MEDICAL SURGICAL NURSING QUESTION AND RATIONALE

SITUATION : Dervid, A registered nurse, witnessed an old woman hit by a motorcycle
while crossing a train railway. The old woman fell at the railway. Dervid Rushed at the
scene.

1. As a registered nurse, Dervid knew that the first thing that he will do at the scene is

A. Stay with the person, Encourage her to remain still and Immobilize the leg while
While waiting for the ambulance.
B. Leave the person for a few moments to call for help.
C. Reduce the fracture manually.
D. Move the person to a safer place.

RATIONALE: The old woman is in the middle of a train railway. It is very unsafe to immobilize here legs and remain still at the middle of a railway considering that a train might come anytime while waiting for an ambulance. Safety is the utmost importance at this point. If letter D is not among the choices and the situation is a little less dangerous, the answer will be A. Remember that in all cases of emergencies, removing the victim from the scene to a much safer place is a priority.

2. Devid suspects a hip fracture when he noticed that the old woman’s leg is

A. Lengthened, Abducted and Internally Rotated.
B. Shortened, Abducted and Externally Rotated.
C. Shortened, Adducted and Internally Rotated.
D. Shortened, Adducted and Externally Rotated

RATIONALE: Sadder should be your keyword. A hip fracture will produce a shortened, adducted and externally rotated extremity. Treatment will evolve in casting the leg and putting it in a extension, neutrally positioned and slight external rotation. In Hip prosthesis, The nurse should maintain the client’s leg in FLEXION, EXTERNAL ROTATION and ABDUCTION to prevent the dislocation of the prosthesis from the acetabulum. Take note of the difference because I mistakenly answered the LATTER in casting a hip fracture thinking that it is similar to the leg positioning in hip dislocation. Just imagine a patient with a cast that has his leg in ABDUCTION, EXTERNAL ROTATION AND FLEXION. It will cause flexion contractures.

3. The old woman complains of pain. John noticed that the knee is reddened, warm to
touch and swollen. John interprets that this signs and symptoms are likely related to

A. Infection
C. Thrombophlebitis
B. Inflammation
D. Degenerative disease

RATIONALE: After a trauma, Inflammation will start almost instantly. Infection occurse 24-48 hours after bone fracture and not immediately. Thrombophlebitis occurs within 4 to 7 days of hospitalization after prolonged immobilization. There is no evidence that the client has a degenerative disease and degenerative diseases will manifest in variety of ways and not after a trauma.

4. The old woman told John that she has osteoporosis; Dervid knew that all of the
following factors would contribute to osteoporosis except

A. Hypothyroidism
B. End stage renal disease
C. Cushing’s Disease
D. Taking Furosemide and Phenytoin

Rationale: B,C,D all contributes to bone demineralization except HYPOTHYROIDISM.
Hyperthyroidism will contribute to bone demineralization as well as Hyperparathyroidism due to the increase in PTH, It will cause the movement of calcium from the bone to the blood causing HYPERCALCEMIA. ESRD will cause increase in PHOPHSATE due to its poor excretion. The amount of phosphate is inversely proportional to the amount of calcium. Cushing disease promotes bone demineralization as well as medications like diuretics and anti convulsant.

5. Martha, The old woman was now Immobilized and brought to the emergency room.
The X-ray shows a fractured femur and pelvis. The ER Nurse would carefully monitor
Martha for which of the following sign and symptoms?

A. Tachycardia and Hypotension
B. Fever and Bradycardia
C. Bradycardia and Hypertension
D. Fever and Hypertension

Rationale: Hemorrhage results in severing of the vascular supply of the bone of the femur and the pelvis due to the fracture leading to bleeding causing the s/s of tachycardia and hypotension.

SITUATION: Mr. D. Rojas, An obese 35 year old MS Professor of OLFU Lagro is
admitted due to pain in his weight bearing joint. The diagnosis was Osteoarthritis.

6. As a nurse, you instructed Mr. Rojas how to use a cane. Mr. Rojas has a weakness on
his right leg due to self immobilization and guarding. You plan to teach Mr. Rojas to hold
the cane

A. On his left hand, because his right side is weak.
B. On his left hand, because of reciprocal motion.
C. On his right hand, to support the right leg.
D. On his right hand, because only his right leg is weak.

RATIONALE: Reciprocal motion is a very important aspect of rehabilitation. Mr. Rojas has a weakness on his right leg. If a human moves his right leg, the left arm will accompany the movement of the right leg. That is what you call RECIPROCAL MOTION which is innate, natural and required to maintain balance. Mr. Rojas has weakness in his RIGHT LEG. If we put the cane on his right arm, The client will then be left UNSUPPORTED when he use his stronger leg [LEFT LEG] and stand with his weaker leg [RIGHT LEG] due to the fact that the opposite arm must accompany the movement of the opposite leg [RIGHT ARM]. In a more easier term, Always put the cane on the opposite of the weaker side. A is not correct because the client is NOT hemiplegic and will never be correct to reason out why the cane must always be at the opposite of the weaker side, it will always be due to reciprocal motion.

7. You also told Mr. Rojas to hold the cane

A. 1 Inches in front of the foot.
B. 3 Inches at the lateral side of the foot.
c. 6 Inches at the lateral side of the foot.
D. 12 Inches at the lateral side of the foot.

RATIONALE: Remove option A, the client will kick off the cane if it was in the front of the foot. Remove option D because that is too far and will cause the cane to poorly support theclient because the side, not the tip, is touching the ground. At 3 inches, imagine how
short it is and will cause a very poor supporting base. The correct answer is anywhere
from 6 to 10 inches for both crutches and cane.

8. Mr. Rojas was discharged and 6 months later, he came back to the emergency room of
the hospital because he suffered a mild stroke. The right side of the brain was affected. At the rehabilitative phase of your nursing care, you observe Mr. Rojas use a cane and you intervene if you see him

A. Moves the cane when the right leg is moved.
B. Leans on the cane when the right leg swings through.
C. keeps the cane 6 Inches out to the side of the right foot.
D. Holds the cane on the right side.

RATIONALE: If the right side of the brain is affected, weakness will always be CONTRALATERAL and therefore, Mr. Rojas will have weakness on his left side. Earlier I told you that cane is held on the opposite side of the weaker side, which in this situation, will be on the RIGHT. Imagine if the client moves his RIGHT LEG together with the RIGHT CANE, it already violated the LAW OF RECIPROCAL MOTION. Moving the right leg will require Mr. Rojas to move his left arm and not the cane, which is on his right.

SITUATION: Alfred, a 40 year old construction worker developed cough, night sweats
and fever. He was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG vaccine during childhood

9. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also
known as

A. PPD
B. PDP
C. PDD
D. DPP

RATIONALE: PPD stands for purified protein derivative. It is used to check for TB exposure. All clients who had BCG need not perform this test because they will always be + .

10. The nurse would inject the solution in what route?

A. IM
B. IV
C. ID
D. SC

RATIONALE: A Wheal is created intradermally and then it is marked and timed. reading will be done within 2 to 3 days.