • Inflammatory bowel disease.
  • Peripheral vascular disease.
  • Multiple sclerosis.
A

Peripheral vascular disease.

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10
Q

Which one of the following is a myth about pain in the older adult?

  • Opioids are often the drug of choice for some types of pain, and are to be used cautiously.
  • Older patients may have more than one source of pain.
  • There is a greater likelihood of having developed a pathological condition that may be accompanied by pain.
  • Elderly people who are confused or cognitively impaired do not have pain.
A

Elderly people who are confused or cognitively impaired do not have pain.

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11
Q

Which of the following represents the break in sounds between the first and second sounds when auscultating Joyce’s blood pressure?

  • Diastolic value.
  • Korotkoff sounds.
  • Auscultatory gap.
  • Phase V.
A

Auscultatory gap

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12
Q

You are having difficulty auscultating Joyce’s heart sounds, specifically S1 and S2. Which of the following would help?

  • Use the bell of the stethoscope to help distinguish the sounds.
  • Palpate the apical impulse.
  • Palpate the carotid pulse while auscultating the heart.
  • Determine the pulse deficit.
A

Palpate the carotid pulse while auscultating the heart.

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13
Q

Which type of pain would be associated with arthritis?

  • Somatic
  • Chronic
  • Visceral
  • Cutaneous
A

Chronic

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14
Q

When assessing Rangi which part of the body would you assess for the presence of central cyanosis?

  • Oral mucosa.
  • Palms.
  • Sclera.
  • Nail beds.
A

Oral mucosa

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15
Q

Which of the following processes is not required in order for effective respiration to occur?

  • Ventilation.
  • Obstruction
  • Perfusion.
  • Diffusion.
A

Obstruction

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16
Q

Which of the following is a warning sign of acute respiratory distress?

  • A blue tinge to the mouth and lips.
  • A respiratory rate of 14 breaths per minute.
  • The patient telling you in long sentences that they are short of breath.
  • An oxygen saturation recording of 93% while the patient is breathing normal room air
A

A blue tinge to the mouth and lips.

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17
Q

Which of the following would be most important for you to remember when auscultating Rangi’s posterior chest?

  • Listen at each site for at least one complete respiratory cycle.
  • Have the patient breathe deep and fast through the mouth.
  • Be alert to the patient’s comfort and offer rest periods.
  • Auscultate the base at the level of the sixth rib.
A

Listen at each site for at least one complete respiratory cycle.

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18
Q

When auscultating the apices of Rangi’s lungs, where would you place your stethoscope?

  • At the level of the diaphragm.
  • Near the level of the eighth rib.
  • Slightly above the clavicle.
  • At about the tenth rib.
A

Slightly above the clavicle.

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19
Q

Which of the following describes a wheeze?

  • Loud bubbly sounds heard during inspiration.
  • High-pitched, musical sounds heard primarily during expiration?
  • Moist sounds, not cleared by coughing
  • High-pitched fine, short crackling noises heard during the end of expiration.?
A

High-pitched, musical sounds heard primarily during expiration

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20
Q

When performing a comprehensive assessment, which part of the body would you assess for information about the motor function of cranial nerve VII?

  • Ears.
  • Mental status examination.
  • Mouth and throat.
  • Head and face.
A

Head and face.

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21
Q

You are preparing to assess Mrs Jones’ distance visual acuity. Given that she wears reading glasses which of the following would be most appropriate?

  • Use the E chart rather than the Snellen chart for testing.
  • Have Mrs Jones keep the glasses on but occlude one eye.
  • Ask Mrs Jones to remove her glasses before testing.
  • Test Mrs Jones near visual acuity instead.
A

Ask Mrs Jones to remove her glasses before testing. coz its only reading glasses

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22
Q

During Mrs Jones’ ocular exam you shine a light into one eye and the pupil of the other eye constricts. What of the following do you interpret this as?

  • Direct reflex.
  • Consensual response.
  • Accommodation.
  • Optic chiasm.
A

Consensual response.

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23
Q

Which of the following questions will help you evaluate Mrs Jones for a hearing impairment?

