30 Questions
What is the primary purpose of the National Licensure Examination (NLE) administered by the Board of Nursing?
To protect the public from incompetent practitioners
Which of the following is NOT a regulatory function of the PRC-Board of Nursing (PRC-BON)?
Evaluate the academic programs of nursing schools
What is the main goal of emphasizing modifiable risk factors to a patient who has had a heart attack?
To prevent another heart attack from happening
Which of the following is a modifiable risk factor that a patient can work on to prevent another heart attack?
High blood pressure
What is the ultimate goal of the National Licensure Examination (NLE) administered by the Board of Nursing?
To ensure public safety by guaranteeing competent nurses
Which of the following is a regulatory function of the Professional Regulation Commission, Board of Nursing (PRC-BON)?
Issuing, suspending, revoking or reissuing certification of registered nurses
What is a clinical manifestation of ketoacidosis that represents the body's attempt to decrease acidosis?
Kussmaul respiration
Which of the following is NOT a clinical manifestation of ketoacidosis?
Cheyne-Stokes breathing
What is the likely cause of appendicitis?
Fecalith
What is the name of the clinical sign of acute appendicitis that is defined as discomfort felt on the slow internal movement of the hip joint?
Obturator sign
Which of the following is a clinical manifestation of ketoacidosis that is related to mental status?
Lethargy
What is the medical condition characterized by inflammation and edema of the appendix due to a kinked or occluded fecalith, tumor, or foreign body?
Appendicitis
What is the term for pupil size asymmetries, often associated with neurological deterioration in severe traumatic brain injury?
Anisocoria
What is the primary goal of the airway step in the ABCD sequence?
Maintaining a patent airway
Which of the following is a late sign of increased intracranial pressure in a client with severe traumatic brain injury?
Brainstem compression
What is the term for the combination of increasing systolic pressure, increasing respiration rate, and bradycardia in a client with severe traumatic brain injury?
Cushing's Triad
In which scenario would the use of an automatic external defibrillator (AED) be indicated?
Ventricular tachycardia
Which of the following respiratory signs would indicate increasing intracranial pressure in the brain stem?
Slow, irregular respiration
What is the recommended maximum degree of head elevation to prevent increasing ICP?
30 to 45 degrees
What is a sign of increasing intracranial pressure?
Unequal pupil size
What is an early indication of deterioration in the neurologic status of a client with severe traumatic brain injury?
Decrease in the level of consciousness
What is the correlation between abnormalities of pupillary response and neurological outcome in severe traumatic brain injury?
Poor neurological outcome
What is the purpose of maintaining a safe CPP of at least 70 mmHg or 80 mmHg in patients with intracranial hypertension?
To ensure adequate cerebral perfusion
What is the name of the position that would be contraindicated in patients with intracranial hypertension?
Trendelenburg position
What is the primary purpose of awareness in problem determination?
To understand the nature of the problem
What is a barrier to goal setting between the nurse and the family?
Failure of the family to perceive the existence of the problem
Why might a family refuse to take action despite perceiving a problem?
Fear of consequences of taking action
What is the primary effect of a family's failure to perceive a problem?
Delayed intervention
What is the main benefit of preventive potential?
Minimizing future health problems
Why is modifiability of the problem an important consideration?
To determine the feasibility of intervention
Study Notes
Ketoacidosis
- Kussmaul respiration is a clinical manifestation of ketoacidosis, representing the body's attempt to decrease acidosis by counteracting the effect of ketone buildup.
- Lethargy is a possible mental status variation in ketoacidosis.
- Acetone breath odor occurs due to elevated ketone levels.
Appendicitis
- Appendicitis occurs when the appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith, tumor, or foreign body.
- Rovsing's sign may be elicited by palpating the left lower quadrant, causing pain to be felt in the right lower quadrant.
- Obturator sign is a clinical sign of acute appendicitis, defined as discomfort felt during slow internal movement of the hip joint while the right knee is flexed.
Nursing Practice
- Airway, Breathing, and Circulation (ABC) principles:
- Airway: opening and maintaining an airway.
- Breathing: providing artificial ventilation by rescue breathing if spontaneous respirations are absent or inadequate.
- Circulation: promoting artificial circulation by external cardiac compression when there is no pulse; administering medications (e.g., epinephrine for asystole).
- Defibrillation: using a standard defibrillator or automatic external defibrillator (AED) for ventricular tachycardia and ventricular fibrillation.
Positioning
- Head elevation up to 30 degrees is recommended to help decrease intracranial pressure (ICP), provided a safe cerebral perfusion pressure (CPP) of at least 70 mmHg or even 80 mmHg is maintained.
Intracranial Pressure (ICP)
- Decreasing systolic pressure, increasing body temperature, and unequal pupil size are signs of increasing ICP.
- Pupillary reactivity is an early indicator of increased ICP.
Barriers to Goal Setting
- Failure of the family to perceive the existence of a problem is a barrier to joint goal setting between the nurse and the family.
Modifiable Risk Factors
- Smoking, high blood pressure, high cholesterol, and being overweight are modifiable risk factors that a patient can work on to prevent another heart attack.
Licensure Examination
- The National Licensure Examination (NLE) is administered by the Professional Regulation Commission, Board of Nursing.
- The examination aims to protect the public from incompetent practitioners and demonstrates expected competency standards.
Regulatory Functions
- The PRC-Board of Nursing (PR-BON) has the power to regulate nursing practice in the Philippines, including enforcing and monitoring quality standards of nursing practice.
Respiratory Signs
- Slow, irregular respiration is a respiratory sign that may indicate increasing intracranial pressure in the brain stem.
Neurological Deterioration
- Early indications of deterioration in neurological status include:
- Dilated, fixed pupil.
- Widening of pulse pressure.
- Decrease in the level of consciousness, an early sign of cerebral hypoxia and increased ICP.
- Decrease in pulse rate.
This quiz assesses the nurse's knowledge of modifiable risk factors to prevent heart attacks. It focuses on the factors that can be controlled by patients to reduce the risk of another heart attack.
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