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Diploma in Nursing · 2023
UGANDA NURSES AND MIDWIVES EXAMINATIONS BOARD
Diploma in Nursing (Extension) – Paper Code: DNE 112
Medical Nursing III
SECTION A: OBJECTIVE QUESTIONS 20 Marks
1. Which of the following does a diploma Nurse instruct a certificate Nurse to perform on a patient with spinal cord compression?
Explanation: Delegation to a certificate nurse (or nursing assistant) should involve routine, non-invasive, and standardized basic care. Skin care (turning and repositioning) to prevent decubitus ulcers is a fundamental nursing task perfect for delegation. Ambulating a patient with spinal compression is highly risky and requires advanced clinical assessment.
2. Which of the following is the most appropriate nursing intervention for a patient with Parkinson’s disease?
Explanation: Parkinson’s patients suffer from severe postural instability and bradykinesia, making it very difficult for them to stand up from deep, soft, or low seating. Using upright, firm chairs with armrests significantly assists them in independently rising to a standing position.
3. The priority nursing intervention for a patient with subarachnoid haemorrhage is to
Explanation: A subarachnoid hemorrhage presents a massive risk for a secondary, fatal “re-bleed.” Any action that increases intracranial pressure—like straining during a bowel movement (Valsalva maneuver)—must be strictly avoided. A high-fiber diet, along with stool softeners, ensures soft stools and prevents this dangerous straining.
4. Which of the following measures should be avoided in the treatment of gout?
Explanation: Gout is caused by hyperuricemia. Acetylsalicylic acid (Aspirin) in low doses can actually decrease the renal excretion of uric acid, worsening the condition. Similarly, thiazide and loop diuretics drastically increase serum uric acid levels, precipitating acute gout attacks.
5. Reduced appetite, reduced physical activity and a coarse skin may be seen in
Explanation: These are classic hallmarks of hypothyroidism (myxedema). A slowed basal metabolic rate leads to profound lethargy (reduced physical activity), weight gain despite a poor appetite, and the dermatological hallmark of dry, thick, and coarse skin.
6. The most appropriate nursing diagnosis for a patient with oedema secondary to kidney disease is
Explanation: Edema occurs because the failing kidneys cannot excrete sodium and water, causing them to accumulate in the intravascular and interstitial spaces. Therefore, “Fluid Volume Excess” is the most direct, accurate NANDA-approved nursing diagnosis.
7. Moon face appearance in Cushing’ syndrome occurs due to
Explanation: Cushing’s syndrome is caused by an excessive level of glucocorticoids (cortisol). Cortisol profoundly alters lipid metabolism, leading to a highly characteristic redistribution and accumulation of fat deposits in the face (moon face), back of the neck (buffalo hump), and trunk (truncal obesity).
8. Which of the following interventions does the Nurse implement for a patient with nephrotic syndrome?
Explanation: Nephrotic syndrome causes massive proteinuria, leading to severe hypoalbuminemia and life-threatening generalized edema (anasarca). Nursing management strictly dictates restricting dietary sodium and fluid intake to prevent further fluid overload and pulmonary edema.
9. A Nurse should prevent dehydration in a patient with loss of fluid to avoid
Explanation: Severe dehydration leads to profound hypovolemia. This drastically drops blood pressure and severely reduces renal perfusion. If uncorrected, this ischemia rapidly destroys the kidney tubules, resulting in Pre-Renal Acute Kidney Injury (Renal Failure).
10. Which action does the Nurse perform first for a patient admitted with hyper thyroidism?
Explanation: In any emergency or medical admission, the fundamental ABCs of resuscitation (Airway, Breathing, Circulation) take absolute precedence. Furthermore, severe hyperthyroidism often presents with a massively enlarged goiter which can physically compress the trachea, making airway patency the undisputed priority.
11. Which of the following is a priority nursing intervention for a patient complaining of lower back pain?
Explanation: For acute, severe lower back pain (often due to muscle spasms or a herniated disc), the initial conservative nursing intervention historically prescribed is short-term bed rest on a firm mattress (often in the Williams position) to immediately relieve the mechanical stress and spasm in the lumbar region.
12. Which of the following symptoms is most indicative for diabetes insipidus?
Explanation: Diabetes Insipidus (DI) results from a lack of Anti-Diuretic Hormone (ADH). Without ADH, the kidneys cannot concentrate urine, leading to massive, life-threatening polyuria. To compensate for this extreme water loss, the patient develops an intense, unquenchable thirst (Polydipsia).
