Preboard July 2010 Nursing Board Exam

Characteristics used to measure the level of nursing care. Criteria are specific characteristics used to measure the standard of care.

The definition of negligence is the omission of an act that a prudent person would have performed; in this case, the act is failure to raise the side rails.

Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and absence of compartment syndrome. Skin integrity is less important.

Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as –1, –2, or –3. A presenting part below the ischial spines, as +1, +2, or +3.

Scoliosis is a lateral deformity of the thoracic spine. This deformity becomes apparent during adolescence. Kyphosis is a vertical curvature of the spine, or “humpback”. Lordosis is an increase in curvature of the lumbar spine. Genu valgum is internal angling of the knees or “knock-knees.”

A stage 4 pressure ulcer involves full-thickness skin loss with exposure of muscle, bone and surrounding support structures. A stage 1 pressure ulcer appears as a nonblanching erythema of intact skin. A stage 2 pressure ulcer involves an area of skin loss that extends to the dermis and has a shallow crater-like appearance/. A stage 3 pressure ulcer involves an area of full-thickness skin loss with a deep crater that extends down through the subcutaneous tissue.

Osteomyelitis is a very serious infection of the bone that is difficult to treat. Long-term I.V. antibiotics are needed to eradicate this type of infection.

Delusion is a false belief to which an individual adheres. Ambivalence is the simultaneous existence of two opposing feelings, needs or wishes. Anhedonia is the inability to experience pleasure. Psychosis is a major disturbance in ego functioning.

The effects of rest and activity on pain are the one of the significant differences between rheumatoid arthritis and osteoarthritis. A patient with rheumatoid experiences morning joint stiffness; a patient with osteoarthritis experiences more pain as the day progresses and may function better after a night of rest.

The best possible Glasgow Coma Scale is 15; the lowest is 3. A score of 8 or less indicates coma. When associated with a new head injury, it indicates a serious traumatic injury, and the airway may be compromise and need intubation.

Their services are provided on an out-patient basis. Primary facilities government and non-government facilities that provide basic out-patient services.

Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s nipples.

When obtaining the history of a patient who may be in labor, the nurse’s highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons.

This question requires an understanding of station as part of the intrapartal assessment process. Based on the client’s assessment findings, this client is ready for delivery, which is the nurse’s top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery.

Amphetamines are central nervous system stimulants. They cause sympathetic stimulation, including hypertension, tachycardia, vasoconstriction, and hyperthermia. Hot, dry skin is seen with anticholinergic agents such as jimsonweed. Pupils will be dilated, not constricted.

The nurse should ask the patient if she had any hemorrhaging during or after delivery. Sheehan’s syndrome, a form of hypopituitarism, is caused by anoxia from postpartal hemorrhage. The earliest signs are inability to lactate and failure to menstruate. Inability to lactate and failure to menstruate aren’t normal or characteristic of gestational diabetes mellitus. Although a support group may be helpful, if the patient has hypopituitarism, this should be diagnosed and treated or she’ll be infertile and experience a gradual deterioration of all function regulated by the pituitary gland.

In case management nursing the patient is assigned to a health care provider who’s responsible for coordinating that patient’s care as long as the patient is within the provider’s service area, such as a hospital or health service.

One of the greatest threats to a hospitalized toddler’s autonomy is complete bed rest. He’s just beginning to assert his independence, is very active, and doesn’t want to be kept in bed.

An autonomous aldosterone- producing adenoma is the most common cause of hyperaldosteronism. Hyperplasia is the second most common cause. Aldosterone secretion is independent of sodium and potassium intake and of pituitary stimulation.

Muscle weakness, bradycardia, nausea, diarrhea and paresthesia of the hands, feet, tongue and face are common with hyperkalemia. The hyperkalemia is transient and occurs from transient hypoaldosteronism when the adenoma is removed. Tremors and diaphoresis and constipation aren’t seen in hyperkalemia.

Allen’s test determines patency by compressing and releasing them one at a time. The hand should regain color within 6 seconds. Homan’s sign tests for blood clots in the leg. Trendelenburg’s test checks for incompetent valves in the legs. Weber’s test determines lateralization of bone conduction by using a tuning fork.

Type 2 diabetes is diagnosed with two fasting blood glucose levels ≥ 126 mg/dl or a casual plasma glucose level ≥ 200 mg/dl and symptoms. Because his first fasting blood glucose level was ≥ 126 mg/dl, it must be repeated to make the diagnosis of type 2 diabetes.

The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are generally checked q4h, at which time the CSM checks can easily be performed.

Blurred vision of other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses.

During this period, which lasts up to the age of 18-21 years, the individual develops a sense of “self.” Peers have a major big influence over behavior, and the major decision is to determine a vocational goal.

The advocator role provides for “the protection of human or legal rights and the securing of quality care for each patient”. The leader role is defined as assertive, self-confident practice in nursing when providing or supervising care. The communicator role is the use of effective interpersonal and therapeutic communication to provide information to make referrals and facilitate problem solving.

