Medicine UNMEB PASTPAPERS Q&A
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Medicine Nursing III - UNMEB Past Papers
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?
(a) Care of the patient's skin to prevent bed sores
Spinal cord compression causes neurogenic deficits including paralysis and sensory loss, leading to immobility and inability to feel pressure. The most critical nursing priority is pressure ulcer prevention through meticulous skin care, 2-hourly turning, pressure-relieving surfaces, and skin inspection. This prevents life-threatening complications like sepsis from infected pressure sores.
SPINAL CORD COMPRESSION PRIORITIES: "P-4" - Pressure care, Paralysis management, Pain control, Prevention of complications (UTI, DVT)
2
Which of the following is the most appropriate nursing intervention for a patient with Parkinson's disease?
(b) Use upright chairs
Parkinson's disease causes postural instability, stooped posture, and difficulty rising from chairs. Upright, armless chairs with firm cushions and high seats facilitate easier transfers, maintain proper spinal alignment, improve lung expansion for dyspnea, and reduce fall risk. This is a key environmental modification for safety and independence.
๐ช Chair Selection Matters: High seat (19-20 inches), firm cushion, armrests, back support. Avoid low sofas - patient can't get up due to bradykinesia!
3
The priority nursing intervention for a patient with subarachnoid haemorrhage is to
(a) Carry out passive movements of the paralysed limbs
Subarachnoid hemorrhage causes neurological deficits including hemiplegia. Passive range of motion exercises prevent contractures, muscle atrophy, joint stiffness, and DVT in paralyzed limbs. This is a critical nursing intervention during the acute phase when patient is immobile. Should be done 2-3 times daily, maintaining full joint range.
SAH NURSING CARE: "PASS" - Prevent vasospasm, Airway maintenance, Seizure precautions, Skin care
4
Which of the following measures should be avoided in the treatment of gout?
(c) Use of acetylsalicylic acid and diuretics
Low-dose aspirin and thiazide diuretics impair renal excretion of uric acid by inhibiting renal tubular secretion. This raises serum uric acid levels and precipitates gout attacks. Alternative antihypertensives (ACE inhibitors, ARBs) and analgesics should be used. Loop diuretics are less problematic but still require caution.
โ ๏ธ Medication Review Essential: Always check patient medications for gout triggers! Aspirin, thiazides, cyclosporine, niacin are common culprits.
5
Reduced appetite, reduced physical activity and a coarse skin may be seen in
(d) Hypothyroidism
Hypothyroidism slows metabolic rate causing fatigue (reduced activity), decreased appetite (despite weight gain from fluid retention), and characteristic dry, coarse, cool skin due to reduced sebaceous gland activity and dermal glycosaminoglycan accumulation. Also associated with hair loss, bradycardia, and cold intolerance - classic triad of slowed metabolism.
HYPOTHYROIDISM: "COARSE" - Cold intolerance, Obesity, Dry skin, Anorexia, Reduced activity, Sluggish, Emaciation (paradoxical with weight gain)
6
The most appropriate nursing diagnosis for a patient with oedema secondary to kidney disease is
(b) Fluid volume excess
Renal disease causes sodium and water retention due to glomerular dysfunction and decreased GFR. This leads to extracellular fluid volume expansion manifesting as peripheral edema, pulmonary edema, hypertension, and weight gain. The primary pathophysiological problem is fluid overload, not deficit. Nursing diagnosis must reflect the actual problem to guide appropriate interventions (fluid restriction, diuretics, dialysis).
๐ง Edema in Renal Disease: First morning periorbital edema is classic! Due to fluid redistribution when supine. Check for pitting edema in dependent areas.
7
Moon face appearance in Cushing's syndrome occurs due to
(d) Accumulation of fat
Excess cortisol causes abnormal redistribution of adipose tissue leading to centripetal obesity with characteristic facial fat pad accumulation (moon face), supraclavicular fat pads, and buffalo hump. This is due to cortisol's effect on lipid metabolism and insulin resistance, not simple edema. The face becomes rounded, plethoric, and may have acne and hirsutism.
