Tiêu đề RECALLS 13 - NP3 - SC ✅

39. Nurse Tala provides bio-behavioral interventions to minimize pain and anxiety of Patient Dolores. Which one of the following is NOT appropriate to be done? A. Music therapy B. Guided imagery C. Distraction D. Stretching 40. A simple relaxation therapy was applied to Patient Dolores. The following steps of relaxation therapy done by Nurse Tala is _________. 1. evaluate and document Ms. Dolores’s response to therapy 2. create a quiet, non-disruptive environment with dim lights and comfortable temperature 3. demonstrate and practice the relaxation intervention 4. consider Dolores’s willingness to participate, past experiences and contraindications 5. individualize the content of the relaxation interventions A. 4, 1, 5, 3, 2 B. 2, 1, 4, 3, 5 C. 3, 2, 4, 1, 5 D. 4, 2, 5, 3, 1 Situation 8 Mia Thermopolis, 4-week-old infant is admitted to the hospital with a history of vomiting. The mother explains that her daughter has an initial problem with the regurgitation which progressed to a projectile vomiting which becomes more forceful. 41. Upon admission, the FIRST nursing action you should perform is ________. A. Switch the child feedings to electrolyte solution B. Call the pediatric ward doctor for the admission C. Assess and weigh the infant D. Begin an IV fluid as ordered 42. Which of the following serum electrolyte imbalances occur in an infant with persistent vomiting? A. Potassium B. Sodium C. Chloride D. Calcium 43. What is the MOST APPROPRIATE nursing diagnosis for this patient? A. Altered Bowel Elimination B. Altered Nutrition C. Fluid volume deficit D. Alteration in Comfort 44. Due to excessive vomiting in Pyloric Stenosis, you should assess the child for which of the following imbalances? A. Respiratory Acidosis B. Metabolic Acidosis C. Metabolic Alkalosis D. Respiratory Alkalosis 45. Before scheduling the infant for surgery, the doctor ordered the administration of parenteral fluid and electrolytes. Which of the following incorporated solutions should be administered through IV? A. Potassium Chloride B. Magnesium Chloride C. Bicarbonate Chloride D. Calcium Chloride Situation 9- Chacha, a 6 month old baby is admitted in the Pediatric unit for acute diarrhea and dehydration. 46. You are in charge of this patient. In your assessment you expect to find which of the following? A. Moderately lethargic B. Bulging fontanelle C. loosening of the skin D. High grade fever 47. Further clinical findings of the child that you have observed include which ONE of the following? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory acidosis D. respiratory alkalosis 48. The child was ordered Oresol (ORS). As a nurse, how would you prepare Oresol treatment for this child? A. Mix 2 sachet of ORS in 1 liter of water B. Mix 1 sachet of ORS in 2 liters of water C. Mix 2 sachet of ORS in 2 liters of water D. Mix 1 sachet of ORS in 1 liter of water 49. The BEST practice for the nursing staff to prevent spread of infection when patient has infectious diarrhea is _________. A. Autoclave linens B. Strict handwashing C. isolate the patient D. wear latex gloves 50. After the Oresol Treatment which of the following is an indication that Oresol is effective? A. Patient is well hydrated B. Refuse to play with other children C. Socialization with other children D. Temperature is 36.8°C 51-55. Situation. Nurse Charm admits Mr. De Guzman, 31 year-old, who was brought to the Emergency room by his co-worker because of severe abdominal pain. He was observed to be very anxious; holding his abdomen with his right hand while bending towards his right side. The Emergency Room doctor made his initial assessment and referred the patient to the Surgical doctor on duty for further assessment. 51. To describe a sensation of severe pain felt for ruptured appendicitis, Nurse Charm applies deep pressure of her finger into the abdomen at a point away from the pain and then releases. This maneuver is termed as __________. A. Perforation B. McBurney’s Point C. Rovsing’s sign D. Rebound tenderness 52. Mr. De Guzman was diagnosed with ruptured appendicitis. When the appendix is suspected ruptured, a generalized abdominal pain is felt and becomes ____________. A. Merely a discomfort and steady rather that intermittent B. Intense and the patient guards the area by living room C. Rigid, stiff and board like feeling D. Tender and focused on the umbilical cord region 53. Immediate surgery was done on Mr. De Guzman. Which of the following measures for pain control is NOT advisable to be done by Nurse Charm while patient De Guzman is having post-op pain? A. Coughing exercises B. Deep breathing C. High-fowler’s position D. Semi-fowler’s position 54. After operation, a nasogastric tube (NGT) was inserted to Patient De Guzman. The rationale for this surgical measure is to _________. A. Prevent use of antibiotics B. Decrease hospitalization to two days C. Decrease pain after the operation D. Avoid the use of analgesics 55. Nurse Charm assesses the pain intensity of Mr. De Guzman. The pain assessment tool APPROPRIATE to be used for Mr. De Guzman is _____________. A. Faces Pain Rating scale B. Visual Rating Scale C. World Rating Scale D. Numeric Rating Scale 56-60. Situation. You are the nurse on night duty in the medical ward. You were assigned by Ms. Felipe, the Charge Nurse of the unit to monitor the status of a 9 year old boy with bronchial asthma. 56. Which of the following manifestations of the child would cause you to be alarmed? A. Excessive sweating B. Choking sensation C. Cough with phlegm D. Generalized chest tightness 57. You would like the child to be comfortable in bed. Which position should you put the child to ease his discomfort? A. Lying on his side B. Prone position C. High Fowler’s Position 4 | Page