  • “Do you have a problem hearing over the telephone?”
  • “Do people complain that you turn the TV volume up too high?”
  • “Do you misunderstand what others are saying and respond inappropriately?”
  • “Do many people you talk to seem to mumble (or not to speak clearly)?”
A

All of the above.

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24
Q

If Mrs Jones has difficulty hearing high-pitched sounds, which of the following would you document this finding as?

  • Otalgia.
  • Presbycusis.
  • Vertigo.
  • Tinnitus.
A

Presbycusis.

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25
Q

Mrs Jones has asked you to present an educational class to her garden club about vision and eye health. As part of the presentation you explain how visual perception occurs. Which of the following would you include in the explanation?

  • Refers to what a person sees with one eye
  • Allows the eyes to focus on near objects.
  • Involves light rays striking the retina
  • Acts as a protective reflex to limit light.
A

Involves light rays striking the retina

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26
Q

Nurses should be aware of the verbal and non-verbal ways patients communicate discomfort. What would be an appropriate assessment tool to use with Molly?

  • PQRSTU.
  • A faces pain scale.
  • A verbal descriptor scale.
  • A numeric rating scale.
A

A faces pain scale

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27
Q

How would you advise Molly and her mum as to the best way to reduce the risk of spreading the disease?

  • Hand hygiene.
  • The use of disposable gloves.
  • The use of isolation precautions.
  • Sterilisation of equipment.
A

Hand hygiene

28
Q

Which of the following would be the most accurate nursing diagnosis for Molly?

  • Molly would like the day off school and has stuck toothpaste in her eye.
  • Pain related to exudate in left eye.
  • Potential visual impairment due to blood shot right eye
  • Conjunctivitis related to itchy eye with pus.
A

Pain related to exudate in left eye.

29
Q

You are aware that it is important to break the chain of infection, which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a patient?

  • Covering the mouth and nose, with your elbow, when sneezing.
  • Wearing disposable gloves.
  • Isolating the patient’s articles.
  • Changing soiled dressings.
A

Changing soiled dressings

30
Q

Which of the following statements about PPE is incorrect?

  • PPE used should be appropriate, fit for the purpose and suitable for the person using/wearing it.
  • Once the task is completed PPE should be removed and disposed of immediately.
  • Take care to prevent contaminating clothing, skin and/or environment whilst removing PPE.
  • You do not need to perform hand hygiene if you have worn gloves.
A

You do not need to perform hand hygiene if you have worn gloves.

31
Q

Which of the following is not an element in the chain of infection?

  • Infectious agent or pathogen.
  • Formation of immunoglobulin.
  • Means of transmission.
  • Reservoir for pathogen growth.
A

Formation of immunoglobulin.

32
Q

Mr London has very limited mobility, how often should you assist him to change position to prevent the development of a pressure injury?

  • Three hourly.
  • Two hourly
  • Six hourly.
  • Four hourly.
A

Two hourly

33
Q

Pressure injuries form primarily as a result of:

  • Prolonged illness or disease.
  • Poor nutrition.
  • Tissue necrosis.
  • Nitrogen build up in underlying tissue.
A

Tissue necrosis.

34
Q

You conduct a Braden scale assessment for Mr London to assess his risk of developing a pressure injury. What risk factors are assessed using the Braden Scale?

  • Physical condition, mental condition, activity, mobility, incontinence.
  • Nutrition, tissue perfusion, infection, age, shear force and friction, moisture.
  • Infection, haemorrhage, dehiscence, evisceration, fistulas.
  • Sensory perception, moisture, activity, mobility, nutrition, friction, shear.
A

Sensory perception, moisture, activity, mobility, nutrition, friction, shear.

35
Q

Based on the Braden scale which one of the following scores places him at the highest level of risk?

  • 23.
A

12

36
Q

When Mr London is in a supine position, what are the potential sites of pressure injury?

  • Neck hyperextension.
  • Unprotected pressure points at ileum, humerus, clavicle, knees and ankles.
  • Unprotected pressure points at sacrum, heels, scapulae, elbows and back of head.
  • The cheek he is lying on, and his abdomen.
A

Unprotected pressure points at sacrum, heels, scapulae, elbows and back of head.