CUSHING'S FEATURES: "M-B-P-T" - Moon face, Buffalo hump, Purple striae, Thin skin
8
Which of the following interventions does the Nurse implement for a patient with nephrotic syndrome?
(b) Restrict fluid intake
Nephrotic syndrome causes massive proteinuria leading to hypoalbuminemia and severe edema. Fluid restriction (typically 1-1.5L/day) is essential to prevent worsening of anasarca, pulmonary edema, and hypertension. Fluid allowance is calculated based on urine output + 500mL insensible losses. Must be combined with salt restriction (<2g/day) and diuretics.
โ ๏ธ Fluid Restriction Challenge: Patients are very thirsty. Use ice chips, small frequent sips, sugar-free gum, and oral hygiene to help manage thirst while restricting fluids.
9
A Nurse should prevent dehydration in a patient with loss of fluid to avoid
(d) Renal failure
Severe dehydration causes prerenal azotemia by reducing renal blood flow and GFR. If prolonged (>6 hours of severe hypoperfusion) it leads to acute tubular necrosis and acute kidney injury (renal failure). This is a preventable cause of AKI. Vigorous fluid replacement with isotonic crystalloids is essential to restore perfusion and prevent irreversible kidney damage.
RENAL FAILURE CAUSES: "PRA" - Pre-renal (dehydration), Renal (ATN, glomerulonephritis), Post-renal (obstruction)
10
Which action does the Nurse perform first for a patient admitted with hyper thyroidism?
(b) Maintain a patent airway
In severe hyperthyroidism or thyroid storm, airway compromise can occur due to tracheal compression from goiter, respiratory muscle weakness, or altered mental status. Airway, Breathing, Circulation (ABCs) is always the priority in any acute admission. Thyroid storm can cause airway edema and laryngeal stridor requiring immediate intervention.
๐จ Thyroid Storm = Emergency! Airway assessment first, then temperature control (cooling blankets), cardiac monitoring, beta-blockers, and PTU (propylthiouracil). ABCs always!
11
Which of the following is a priority nursing intervention for a patient complaining of lower back pain?
(a) Ensure bed rest
Acute mechanical low back pain requires short-term bed rest (24-48 hours) to reduce spinal loading and muscle spasm. Short periods of rest allow acute inflammation to settle while preventing deconditioning. Prolonged bed rest >2 days is harmful and leads to muscle weakness. Should be combined with proper positioning (semi-Fowler's with knees flexed) and gradual mobilization.
BACK PAIN MANAGEMENT: "REST" - Rest (short-term), Exercise (gradual), Support, Traction (if indicated)
12
Which of the following symptoms is most indicative for diabetes insipidus?
(b) Polydipsia
Diabetes insipidus is characterized by deficiency of ADH (central) or resistance to ADH (nephrogenic) causing massive polyuria (5-20L/day). Excessive water loss triggers intense thirst (polydipsia) as a compensatory mechanism. This is the hallmark symptom along with dilute urine (low specific gravity) and nocturia. Polydipsia is more prominent than in DM as the dehydration is more severe.
๐ง DI vs DM: DI = Dilute urine, huge volumes, severe thirst. DM = Glucose in urine, moderate polyuria, weight loss, hyperglycemia.
13
The neuropathic pain following one or more skin dermatomes lasting for 1-10 days is most likely due to
(c) Herpes zoster
Herpes zoster (shingles) is reactivation of varicella-zoster virus in dorsal root ganglia, causing severe burning, stabbing neuropathic pain in a unilateral dermatomal distribution that precedes the vesicular rash by 1-5 days. Pain may persist for weeks (post-herpetic neuralgia). The dermatomal pattern is pathognomonic and distinguishes it from other skin conditions.
SHINGLES PAIN: "PHN" - Precedes rash, Hyperalgesia, Neuropathic quality, Dermatomal distribution
14
Which of the following pieces of advice does the nurse share with a patient of osteoporosis?