The occipital lobe of the brain is responsible for vision. The motor cortex is responsible for movement, the parietal lobe is responsible for sensation and body awareness, and the temporal lobe is responsible for hearing, language, comprehension and recall.

Rightmost box. The leftmost box is occupied by the highest authority while the lowest level worker occupies the rightmost box.

Although microorganisms that cause sepsis syndrome can enter through the skin, GI tract or respiratory tract, the most common portal of entry is the urinary tract via urinary catheters, suprapubic tubes, and cystoscopic examination.

Ureterolithiasis typically causes such acute, severe pain that the patient can’t rest and becomes increasingly anxious. Therefore, the nursing diagnosis of pain takes highest priority. Risk for infection and altered urinary elimination are appropriate once the patient’s pain is controlled. Altered nutrition: less than body requirements isn’t appropriate at this time.

Ego integrity vs. despair. The client belongs to the middle adulthood stage (30 to 65 yrs.) The developmental task generativity is characterized by concern and care for others. It is a productive and creative stage. Option A Infancy stage (0 – 18 mos.) is concerned with gratification of oral needs. Option B School Age child (6 – 12 yrs.) is characterized by acquisition of school competencies and social skills. Options C Late adulthood ( 60 and above) Concerned with reflection on the past and his contributions to others and face the future.

Otorrhea and rhinorrhea are classic signs of a basilar skull fracture. Injury to the dura commonly occurs with this fracture, resulting in CSF leaking through the ears and nose. Any fluids suspected of being CSF should be checked for glucose or have a halo test done.

Glucose-6-phosphate dehydrogenase deficiency (G6PD) is an X-linked recessivehereditary disease characterized by abnormally low levels of glucose-6-phosphate dehydrogenase (abbreviated G6PD or G6PDH), a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism.

The nurse has to conduct community diagnosis to determine nursing needs and problems. Community-based practice means providing care to people in their own natural environments: the home, school and workplace, for example.

Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say “mama” in the sense that it refers to their mother at this time.

A patient with COPD breathes by a hypoxic drive that requires a higher partial pressure of arterial carbon dioxide level. If too much oxygen is delivered, the patient may not be able to breathe spontaneously and may require intubation.

The pain in the epigastric area is associated with gastric ulcer disease. Pain below or at the umbilicus is associated with appendicitis. Abdominal pain that occurs after a high-fat meal is associated with cholecystitis.

Patients with unstable condition should be given highest priority by the nurse. The client who has fever, and who is diaphoretic and restless is with unstable condition.

Primary intention healing occurs where the tissue surfaces have been approximated and there has been minimal or no loss of tissue. A surgical incision has minimal tissue loss and heals through the process of collagen synthesis, also called primary intention.

Normal heart rate of the newborn is 120 to 160 bpm. Choices A, B, and C are normal assessment findings (uneven head shape is molding).

The signs and symptoms (defining characteristics) of an actual nursing diagnosis are subjective and objective data or information that signals the existence of an actual health problem.

Battery is the harmful or offensive touching of another’s person. Libel is false accusations—written, printed or typed- that are made with malicious intent. Assault is a threat or attempt to make bodily contact with another person without the other person’s consent. Negligence is the omission of an act that a prudent person would have performed.

If the child is hungry he/she more likely would finish his meals. Therefore, the mother should be advised not to give snacks to the child. The child is a “busy toddler.” He/she will not able to keep still for a long time.

Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breast-feeding after surgery is possible. Still, it’s good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother’s ability to meet all of her baby’s nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client’s psychological adaptation to mothering may be dependent on how successfully she breast-feeds.

The diaphragm of a stethoscope detects high-pitched sound best; the bell detects low pitched sounds best. Palpation detects thrills best.

When examining a toddler or any small child, the best way to perform the exam is from least to most intrusive. Starting at the head or abdomen is intrusive and should be avoided. Proceeding from distal to proximal is inappropriate at any age.

Immediate bed rest is necessary to prevent further injury. Both eyes should be patched to avoid consensual eye movement and the patient should receive early referral to an ophthalmologist. If the macula is attached and central visual acuity is normal, an ophthalmologist should treat the condition immediately. Retinal reattachment can be accomplished by surgery only. If the macula is detached or threatened, surgery is urgent, prolonged detachment of the macula results in permanent loss of central vision.

Angina is caused by altered tissue perfusion to the myocardium, which results in ischemia. Treatment is aimed t reversing ischemia. Pain and anxiety should also be addressed, but they don’t take priority over altered tissue perfusion. Cardiac output may or many not be affected with angina.

A mature experienced nurse. The unstable, aggressive client should be assigned to the most experienced nurse. Options A, C and D. A shy, inexperienced, soft spoken nurse may feel intimidated by the angry patient.

Lead poisoning may be caused by inhalation of dusk and smoke from leaded gas. It may also be caused by lead-based paint, soil, water (especially from plumbings of old houses).