37
Q

You notice Mr London has partial- thickness skin loss involving the epidermis and possibly dermis in the sacral region, what stage of injury will you document in the patient records?

  • Stage II
  • Stage I.
  • Stage IV.
  • Stage III.
A

Stage II

38
Q

During assessment of Mr London you note a reddened area over his coccyx. What should your next actions for him include?

  • Insert a urinary catheter to prevent moisture from urinary incontinence.
  • Massage the area and reposition the patient.
  • Reposition the patient off the coccyx and reassess in one hour.
  • Placing the patient in a Fowlers position and return in three hours.
A

Reposition the patient off the coccyx and reassess in one hour.

39
Q

What is the name given to the progressive deteriorating organic mental disorder that can be associated with the ageing process?

  • Depression.
  • Psychosis
  • Dementia
  • Delirium
A

Dementia

40
Q

How could you advise Mrs London to best manage Mr London when he is experiencing confusion?

  • Giving thorough, detailed directions
  • Providing simple directions with physical assistance if necessary. I agree
  • Give directions in a very loud firm voice.
  • Doing everything for Mr London.
A

Providing simple directions with physical assistance if necessary.

41
Q

You ask whether Mr London has had any hallucinations. A hallucination is a disorder of…

  • Affect.
  • Orientation.
  • Perception.
  • Memory.
A

Perception

42
Q

Your assessment includes identifying if Mr London has an acute infection. An infection can cause an acute confusional state, known as

  • Delirium.
  • Korsakoff’s syndrome.
  • Alzheimer’s
  • Dementia.
A

Delirium

43
Q

Which of the following is not a characteristic of dementia?

  • Chronic confusion.
  • Diffuse physiological disruption.
  • Progressive.
  • A disease of the brain.
A

Diffuse physiological disruption

44
Q

If Mr London were to fabricate an event to fill in memory gaps this would be called

  • Confabulation.
  • Flight of ideas.
  • Hallucination.
  • Elation.
A

Confabulation.

45
Q

Which of these is incorrect in relation to delirium?

  • It is an acute confusional state.
  • There is no available treatment.
  • It is important to find the cause.
  • The core impairment is related to alertness, attention, and awareness.
A

There is no available treatment.

46
Q

You have a second year student nurse on placement who asks for some advice on becoming more confident and proficient with a comprehensive assessment. Which of the following would be most important for the student nurse to remember?

  • Ensure you build rapport with the patient by providing lots of personal information.
  • Allow the patient a coffee break between the two parts of the history/exam.
  • Intersperse the physical exam with the history.
  • Establish a routine for the assessment.
A

Establish a routine for the assessment.

47
Q

What type of assessment are you most likely to perform on Sarah today?

  • Thorough.
  • Focused.
  • Emergency.
  • Ongoing.
A

Focused

48
Q

What specific assessment would you consider when assessing Sarah?

  • Vital signs.
  • Cardiovascular.
  • Pain scale.
  • Neurological.
A

Pain scale

49
Q

A nursing diagnosis is:

  • The diagnosis and treatment of human responses to health and illness.
  • The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client’s medical history, and the results of diagnostic tests.
  • The advancement of the development, testing, and refinement of a common nursing language.
  • A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes.
A

A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes.

50
Q

When working with patients in pain nurses need to recognise and avoid common misconceptions and myths about pain. With regard to the pain experience, which one of the following is correct?

  • The patient is the best authority on the pain experience.
  • Chronic pain is mostly psychological in nature.
  • Regular use of analgesics leads to drug addiction.
  • The amount of tissue damage is accurately reflected in the degree of pain perceived
A

The patient is the best authority on the pain experience.

51
Q

Sarah describes her pain as coming on quickly and being of short duration. What type of pain is this?

  • Referred.
  • Acute.
  • Radiating.
  • Deep visceral.
A

Acute

52
Q

You are educating Sarah about analgesics for pain relief. Included in the teaching is the fact that analgesics containing codeine may cause:

  • Headaches.
  • Muscle weakness.
  • Hypertension.
  • Constipation.
A

Constipation.