(a) Consume more milk and vitamin D
Osteoporosis is characterized by low bone mass and microarchitectural deterioration. Calcium (1000-1200mg/day) and Vitamin D (800-1000 IU/day) are essential for bone mineralization and reducing fracture risk. Milk provides calcium, phosphorus, and protein. Vitamin D enhances calcium absorption from gut. This is foundational non-pharmacological treatment alongside weight-bearing exercise.
๐ฅ Calcium Sources: Milk (300mg/cup), yogurt, cheese, sardines with bones, fortified foods. Vitamin D from sunlight (15 min daily), fatty fish, supplements.
15
A diploma nurse educates certificate nurses that risk factors for osteoporosis in women exclude
(a) Late menopause
Late menopause (after age 52) is actually PROTECTIVE against osteoporosis. Longer exposure to estrogen preserves bone density for a greater period. Early menopause (before 45) is a major risk factor. The question asks what to "exclude" from risk factors, making late menopause the correct answer as it's not a risk factor but rather protective.
OSTEOPOROSIS RISK FACTORS: "SCALE-OF" - Smoking, Corticosteroids, Alcohol, Low estrogen, Early menopause, Sedentary, Ovaries removed, Family history
16
A nurse relates sleep disturbance in a patient with diabetes insipidus to
(c) Polyuria
Nocturia (nighttime polyuria) is the direct cause of sleep disturbance in DI. Patients must wake frequently to void large volumes of dilute urine (3-20L/day). This disrupts sleep architecture, causing daytime fatigue, irritability, and decreased quality of life. The excessive urine output is due to inability to concentrate urine, not reduced osmolality (which is a lab finding, not a symptom).
๐ Nocturia Impact: Getting up >2 times/night significantly impairs sleep quality. Consider desmopressin at bedtime to allow sleep, but monitor for hyponatremia!
17
Which of the following conditions affect the fifth cranial nerve?
(d) Trigeminal neuralgia
The 5th cranial nerve is the trigeminal nerve (CN V). Trigeminal neuralgia causes severe lancinating pain along the distribution of one or more branches (ophthalmic V1, maxillary V2, mandibular V3) of CN V. The pain is triggered by light touch, chewing, talking, or brushing teeth. Bell's palsy affects CN VII (facial nerve), Parkinson's affects basal ganglia, and Myasthenia Gravis affects neuromuscular junctions.
CRANIAL NERVE V: "TRI" - Three branches (V1, V2, V3), Pain Triggered by touch, Intense lancinating pain
18
What immediate nursing action does the nurse take while caring for a patient suffering from renal failure who complains of difficulty in breathing?
(a) Elevate the head of the bed
Difficulty breathing (dyspnea) in renal failure is often due to pulmonary edema from fluid overload. Elevating the head of the bed 30-45ยฐ is an immediate, independent nursing action that improves lung expansion, reduces venous return to the heart (decreasing preload), decreases work of breathing, and alleviates anxiety. This should be done while preparing other interventions.
๐๏ธ Positioning Saves Lives: In pulmonary edema, sitting upright can decrease venous return by up to 500mL, providing immediate symptom relief while medical therapy is prepared!
19
While assessing range of motion in a patient's hand, the nurse requests the patient to
(d) Make a fist and then oppose each finger to the thumb
Assessing full hand function requires testing all joints and movements. Making a fist tests finger flexion and extension; thumb opposition tests thenar muscle function and C8-T1 nerve roots. This comprehensive assessment evaluates range of motion, coordination, and fine motor skills essential for activities of daily living (eating, dressing, writing). The "wave" test only assesses wrist movement, grip strength doesn't test ROM, and rapid palm rotation tests pronation/supination only.
HAND ASSESSMENT: "FIST" - Finger flexion/extension, Index-thumb opposition, Sensation, Thenar strength
20
Which assessment finding does the nurse expect to see in a patient with effusion of the right knee?
(a) Limitation in movement and accompanying pain
Knee effusion (excess synovial fluid in joint space) causes stretching of the joint capsule, which activates pain receptors and mechanically limits range of motion. The knee appears swollen (bulging suprapatellar pouch, positive patellar tap test), feels tight, and patient cannot fully flex or extend. Pain worsens with movement due to increased pressure. This is the most consistent finding.
