APRIL 1999 PAPER 1

CLINICAL NURSING ESSAY –TYPE TEST ITEMS

SCENARIO 1 ITEM 1
Jimmy, a 17 yr old secondary school student, was brought to the A&E by his parents.
They were concerned about the following changes in his behavior.
 Mood swings

 Rigid posture

 Staring into space without speaking

 Loss of weight

They suspected that he is a substance abuser. He was subsequently admitted to the

psychiatric unit for observation and treatment.
ITEM 1
Specify nursing intervention measures for the following nursing diagnosis developed
for jimmy.
1. Alteration in nutrition (8pts)
2. Impaired verbal communication (8pts)
3. Ineffective individual coping (8pts)
Total 24 points
*Approximately 250 words

SCENARIO 2 ITEM 2
Mrs. Mary Mark 33yrs is the mother of 4 children ages 5-12. She was admitted to the
surgical unit with a history of Breast Cancer and was scheduled for Right Total
Mastectomy. Her husband accompanied her and they were both fearful and anxious.
Surgery was performed 2 days later. She returned to the unit with blood transfusion in
progress and vacuum drainage institu. She was restless and complained of severe pain.
ITEM #2
Determine the nursing intervention measures, which will assist Mrs. Mark in meeting
the following needs during the first 48 hrs after surgery.
A. Comfort (8pts)
1. Position on unaffected side
2. Position affected arm elevated on pillow
3. Assist with turning
 4. Meet hygienic needs
5. Ensure bed is clean and wrinkled free
6. Ensure quiet environment
7. Ensure deep breathing exercises
8. Diversional activities
9. Assess pain level using pain scale
10.Analgesics as ordered for pain
11.First post op day instruct pt to get up out of bed unaffected
side to prevent DVT

B. Fluid and Electrolyte (6 pts)

1. Monitor blood transfusion and maintain at right rate
2. Monitor I and O charts
3. Monitor drains and chart output
4. Maintain NPO status initially to prevent paralytic ileus
5. Graduated feed or fluids as ordered when fully awake
6. Administer fluids as ordered
7. Monitor urine output
C. Safety and Security (8pts)
1. Monitor for reaction to blood transfusion
2. Monitor dressings for signs of hemorrhage
3. Ensure hemorrhage drainage system is patent, asses
drainage site, noting colour and consistency
4. Monitor V/S Q15 mins for the first hr then 1/2 hrly until
stable
5. Place pt in lateral position until fully awake
6. Elevate affected arm on pillow
7. Nurse pt with bed rails
8. Ensure pt airway
9. Give humidified oxygen 3-5 L as ordered/ prn
10.Ambulate first post op day to prevent clot formation and
constipation
11. First post op day encourage use of affected arm such as
opening and closing fist, flexing and extending elbow
each hour.
12.Perform drain site care using aseptic technique
13.Ensure no B/P on affected and post sign alerting
members of the health team. Ensure no IM injection or
venepuncture is done on that hand.
14.Administer prophylactic antibiotics as ordered
 15.Monitor site for signs of infiltration or infection
D. Love and Belonging (6 pts)

1. Develop a nurse pt relationship

2. Encourage pt to verbalize feelings re change in body structure
3. Encourage pt to look at op site
4. Encourage husband to support and look at op site
5. Counseling
6. Refer to support groups on discharge
7. Involve family in care
8. Assess pt for fear and uncertainty , apprehension

E. Patient and Family Education / Discharge Teaching

1. Ensure that affected hand is never used for B/P, injections, or
venepuncture
2. On discharge continue with simple exercises such as squeezing a
ball, bending and extending the elbow, combing hair
3. Avoid placing affected extremity in dependent position for long
periods.
4. If edema is present elevate hands as much as necessary. If edema
increases notify HCP immediately
5. Maintain hygienic needs and avoid getting dressing wet if discharged
with one.
6. If discharged with drains, teach how to empty and re-apply vacuum
pressure to drains. Teach to observe colour, consistency and to asses
site for signs of infection (redness, swelling, heat, odour)
7. Do not carry heavy objects in the affected arm (pocket book,
package)
8. Wear rubber gloves when washing dishes and gardening.
9. Use unaffected arm when removing hot items from the oven or
protect affected arm by wearing padded gloves or pot holders.
10.Use thimble when sewing, wash needle pricks and covers as
necessary.
11.Use softening lotions or creams to keep hand in soft supple
condition.
12.Take care when trimming nails, do not use scissors
13.Avoid sun burn. Wear protective clothing or use sunscreen.
14.Tend to cuts immediately by washing and applying protective
covering.
15.Use insect repellant when in an area where biting and stinging insects
maybe
16.Keep follow up appointments
17.Take medication as prescribe
18.Refer to support groups
19.Teach signs and symptoms of infection
20.Wear medical alert bracelet
21.Do not wear constricting clothing or jewelry on the affected arm
22.Self breast examination monthly.
23.Yrly mammograms
24.Refer to available resources
25.Tell about prosthesis and refer to appropriate personnel.
 Total 28 points
*Approximately 400-450 words