13. The neuropathic pain following one or more skin dermatomes lasting for 1-10 days is most likely due to
Explanation: Herpes Zoster (Shingles) is the reactivation of the Varicella-Zoster virus, which lies dormant in the dorsal root ganglion. When it reactivates, it travels down the specific sensory nerve, causing an extremely painful, vesicular rash strictly limited to a specific unilateral dermatome.
14. Which of the following pieces of advice does the nurse share with a patient of osteoporosis?
Explanation: Osteoporosis causes porous, brittle bones. A cornerstone of management is maximizing bone density through nutrition. The nurse must highly encourage the intake of calcium-rich foods (like milk) and Vitamin D, which is essential for the intestinal absorption of that calcium. (Weight-bearing exercises are also encouraged, making (c) incorrect).
15. A diploma nurse educates certificate nurses that risk factors for osteoporosis in women exclude
Explanation: Estrogen is highly protective of bone density. Early menopause strips the body of estrogen prematurely, massively increasing osteoporosis risk. Conversely, late menopause means the woman’s skeleton benefits from the protective effects of estrogen for a longer duration, making it a protective factor, not a risk factor.
16. A nurse relates sleep disturbance in a patient with diabetes insipidus to
Explanation: Because Diabetes Insipidus causes the uncontrolled excretion of massive amounts of dilute urine (up to 20 liters a day), the patient suffers from severe nocturia. They must wake up constantly throughout the night to urinate (polyuria) and to drink water (polydipsia), completely fracturing their sleep cycle.
17. Which of the following conditions affect the fifth cranial nerve?
Explanation: The fifth cranial nerve (CN V) is the Trigeminal nerve, responsible for sensation in the face. Trigeminal Neuralgia is a chronic pain condition specifically affecting this nerve. (Bell’s palsy affects the Facial nerve, CN VII).
18. What immediate nursing action does the nurse take while caring for a patient suffering from renal failure who complains of difficulty in breathing?
Explanation: Dyspnea in renal failure is usually due to severe fluid overload leading to pulmonary edema. The fastest, most immediate independent nursing action is to sit the patient upright (High-Fowler’s position). This uses gravity to pull fluid to the lung bases and drops the diaphragm, instantly maximizing lung expansion.
19. While assessing range of motion in a patient’s hand, the nurse requests the patient to
Explanation: Option (d) is the most comprehensive assessment of hand and digit Range of Motion (ROM). Making a fist tests the flexion of all interphalangeal and metacarpophalangeal joints, and opposing each finger tests the complex, multi-axial rotation and dexterity of the thumb saddle joint.
20. Which assessment finding does the nurse expect to see in a patient with effusion of the right knee?
Explanation: A joint effusion is an abnormal buildup of synovial fluid within the joint capsule. This rapid accumulation of fluid drastically increases internal joint pressure, causing severe, throbbing pain and physically blocking the joint from achieving its full range of motion.
SECTION A: FILL IN THE BLANK SPACES 10 Marks
OSTEOARTHRITIS
DAILY WEIGHING
TRANSVERSE MYELITIS
MOTOR CONTROL / MOVEMENT
ADDISONIAN CRISIS
CUSHING’S SYNDROME
TRIGEMINAL NEURALGIA
LYMPHOMA
INFECTION / INFLAMMATION
DIABETES INSIPIDUS
SECTION B: SHORT ESSAY QUESTIONS 10 Marks
Question 31: Complications of Lymphangitis (5 Marks)
State five (5) complications of lymphangitis:
- Septicemia (Sepsis): The localized infection rapidly enters the bloodstream, causing a life-threatening systemic inflammatory response.
- Abscess Formation: The infection centralizes and forms painful, pus-filled pockets within the lymphatic channels or surrounding soft tissues.
- Cellulitis: The bacterial infection spreads aggressively beyond the lymphatic vessels into the deeper dermal and subcutaneous skin layers.
- Lymphedema: Severe, chronic inflammation permanently damages the lymphatic vessels, preventing fluid drainage and causing chronic swelling of the limb.
- Suppurative Thrombophlebitis: The infection extends from the lymphatics into adjacent veins, causing blood clots heavily infected with bacteria.
Question 32: Signs and Symptoms of Parkinson’s Disease (5 Marks)
Outline five (5) signs and symptoms of Parkinson’s disease:
- Resting Tremors: A highly characteristic “pill-rolling” tremor in the hands and fingers that is most prominent when the limb is completely at rest.