๐ Patellar Tap Test: With knee extended, compress suprapatellar pouch, then tap patella. Positive if it "floats" and taps femur (indicates effusion >30-40mL).
SECTION B: Fill in the Blank Spaces (10 marks)
21
A degenerative joint disease characterized by destruction of articular cartilage and growth of bone tissue is called
Osteoarthritis
Osteoarthritis is the most common type of arthritis, characterized by progressive destruction of articular cartilage due to mechanical wear and tear, and formation of osteophytes (bone spurs) at joint margins. It involves subchondral bone sclerosis, synovial inflammation, and loss of joint space. Risk factors include age, obesity, joint injury, and genetics. Management focuses on pain control, exercise, weight management, and joint replacement in severe cases.
22
Apart from maintaining a fluid balance chart, the salt and water status of a patient is carefully monitored by
Monitoring electrolytes / serum osmolality / daily weight
Daily weights are the most sensitive indicator of fluid status changes - 1kg gain = 1L fluid retained. Electrolytes (especially sodium) reveal dysnatremia. Serum osmolality (normal 275-295 mOsm/kg) reflects concentration of solutes and helps differentiate types of hyponatremia. Fluid balance charts track intake vs output but don't reflect internal distribution or concentration. All three together provide comprehensive assessment of volume status.
23
Inflammation of both sides of one section of the spinal cord is termed as
Transverse myelitis
Transverse myelitis is acute inflammation across the entire width (transverse) of the spinal cord at a single level, causing motor, sensory, and autonomic dysfunction below the lesion. Etiologies include autoimmune diseases (MS, SLE), infections (viral, bacterial), and idiopathic. Presents with rapid onset of bilateral weakness, sensory loss, and sphincter dysfunction. Requires urgent treatment with high-dose corticosteroids and immunosuppression.
24
The brain changes caused by Parkinson's disease begin in a region that plays a key role in
Movement control / motor function / the substantia nigra
Parkinson's disease pathology begins in the substantia nigra pars compacta, where dopaminergic neurons degenerate. These neurons project to the striatum (caudate and putamen) via the nigrostriatal pathway, forming the basal ganglia motor circuit. Loss of dopamine disrupts the balance between direct and indirect motor pathways, leading to bradykinesia, rigidity, tremor, and postural instability. The substantia nigra is critical for initiating and controlling voluntary movements.
25
The Nurse administers high doses of corticosteroids and fluids in a patient suffering from
Adrenal crisis / Adrenal insufficiency / Septic shock (if related to infection causing adrenal insufficiency)
Adrenal crisis is a life-threatening emergency due to acute cortisol deficiency, characterized by hypotension, hypoglycemia, hyponatremia, and hyperkalemia. Treatment requires immediate IV hydrocortisone 100mg bolus then 50-100mg every 6 hours to replace glucocorticoids, and aggressive IV isotonic saline (1-2L in first hour) to correct hypotension and dehydration. Glucose may be needed for hypoglycemia. Early treatment prevents cardiovascular collapse and death.
26
Increased excretion of cortisol may be found in a condition known as
Cushing's syndrome / Hypercortisolism
Cushing's syndrome is characterized by chronic excess cortisol production from adrenal tumors, pituitary ACTH-secreting adenoma (Cushing's disease), or ectopic ACTH secretion. Urinary free cortisol excretion is markedly elevated (>3x normal). Clinical features include moon face, buffalo hump, centripetal obesity, purple striae, muscle wasting, osteoporosis, hypertension, glucose intolerance. Diagnosis confirmed by dexamethasone suppression test and 24-hour urinary cortisol measurement.
