ACTUAL EXAMINATION TEST COMPLETE
QUESTIONS AND DETAILED SOLUTIONS
VERIFIED
⩥ Meningitis first step. Answer: o Antibiotics - penicillin (ampicillin)
AND cephalosporin
o Corticosteroids
⩥ Multiple sclerosis and urinary retention. Answer: o Sensation of void
heeded immediately (bed pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
⩥ Acute renal failure priority. Answer: o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
⩥ Acute Respiratory distress priority findings. Answer: o Hypoxia
,o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial
fluid and bronchial obstruction)
⩥ End of life plan of care. Answer: o Signs and symptoms of impending
death are recognized and communicated in developmentally appropriate
language for children and patients with cognitive disabilities with
respect to family preference. Care appropriate to this phase of illness is
proved to the patient and the family
⩥ Cushing Syndrome. Answer: o Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying
disease
o Alternate day therapy decrease symptoms and allows adrenal glands to
recover
⩥ Valve replacement teaching. Answer: o Anticoagulant therapy
(frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
, ⩥ Cancer intractable pain plan of care. Answer: o Pain, other symptoms
and side effects are managed based on the best available evidence, with
attention to disease-specific pain and symptoms, which are skillfully and
systematically applied. ??????
⩥ Schizophrenia nursing diagnoses and interventions. Answer: - Dx: 2
or more S&S for over 6 mo (Positive= delusions, hallucinations,
disorganized speech or Negative= 6 A's Anhedonia, Flat Affect, Apathy,
Anergia, Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower
environmental stimuli, monitor suicidal ideation, 1st or 2nd generation
antipsych
⩥ Grief process therapeutic response. Answer: Allow the 5 steps of
grieving (DABDA), active listening and offer a supportive presence
⩥ Dementia action refusing ADLs. Answer: Encourage finger foods,
distraction, speak therapeutically
⩥ Alcohol withdrawal. Answer: - Needs to be done under medical
supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam,
reduce temp.
- Tremors, nausea, vomiting