Test 1

Question 1

Describe the process of placing a patient on a bedpan.

Answer 1

1. Ensure patient is positioned high in the bed.
2. Raise the patient’s head about 30 degrees.
3. Provide support to the upper torso.
4. Ask the patient to raise the hips by bending the knees and lifting the hips upward.
5. Place hand palm up under the patient’s sacrum, resting the elbow on the mattress.

Question 2

List the 4 psychical examination techniques.

Answer 2

• Palpation
• Percussion
• Auscultation
• Inspection

Question 3

Differentiate between friction and shear.

Answer 3

Friction

• Caused by mechanical force e.g., the patient being dragged across bed linens
• Damage to the epidermis

Shear

• A force exerted parallel to the skin that occurs due to gravitational force on the body
• Stretches underlying tissue capillaries, resulting in necrosis within deep tissue layers

Friction is the mechanical force that causes shear.

Question 4

Differentiate between semi-fowler’s and high fowler’s.

Answer 4

In a semi-fowler’s position, the head of the bed is raised to approximately 30 degrees.

In high fowler’s position the bed is raised to approximately

Question 5

What is the recommended exercise guideline for older adults?

Answer 5

150 minutes of moderate- to vigorous-intensity aerobic physical activity a week

Question 6

List the steps for making a nursing diagnosis.

Answer 6

1. Review assessment data, noting objective and subjective clinical criteria
2. Cluster clinical criteria that form a pattern
3. Choose a diagnostic label
4. Consider context of the patient’s health problem and select a related factor

Question 7

Define dysphagia

Answer 7

Dysphagia: Abnormal swallowing, which can lead to aspiration.

Question 8

Differentiate between isotonic and isometric and resistive isometric exercise.

Answer 8

Isometric exercise: Engaging muscles with no movement e.g. quadriceps set exercises

Isotonic exercise: Involves putting a constant amount of weight or tension on your muscles while moving your joints through a full range of motion e.g. walking, swimming

Restorative isometric exercise: Contraction of muscles while pushing against a stationary object e.g. push ups

Question 9

What does the Braden scale evaluate?

Answer 9

Risk factors that place the patient at risk for skin breakdown

Question 10

Describe the various conceptualizations of health.

Answer 10

Health as stability refers to physiological norms, whereas health as actualization refers to human potential

Question 11

What actions would you take while assessing the feet of a patient with diabetes?

Answer 11

• Assess whether sensation is intact
• Inspect the toenails and trim them if required
• Palpate the pulse of the posterior tibial artery

Question 12

What are the six sub-scales of the Braden scale?

Answer 12

1. Moisture
2. Sensory perception
3. Activity
4. Mobility
5. Nutrition
6. Friction

Question 13

Which complications should you be observant for in a patient with dysphasia?

Answer 13

• Aspiration pneumonia
• Dehydration
• Weight loss

Question 14

How to tell that a person with dark skin has developed a pressure injury.

Answer 14

• The localized area of the skin appears purple
• The skin colour remains unchanged on the application of pressure
• The skin becomes cool

Question 15

How would you reduce the risk of thrombus formation in an immobile patient?

Answer 15

• Adequate fluid intake
• Use of elastic stockings
• Leg, ankle and foot exercises

Question 16

What guidelines would a nurse follow to reduce errors in the nursing diagnosis statement.

Answer 16

• Identify treatable etiology or risk factors
• Identify the problems cause by the treatment
• Identify the patients response

Question 17

What factors are included in the general survey during a physical assessment of a patient?

Answer 17

• Age and gender
• Body type
• Body odour
• Sign of abuse

Question 18

Which actions help decrease the risk of aspiration when feeding a patient experiencing dysphagia?

Answer 18

• Sit the patient upright in a chair
• Place food in the unaffected side of the mouth
• Feed the patient slowly, allowing time to chew and swallow

Question 19

Which assessment is performed first when conducting a general survey?

Answer 19

Appearance and behaviour

Question 20

What factors would place an older adult at risk of developing pressure injuries?

Answer 20

• Urinary incontinence
• Impaired sensory perception
• Immobility
• Impaired cognition

Question 21

What are the benefits of exercise?

Answer 21

• Decreased fatigue
• Improved stress tolerance
• Increased basal metabolic rate
• Lower resting heart rate

Question 22

How does the WHO define health?

Answer 22

A state of complete physical, mental and social well-being.

Question 23

In which ways does the skin act as a primary defence against infections?

Answer 23

• Provides a barrier to microorganisms
• Contains fatty acids that have antibacterial action
• Helps in removing organisms when they adhere to outer layers of the skin

Question 24

Differentiate between the 3 types of nursing diagnoses.

Answer 24

Risk diagnosis: Describes human responses to health conditions or life processes that may develop in a vulnerable individual, family or community.

Actual diagnosis: Describes human responses or life processes that exist in an individual, family or community.

Health promotion: A clinical judgment of a person’s, family’s or community’s motivation, desire and readiness to increase well-being.

Question 25

Which type of exercise improves performance of daily activities?

Answer 25

Resistance training

Question 26

How much exercise is recommended for a patient with type 2 diabetes?

Answer 26

150 minutes per week

Question 27

What actions would a nurse take while providing care for a patient with reduced sensation in both feet?

Answer 27

• Wash the feet in lukewarm water and dry them well
• File the toenails straight across

Question 28

How do you reduce the risk of back injury when moving a patient?

Answer 28

• Positioning self close to the bed
• Keeping back, neck, pelvis and feet aligned

Question 29

What are the risks to a patient with a Foley Cather if the collection bag is at waist level?

Answer 29

• Infection
• Reflux of urine

Question 30

What are some examples of clear liquids?

Answer 30

• Tea
• Coffee
• Carbonated beverages