27
Pain in the face triggered by touching, shaking the face, eating, talking or cleaning teeth may be due to a condition called
Trigeminal neuralgia
Trigeminal neuralgia causes brief, unilateral, electric shock-like facial pain lasting seconds, triggered by light touch or vibration in specific trigger zones. Attacks can be triggered by chewing, talking, brushing teeth, shaving, or even wind on the face. Pain follows the distribution of maxillary (V2) or mandibular (V3) branches of CN V. Treatment includes carbamazepine (first-line), gabapentin, or surgical microvascular decompression for refractory cases.
28
Abnormal proliferation of lymphatic cells is characteristic of a cancer called
Lymphoma / Leukaemia (in some forms affecting lymphocytes)
Lymphoma is malignancy of lymphoid cells (B-cells, T-cells, NK cells) in lymphatic system, presenting as solid tumors in lymph nodes, spleen, and extranodal sites. Hodgkin's lymphoma has Reed-Sternberg cells; non-Hodgkin's is more common and diverse. Leukemia involves malignant lymphocytes in blood and bone marrow. Both involve lymphatic cell proliferation but lymphoma forms tumors while leukemia circulates in blood. Diagnosis requires lymph node biopsy and immunophenotyping.
29
Enlargement of a group of lymph nodes occurs due to localised
Infection / Inflammation / Cancer (metastasis or lymphoma)
Lymphadenopathy is the enlargement of lymph nodes in response to antigenic stimulation. Localized lymphadenopathy suggests pathology in the drainage area: bacterial/viral infection, inflammation, or malignant metastasis. Infectious causes include streptococcal pharyngitis (cervical nodes), dental abscess (submandibular), cellulitis (regional nodes). Cancer causes hard, fixed, non-tender nodes. Acute infections produce tender, mobile, warm nodes. Diagnosis may require fine needle aspiration or biopsy if persistent >4 weeks.
30
Increased urination of about 20 frequencies per day is seen in patients with a condition known as
Diabetes mellitus / Diabetes insipidus
Polyuria is defined as urine output >3L/day or voiding >20 times/day. Diabetes mellitus causes osmotic diuresis from glucosuria (urine is sweet, positive glucose). Diabetes insipidus causes water diuresis from ADH deficiency (urine is dilute, low specific gravity). UTI causes frequent small-volume voids with dysuria. True polyuria with large volumes points to DM or DI and requires investigation with fasting glucose, HbA1c, serum/urine osmolality, and water deprivation test.
SECTION B: Short Essay Questions (10 marks)
31
State five (5) complications of lymphangitis.
1. Sepsis and septic shock: Bacteria (usually Strep pyogenes) can spread through lymphatics into bloodstream, causing systemic inflammatory response, hypotension, organ failure, and death.
2. Cellulitis: Infection spreads from lymphatic vessels to surrounding subcutaneous tissues, causing diffuse skin inflammation, pain, and increased risk of abscess formation.
3. Abscess formation: Localized collections of pus can develop along inflamed lymphatic tracts or in regional lymph nodes, requiring surgical drainage.
4. Chronic lymphedema: Repeated inflammation damages lymphatic vessel valves and walls, leading to permanent impaired lymphatic drainage and persistent limb swelling.
5. Tissue necrosis and gangrene: Severe infection compromises blood supply, causing tissue ischemia, necrosis, and potentially requiring amputation in extreme cases.
LYMPHANGITIS COMPLICATIONS: "SCALT" - Sepsis, Cellulitis, Abscess, Lymphedema, Tissue necrosis
32
Outline five (5) signs and symptoms of Parkinson's disease.
1. Tremor (resting tremor): Pills-rolling tremor that occurs at rest, typically starts unilaterally in the hand, disappears with voluntary movement and sleep.
2. Bradykinesia (slowness of movement): Difficulty initiating movements, reduced amplitude and speed, causing shuffling gait, reduced arm swing, and micrographia.
3. Rigidity (muscle stiffness): Increased resistance to passive movement, described as cogwheel or lead-pipe rigidity, causing pain and limited range of motion.
4. Postural instability and gait changes: Stooped posture, loss of balance, shuffling gait with short steps, difficulty turning, increased fall risk.
5. Speech and facial expression changes: Hypophonia (soft speech), monotone voice, dysarthria, and masked facies (reduced facial animation).