SCENARIO 3
ITEM 3
ITEM 3
Describe in approximately 300-350 words, the
nursing intervention measures for Mr. Brown over
the next 48 hours to meet the following needs:
A. Oxygen
(10pts)
1. Maintain air way patency
2. place in high fowlers position to
facilitate diaphragmatic
expansion aiding in adequate
ventilation
3. Auscultate breath sounds Q2-
4Hrs noting adventitious sounds
which could indicate congestion.
4. Encourage pt to cough and deep
breathe to clear airway and to
facilitate oxygen delivery to
lungs.
5. Administer oxygen 3-5L as
ordered to improve tissues
oxygenation.
6. Monitor ABG’s to detect severe
hypoxia or acidosis
7. Monitor o2 sat. to detect the
amount of o2 available to tissues
8. Monitor for cyanosis which
would indicate tissues hypoxia
9. Ensure that pt does not smoke as
this reduces the o2 capacity of the
lungs and causes more hypoxia.
 10.Ensure that room is adequately
ventilated.-improve oxygen
circulation.
11.Administer meds as ordered
(lasix, digoxin) to reduce
accumulation / edema , to
improve cardiac output so that
respiratory function will
improved respectedly.
12.Ensure pt does not have on tight
clothing –this could prevent
maximum lung expansion (to
prevent restriction)
13.Monitor V/S esp. respiration for
rate, depth, for baseline data
which will assist in determining
any improvement or deterioration

B.
C. Rest, Activity and Comfort
(3pts)
1. Cluster nsg care activities, allowing
time for rest, to avoid fatigue.
2. Monitor response to each activity and
observe for the development of
dyspnea to determine tolerance levels.
3. Assess V/S prior to activity,
immediately after and 3 mins later to
determine the length of time V/S take
to return to baseline which determines
the degree of cardiac deconditioning
and shows the ns how to plan
activities.
4. Limit activities to avoid fatigue that
demands more cardiac output than the
heart can manage.
5. Ensure pt is in high fowlers position to
promote comfort
6. Elevate limbs at interval to help
reduce edema
 7. Ns pt on stress reduction mattress.
8. Assist to change position Q2Hrly
9. Assist with ADOL
10.Strict bed rest
11. Place items within easy reach
(personal items)
12.Monitor stressful situations that cause
exertion e.g. too much visitors and
address this.
13.Administer meds as ordered
D. Elimination
(4pts)
1. Strict intake and output charting
to monitor fluid balance
2. Fluid restrictions as ordered to
prevent fluid overload
3. Monitor urinary frequency to
identify if kidney is being
adequately perfuse.
4. Administer diuretics as ordered to
increase urinary output.
5. Provide privacy to promote
elimination.
6. Administer cardiac glycosides to
improve blood flow to the
kidney’s/urinary system to aide in
excretion of excess fluid
7. Palpate bladder for distension and
provide measures to aid in
urination.
8. Assist with catheterization if
necessary
9. Assess effectiveness of diuretics

E. Safety and Security

(3pts)
1. Weigh pt daily before breakfast to
determine wt gain indicating fluid
retention
 2. Ensure low sodium as ordered to
prevent tubular reabsorption of water
leading to increased edema
3. Administer meds as ordered e.g. slow
K to replace K to maintain electrolyte
imbalance
4. Asses pulse rate before administering
digoxin and give only if above 60 bpm
5. Assess or monitor for signs of digitalis
toxicity (tachycardia, headache,
confusion)
6. Monitor lab results for serum digitalis
and K levels
7. Maintain fluid restrictions
8. Administer antihypertensives as
ordered
9. Nurse pt with bed rails up
10.Assess for hypokalemia (weak, tready
pulse, postural hypotension, anxiety,
lethargy, confusion, N&V)
11.Assess mental status
F. Psychosocial
(6pts)
1. Establish rapport to develop a nurse pt
relationship
2. Maintaining a calm and quiet
environment to provide psychosocial
rest by.
3. Encourage pt to verbalize fears for
identification of fears so that they can
be alley
4. Answer question truthfully and listen
to pts fears and concerns to develop
trust.
5. Involve or encourage family to
participate in care to provide
emotional support.
6. Encourage pt to participate in and
make decisions about care to
 allow/provide/ give, pt a sense of
worth
7. Assess for signs of anxiety to alley
anxiety.
8. Counsel pt about life style changes to
encourage adherence with therapy.
9. Refer to support groups to provide
additional emotional support and
develop new coping skills.
10.Refer to substance abuse centre for
rehabiltation.

Total 26 points

SCENARIO 4
ITEM 4
Mr. Service a seventy-five (75) year old
businessman is admitted to the surgical ward with a
diagnosis of Cancer of the prostate. He had a
radical prostatectomy performed and is returning to
the ward from Recovery Room He is receiving
blood transfusion and he is on continuous bladder
irrigation.
ITEM 3
Discuss the post operative nursing care for Mr.
Service during the first 24 hours, focusing on the
following needs:

A. Safety and Security

(12pts)
B. Fluid and Electrolytes
(6pts)
C. Psychosocial
(6pts)
Total 24 points
*Approximately 400-500 words