- Bradykinesia: Extreme slowness in the initiation and execution of voluntary movements, making routine tasks like buttoning a shirt incredibly difficult.
- Muscle Rigidity: Increased resistance to passive movement resulting in a stiff, jerky “cogwheel” rigidity when limbs are moved by an examiner.
- Postural Instability: Loss of normal postural reflexes leading to a stooped posture, a shuffling gait, and a severely increased risk of falling backward.
- Mask-like Facies: Severe loss of facial muscle mobility, resulting in a blank, staring, expressionless face and decreased blinking.
SECTION C: LONG ESSAY QUESTIONS 60 Marks
Question 33: Osteoarthritis (20 Marks)
(a) State five (5) signs and symptoms of osteoarthritis (5 marks):
- Activity-Induced Joint Pain: A deep, aching joint pain that specifically worsens with physical weight-bearing activity and is relieved by rest.
- Morning Stiffness: Joint stiffness upon waking up, which characteristically lasts for a short duration (less than 30 minutes) before loosening up with movement.
- Crepitus: A harsh, audible grating or crackling sensation felt within the joint when moved, caused by bone rubbing on bone where cartilage is lost.
- Bony Enlargements: Hard, painless bony outgrowths at the finger joints, specifically known as Heberden’s nodes (DIP joints) and Bouchard’s nodes (PIP joints).
- Decreased Range of Motion: Progressive inability to fully extend or flex the affected joint due to bone spurs (osteophytes) blocking movement.
(b) Outline ten (10) nursing interventions for managing a patient with osteoarthritis (10 marks):
- Administer prescribed NSAIDs or acetaminophen to control pain and inflammation.
- Apply heat packs to relieve joint stiffness and cold packs to numb acute pain.
- Educate the patient on strict weight reduction to minimize mechanical stress on knees and hips.
- Advise balancing periods of activity with scheduled rest periods to prevent joint exhaustion.
- Collaborate with a physiotherapist for safe, low-impact muscle-strengthening exercises (like swimming).
- Provide and teach the correct use of assistive devices (canes, walkers) to offload joint pressure.
- Assess the home environment and advise on modifications (grab bars, removing rugs) to prevent falls.
- Teach joint-protection techniques, such as using two hands to lift heavy objects.
- Encourage the use of custom orthotic splints or braces to stabilize severely weakened joints.
- Provide continuous psychological support and counseling to help the patient cope with chronic pain.
(c) Outline five (5) effects of osteoarthritis on a patient’s daily life (5 marks):
- Loss of Independence: The inability to perform basic Activities of Daily Living (ADLs) such as dressing, cooking, or bathing without assistance.
- Social Isolation: Severe mobility restrictions prevent the patient from attending social gatherings, church, or community events, leading to loneliness.
- Economic Hardship: Chronic pain and physical limitations often force early retirement or job loss, leading to severe financial strain.
- Sleep Deprivation: Unrelenting, deep joint pain frequently wakes the patient at night, leading to chronic exhaustion and irritability.
- Psychological Distress: The chronic nature of the pain and the loss of physical capability frequently trigger severe clinical depression and anxiety.
Question 34: Hypothyroidism (20 Marks)
(a) State ten (10) clinical features of hypothyroidism (5 marks):
- Unexplained, stubborn weight gain.
- Extreme cold intolerance.
- Profound fatigue and lethargy.
- Severe, chronic constipation.
- Dry, coarse, and flaky skin.
- Bradycardia (abnormally slow heart rate).
- Hoarse, croaky voice.
- Heavy or irregular menstrual periods.
- Muscle weakness and aching joints.
- Depression and slowed cognitive thinking.
(b) Outline ten (10) specific nursing interventions implemented in the management of a patient with hypothyroidism for the first 48 hours of admission (10 marks):
- Temperature Regulation: Provide extra blankets, warm clothing, and a draft-free room to combat severe cold intolerance, but avoid direct heat sources (like hot water bottles) due to decreased skin sensation.
- Respiratory Monitoring: Assess respiratory rate and depth continuously, as severe hypothyroidism depresses the respiratory drive and can lead to hypoxia.
- Cardiac Assessment: Perform continuous ECG monitoring and vital checks to detect dangerous bradycardia, hypotension, or signs of heart failure.
- Medication Administration: Administer prescribed synthetic thyroid hormones (Levothyroxine) exactly on time, strictly on an empty stomach, to ensure maximum absorption.
- Dietary Management: Provide a low-calorie, high-fiber diet to address the slowed metabolic weight gain and severe gastrointestinal sluggishness.