6. Autonomic and non-motor symptoms: Constipation, orthostatic hypotension, depression, cognitive impairment, and REM sleep behavior disorder.
PARKINSON'S SIGNS: "TRAP" - Tremor, Rigidity, Akinesia/Bradykinesia, Postural instability
SECTION C: Long Essay Questions (60 marks)
33
(a) State five (5) signs and symptoms of osteoarthritis. (5 marks)
(b) Outline ten (10) nursing interventions for managing a patient with osteoarthritis. (10 marks)
(c) Outline five (5) effects of osteoarthritis on a patient's daily life. (5 marks)
(b) Outline ten (10) nursing interventions for managing a patient with osteoarthritis. (10 marks)
(c) Outline five (5) effects of osteoarthritis on a patient's daily life. (5 marks)
(a) Signs and Symptoms of Osteoarthritis:
1. Joint pain: Deep, aching pain worsened by activity and weight-bearing, relieved by rest; late-stage pain may occur at rest and at night.
2. Joint stiffness: Morning stiffness lasting <30 minutes; stiffness also occurs after periods of inactivity (gelling phenomenon).
3. Decreased range of motion: Progressive loss of joint mobility due to pain, effusion, osteophyte formation, and muscle contractures.
4. Crepitus: Grating or crackling sensation/sound on joint movement due to roughened articular surfaces and loss of cartilage.
5. Joint swelling and tenderness: Bony enlargement from osteophytes, effusion from synovitis, and tenderness along joint line.
6. Muscle weakness and atrophy: Due to disuse and reflex inhibition of muscles around affected joint.
(b) Nursing Interventions for Osteoarthritis:
1. Pain management: Administer analgesics (acetaminophen first-line, NSAIDs) as prescribed, monitor effectiveness and side effects (GI bleeding, renal function).
2. Heat and cold therapy: Apply warm compresses or paraffin wax for stiffness; cold packs for acute inflammation. Educate on safe application times (15-20 min).
3. Exercise promotion: Encourage low-impact activities (walking, swimming, cycling) to maintain joint mobility and muscle strength without excessive stress.
4. Weight management: Educate on calorie restriction and exercise to reduce mechanical stress on weight-bearing joints (knees, hips).
5. Joint protection techniques: Teach proper body mechanics, avoid prolonged standing, use larger joints for tasks, and pace activities.
6. Assistive devices: Recommend canes, walkers, grab bars, raised toilet seats, and jar openers to reduce joint stress and improve independence.
7. Patient education: Explain disease process, importance of medication adherence, exercise, and self-management strategies.
8. Psychosocial support: Address depression, anxiety, and social isolation related to chronic pain and functional limitations. Refer to support groups.
9. Sleep promotion: Assess sleep patterns, ensure pain control before bedtime, recommend supportive mattress and positioning.
10. Monitor for complications: Watch for GI bleeding with NSAIDs, falls due to pain/instability, and depression requiring intervention.
(c) Effects of Osteoarthritis on Daily Life:
1. Reduced mobility: Difficulty walking, climbing stairs, standing for long periods, limiting independence and community participation.
2. Difficulty with self-care activities: Struggles with dressing (especially lower limbs), bathing, toileting, and grooming due to joint pain and stiffness.
3. Sleep disturbance: Night pain and difficulty finding comfortable position leads to fragmented sleep and daytime fatigue.
4. Work and social limitations: Reduced ability to perform job duties, participate in hobbies, social events, and maintain relationships, leading to isolation.
5. Psychological impact: Chronic pain causes frustration, anxiety, depression, feelings of helplessness, and reduced quality of life.
OA IMPACT: "P-S-W-O-P" - Pain, Stiffness, Work limitation, Obesity cycle, Psychological distress
34
(a) Describe with rationale five (5) measures employed to prevent suicidal attempts for patients admitted in hospital. (10 marks)
(b) Explain ten (10) responsibilities of a nurse in assessment for suicidal behaviour. (10 marks)
(b) Explain ten (10) responsibilities of a nurse in assessment for suicidal behaviour. (10 marks)
(a) Hospital Suicide Prevention Measures:
1. Continuous observation (1:1 constant nursing): RATIONALE: High-risk patients require arm's-length supervision to prevent unsupervised attempts, provide immediate intervention, and deter impulsive acts.