53
Q

What is the most appropriate assessment for Mrs Jacobs?

  • Peripheral vascular.
  • Apical pulse.
  • Glasgow Coma Score.
  • Special senses
A

Glasgow Coma Score.

54
Q

In the ABCDE of initial assessment and treatment in acute situations, the ‘D’ refers to:

  • Defibrillation.
  • Danger.
  • Disease.
  • Disability.
A

Disability.

55
Q

Damage to which area of the brain is likely to have resulted in Thelma’s symptoms?

  • Broca’s area
  • Occipital lobe
  • Frontal lobe
  • Primary somatosensory area
  • Premotor area
A

First and third

56
Q

Identify an appropriate nursing diagnosis for Thelma.

  • Falls Risk r/t confused state and right sided weakness.
  • Impaired communication r/t CVA.
  • Pain in L hip r/t fractured neck of femur.
  • Impaired mood r/t depression.
A

Falls Risk r/t confused state and right sided weakness.

57
Q

An appropriate SMART goal for Thelma is?

  • “For Thelma not to have a fall”.
  • “For Thelma to have a pain score of ≤1 by the end of today’s shift”.
  • “Thelma’s risk of falls will be reduced”.
  • “For Thelma to be able to mobilise to the toilet with assistance of one person”.
A

“For Thelma to have a pain score of ≤1 by the end of today’s shift”.

58
Q

Identify the correct nursing intervention for Thelma.

  • Perform a pain scale as part of checking Thelma’s vital signs.
  • Provide pressure area care every four hours or as often as needed.
  • Withhold any food or fluids until her ability to safely swallow has been assessed by a speech language therapist.
  • All of the above.
A

All of the above

59
Q

Which critical thinking skill helps you to see relationships among the data?

  • Validation.
  • Clustering related cues.
  • Identifying gaps in data.
  • Distinguishing relevant from irrelevant.
A

Clustering related cues.

60
Q

The GP Practice nurse decides to complete a full set of vital signs. At which time of the day would the nurse expect to obtain the lowest body temperature?

  • Late evening
  • Late afternoon
  • Early afternoon
  • Early morning
A

Early Morning

61
Q

The practice nurse asks you to take Richards blood pressure. When deciding where to place the cuff on Richards arm, which action is the most appropriate?

  • The bladder inside the cuff encircles 50% of the arm circumference
  • The cuff is placed about 2.5cm above the antecubital area
  • The cuff starts to be wrapped at the end of the bladder
  • The cuff is wrapped loosely around the arm
A

The cuff is placed about 2.5cm above the antecubital area

62
Q

Richard is lying down on the examination table when you monitor his blood pressure. Which of the following would you expect?

  • Blood pressure will be slightly lower than his normal reading
  • No change, since position rarely affects the blood pressure
  • Blood pressure will be slightly higher than his normal reading
  • Questionable accuracy of the reading
A

Blood pressure will be slightly lower than his normal reading

63
Q

As there are several things happening in the clinic at the moment you need to consider clinical priority. Clinical priorities:

  • Are based on the assessment data collected.
  • Is learning from process to inform practice.
  • Involve preparing for and taking action.
  • All of the above.
A

All of the above

64
Q

An appropriate nursing diagnosis for Richard would be:

  • Richards urine will no longer smell of fish.
  • The cause of Richards urinary symptoms will be identified.
  • Richard will drink less to reduce frequency of urination.
  • Potential risk of urinary tract infection as evidenced by increased frequency of urination, reduced volumes and offensive odour
A

Potential risk of urinary tract infection as evidenced by increased frequency of urination, reduced volumes and offensive odour.

65
Q

What is the most appropriate nursing intervention?

  • Advise Richard to drink more fluid to flush out the fishy smell.
  • Call the doctor urgently requesting a full course of antibiotics.
  • Obtain a urinalysis and perform a dipstick urine test.
  • Reassure Richard that eating fish all weekend has not been the cause of his symptoms
A

Obtain a urinalysis and perform a dipstick urine test.

Management of Nursing Care (1 decks)

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