- Bowel Care: Push adequate fluid intake and administer prescribed stool softeners to prevent severe fecal impaction or paralytic ileus.
- Neurological Checks: Monitor the patient’s level of consciousness frequently to catch early signs of slipping into a fatal myxedema coma.
- Skin Care: Apply rich emollients and lotions to prevent breakdown of the characteristically dry, fragile, and edematous skin.
- Medication Caution: Withhold or drastically reduce the dose of any sedatives, narcotics, or anesthetics, as the slowed metabolism makes the patient exquisitely sensitive to these drugs.
- Safety/Fall Precautions: Keep the bed in a low position and assist with all ambulation due to the patient’s severe muscle weakness and slowed reflexes.
(c) Outline five (5) complications of hypothyroidism (5 marks):
- Myxedema Coma: A rare, extreme, and life-threatening decompensation causing hypothermia, cardiovascular collapse, and profound unconsciousness.
- Heart Disease: Chronic high cholesterol (caused by slow metabolism) leads to severe atherosclerosis, coronary artery disease, and eventual heart failure.
- Peripheral Neuropathy: Long-term untreated disease causes structural damage to peripheral nerves, leading to pain and numbness in the limbs.
- Severe Infertility: Disruption of ovulation cycles making it incredibly difficult for affected women to conceive, or leading to birth defects if pregnant.
- Major Depression: The profound biochemical slowing of brain activity can result in severe, treatment-resistant clinical depression.
Question 35: Addison’s Disease (20 Marks)
(a) State five (5) causes of Addison’s disease (5 marks):
- Autoimmune Adrenalitis: The body’s immune system erroneously attacks and destroys the adrenal cortex (accounts for ~80% of cases).
- Tuberculosis: The TB mycobacterium physically infiltrates and destroys the adrenal glands, common in developing nations.
- Metastatic Carcinoma: Cancers originating in the lungs, breasts, or other organs spread to and consume the adrenal tissue.
- Bilateral Adrenal Hemorrhage: Massive bleeding into the adrenal glands often triggered by severe trauma, anticoagulant use, or meningococcal sepsis (Waterhouse-Friderichsen syndrome).
- Fungal Infections: Severe systemic fungal infections like histoplasmosis or cryptococcosis invading the adrenal structures.
(b) State ten (10) clinical manifestations of Addison’s disease (5 marks):
- Hyperpigmentation (bronzing) of the skin.
- Profound, unrelenting fatigue.
- Postural (orthostatic) hypotension.
- Severe, unexplained weight loss.
- Nausea, vomiting, and diarrhea.
- Intense craving for salty foods.
- Hypoglycemia (low blood sugar).
- Diffuse abdominal or flank pain.
- Irritability and severe depression.
- Muscle weakness and joint pains.
(c) Outline ten (10) specific nursing interventions for a patient with Addison’s disease, till discharge (10 marks):
- Hormone Replacement: Strictly administer the prescribed oral corticosteroids (e.g., Hydrocortisone) and mineralocorticoids (e.g., Fludrocortisone) exactly on the prescribed schedule to mimic natural circadian rhythms.
- Fluid Resuscitation: Establish a large-bore IV and aggressively administer normal saline or 5% Dextrose in normal saline to reverse severe dehydration and hypoglycemia.
- Electrolyte Monitoring: Continuously monitor laboratory results, specifically watching for life-threatening hyperkalemia (high potassium) and hyponatremia (low sodium).
- Orthostatic Vital Signs: Measure blood pressure while the patient is lying down, sitting, and standing to detect dangerous orthostatic drops, preventing syncope and falls.
- Dietary Management: Provide and encourage a specialized diet that is high in sodium, high in complex carbohydrates, and adequate in protein.
- Stress Minimization: Place the patient in a quiet, temperature-controlled, low-stress environment, as their body physically cannot produce cortisol to handle any form of physical or emotional stress.
- Infection Prevention: Enforce strict aseptic techniques and limit visitors, as the patient is highly vulnerable, and even a mild infection can trigger a fatal Addisonian crisis.
- “Sick Day Rules” Education: At discharge, rigorously teach the patient that they must double or triple their steroid dose during times of illness, fever, or severe stress to survive.
- Emergency Kit Training: Instruct the patient and family on how to properly draw up and inject emergency IM Hydrocortisone (Solu-Cortef) if the patient begins vomiting and cannot take oral pills.
- Medical Identification: Ensure the patient understands they must wear a medical alert bracelet at all times so emergency responders know to immediately inject steroids if they are found unconscious.