2. Environmental safety and ligature risk removal: RATIONALE: Removing belts, cords, sharps, plastic bags eliminates tools for hanging, cutting, and suffocation which account for 75% of inpatient suicides.
3. Safety room placement near nursing station: RATIONALE: Enables frequent visual checks (every 15 minutes) and rapid response while maintaining patient dignity and therapeutic milieu.
4. Restricted visiting and contraband checks: RATIONALE: Prevents smuggling of means (drugs, sharps) and protects vulnerable patients from harmful external influences or abusive relationships.
5. Rapid medication stabilization and ECT: RATIONALE: Aggressive treatment of depression/psychosis with close monitoring reduces suicidal ideation intensity and provides neurochemical stabilization within 48-72 hours.
(b) Nurse Responsibilities in Suicidal Behaviour Assessment:
1. Establish therapeutic rapport: Build trust to encourage honest disclosure of suicidal thoughts without fear of judgment or punitive measures.
2. Direct questioning about ideation: Ask explicitly: "Are you thinking about killing yourself?" This does not plant ideas but gives permission to discuss.
3. Assess lethality and specificity of plan: Determine method, timeline, means availability, and lethality to evaluate immediacy of risk.
4. Evaluate protective factors: Identify reasons for living (family, faith, future plans) that may buffer against suicide.
5. Review past suicidal behavior: Document previous attempts, methods, and family history - strongest predictor of future suicide.
6. Assess command hallucinations: Ask if voices are instructing self-harm - significantly increases violence risk.
7. Monitor warning signs: Observe for giving away possessions, sudden mood improvement (may indicate decision to attempt), preoccupation with death.
8. Conduct risk stratification: Use standardized tools like SAD PERSONS scale or Columbia Protocol to quantify risk level.
9. Document comprehensively: Record verbatim statements, behaviors, findings, and interventions in objective language for legal continuity.
10. Implement and communicate safety plan: Initiate observation, inform team, notify psychiatrist, and engage family in safety planning.
SUICIDE ASSESSMENT: "DIRECT-SCAN" - Direct question, Ideation, Resources, Evaluate plan, Timeline, Command hallucinations, Assess past, Note warning signs
35
(a) Outline five (5) characteristic physical features of severe mental retardation. (5 marks)
(b) Describe four (4) methods used to diagnose mental retardation. (8 marks)
(c) State seven (7) primary prevention measures of mental retardation. (7 marks)
(b) Describe four (4) methods used to diagnose mental retardation. (8 marks)
(c) State seven (7) primary prevention measures of mental retardation. (7 marks)
(a) Physical Features of Severe Mental Retardation (IQ 20-34):
1. Dysmorphic facial features: Abnormal skull shape (microcephaly), widely spaced eyes, low-set ears, flattened nasal bridge indicative of genetic syndromes (Down, Fragile X).
2. Gross motor delays and abnormal gait: Unable to walk until age 4-6 years, may never ambulate independently; ataxic, spastic, or puppet-like movements.
3. Growth retardation: Short stature, failure to thrive, obesity in institutional settings due to hormonal or nutritional factors.
4. Sensory impairments: High prevalence of visual deficits (cataracts, cortical blindness) and hearing loss from infections or genetic disorders.
5. Self-injurious behaviors and stereotypies: Hand-biting, head-banging, rocking, spinning due to inability to communicate needs, sensory seeking, or frustration.
(b) Methods to Diagnose Mental Retardation:
1. Standardized intelligence testing: Use Wechsler Scales or Stanford-Binet; must show IQ <70 (2 SD below mean) considering cultural and sensory limitations.
2. Adaptive behavior assessment: Vineland Adaptive Behavior Scales evaluate conceptual, social, and practical skills limitations in 2+ areas.
