ANCC MEDICAL SURGICAL NURSING
COMBINED EXAMS FULLY SOLVED TEST PAPER
GRADED A+
◉ Triple H therapy for
Subarachnoid Hemorrhage- induced
Vasospasm.
Answer: Nimodipine or Nimotop is a calcium channel blocker which
causes vasodilation of the blood vessels. is hypervolemia,
hypertension, and hemodilution. These three factors will maintain
the patency of the vessels, making it difficult for them to
vasoconstrict. Vasospasm left unchecked can cause stroke,
neurological compromise, and death.
◉ Iatrogenic.
Answer: Adverse effects caused by dx procedure or treatment
◉ Confussion assessment method(cam).
Answer: Dx delirium
1 Acute onset
2 Inattention
3 Disorganized thinking
,4 ALOC
1,2. And 3 or 4 is positive
◉ The Confusion Assessment Method.
Answer: Onset: Acute changes in mental status. · Attention:
Inattentive, stable, or fluctuating. · Thinking: Disorganized, rambling,
switching topics, illogical. ·
Level of consciousness: Altered (ranging from alert to coma). ·
Orientation: Time, place, person. ·
Memory: Impaired. ·
Perceptual disturbances: Hallucinations, illusions. Psychomotor
abnormalities: Agitations or retardation. ·
Sleep-wake cycle: Awake at night, sleepy in the daytime.
◉ Nursing process.
Answer: Assessment: Collecting data, history, and completing a
physical exam.
Diagnosis: Analyzing data, determining needs and problems, and
applying a nursing diagnosis.
Planning: Setting priorities, setting goals and expected outcomes,
and planning interventions and strategies of care.
Implementation: Applying interventions/treatments. Evaluation:
Reassessing and auditing.
, ◉ Diabetes insipidus.
Answer: Extreme thirst and urination cause by imbalance in body
fluid
◉ CAGE.
Answer: Alcoholism screening-
C -Cutting down: Do you think about trying to cut down on drinking?
A -Annoyed at criticism: Are people starting to criticize your
drinking?
G -Guilty feeling: Do you feel guilty or try to hide your drinking?
E -Eye opener: do you increasingly need a drink earlier in the day?
◉ Braden score.
Answer: PU risk assessment
◉ PUSH score.
Answer: Pressure Ulcer Scale for Healing- measure over time to
indicate healing or deterioration
◉ Five Stages of grief.
Answer: 1. Denial
COMBINED EXAMS FULLY SOLVED TEST PAPER
GRADED A+
◉ Triple H therapy for
Subarachnoid Hemorrhage- induced
Vasospasm.
Answer: Nimodipine or Nimotop is a calcium channel blocker which
causes vasodilation of the blood vessels. is hypervolemia,
hypertension, and hemodilution. These three factors will maintain
the patency of the vessels, making it difficult for them to
vasoconstrict. Vasospasm left unchecked can cause stroke,
neurological compromise, and death.
◉ Iatrogenic.
Answer: Adverse effects caused by dx procedure or treatment
◉ Confussion assessment method(cam).
Answer: Dx delirium
1 Acute onset
2 Inattention
3 Disorganized thinking
,4 ALOC
1,2. And 3 or 4 is positive
◉ The Confusion Assessment Method.
Answer: Onset: Acute changes in mental status. · Attention:
Inattentive, stable, or fluctuating. · Thinking: Disorganized, rambling,
switching topics, illogical. ·
Level of consciousness: Altered (ranging from alert to coma). ·
Orientation: Time, place, person. ·
Memory: Impaired. ·
Perceptual disturbances: Hallucinations, illusions. Psychomotor
abnormalities: Agitations or retardation. ·
Sleep-wake cycle: Awake at night, sleepy in the daytime.
◉ Nursing process.
Answer: Assessment: Collecting data, history, and completing a
physical exam.
Diagnosis: Analyzing data, determining needs and problems, and
applying a nursing diagnosis.
Planning: Setting priorities, setting goals and expected outcomes,
and planning interventions and strategies of care.
Implementation: Applying interventions/treatments. Evaluation:
Reassessing and auditing.
, ◉ Diabetes insipidus.
Answer: Extreme thirst and urination cause by imbalance in body
fluid
◉ CAGE.
Answer: Alcoholism screening-
C -Cutting down: Do you think about trying to cut down on drinking?
A -Annoyed at criticism: Are people starting to criticize your
drinking?
G -Guilty feeling: Do you feel guilty or try to hide your drinking?
E -Eye opener: do you increasingly need a drink earlier in the day?
◉ Braden score.
Answer: PU risk assessment
◉ PUSH score.
Answer: Pressure Ulcer Scale for Healing- measure over time to
indicate healing or deterioration
◉ Five Stages of grief.
Answer: 1. Denial