3. Comprehensive medical and genetic evaluation: Includes karyotyping, metabolic screening, neuroimaging, and detailed prenatal/perinatal history.
4. Developmental history and clinical observation: Gather milestones from multiple caregivers; direct observation of play, communication, and social interaction in natural settings.
(c) Primary Prevention Measures of Mental Retardation:
1. Genetic counseling and prenatal screening: Identify carrier status for inherited disorders, offer amniocentesis/CVS for high-risk pregnancies.
2. Rubella immunization: Vaccinate all girls before childbearing age to prevent congenital rubella syndrome (deafness, heart defects, MR).
3. Prevention of neural tube defects: Periconceptual folic acid supplementation (0.4mg daily) reduces risk by 70%; food fortification.
4. Prevention of birth injuries: Quality antenatal care, skilled birth attendance, emergency obstetric care to prevent hypoxic-ischemic encephalopathy.
5. Treatment of neonatal jaundice: Prompt phototherapy or exchange transfusion prevents kernicterus-induced brain damage.
6. Prevention of lead poisoning: Remove lead-based paints, screen high-risk children, treat elevated levels >45 ยตg/dL.
7. Early treatment of infections: Prompt diagnosis and treatment of meningitis, encephalitis, and congenital infections with appropriate antibiotics/antivirals.
๐ถ Critical Period: Most brain development occurs in first 1000 days (conception to age 2). Prevention must start BEFORE pregnancy with folic acid, vaccination, nutrition, and avoiding teratogens!
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Medical Nursing III Revision Guide
Paper Code: DNE 112 | Year 1, Semester 1 | June 2022
SECTION A: Objective Questions (20 marks)
๐ก Exam Strategy: Medical nursing questions test your understanding of pathophysiology and clinical priorities. Always identify the underlying mechanism first!
1
The most common cause of glomerulonephritis is
(c) Streptococcus
Post-streptococcal glomerulonephritis is the most common cause worldwide, especially in children. Following an infection (strep throat or impetigo) caused by Streptococcus pyogenes, immune complexes deposit in glomeruli, triggering inflammation. It typically presents 1-3 weeks after infection with hematuria, proteinuria, edema, and hypertension.
GN CAUSES: "STREP" - Streptococcus (post-infectious), Systemic diseases (SLE, HSP), Rapidly progressive, Endocarditis, Post-infectious
2
When planning a diet for a patient with renal failure, the nurse remembers to include
(b) Adequate calories, high carbohydrates, limited protein
Renal failure diet aims to reduce uremic toxin buildup while preventing malnutrition. Limited protein (0.6-0.8 g/kg/day) reduces urea production. High carbohydrates provide non-protein calories to prevent muscle catabolism. Adequate calories (30-35 kcal/kg) maintain energy and prevent protein breakdown. Fat is also included. Sodium, potassium, and phosphate are restricted.
๐ฝ๏ธ CRITICAL: Malnutrition is present in 20-50% of dialysis patients. Diet must balance limiting toxins while maintaining nutrition. Involve dietitian!
3
The nurse suspects a client who complains of excessive thirst and passing a large volume of very dilute urine to be suffering from
(b) Diabetes insipidus
Diabetes insipidus is characterized by polyuria (large dilute urine) and polydipsia (excessive thirst). Key phrase: "very dilute urine". Caused by ADH deficiency (central) or kidney unresponsiveness (nephrogenic). Urine specific gravity <1.005. Confirmed by water deprivation test. Hyperglycemia causes osmotic diuresis but urine has glucose, not necessarily "dilute".
DI vs DM: DI = Dilute urine + ADH problem, DM = Glucose in urine + insulin problem
4
The goal of care when treating a patient with diabetes mellitus is to
(d) Control blood glucose levels
The primary goal of diabetes management is glycemic control - maintaining blood glucose within target range (fasting 80-130 mg/dL, postprandial <180 mg/dL). This prevents acute complications (DKA, HHS, hypoglycemia) and chronic microvascular/macrovascular complications (retinopathy, nephropathy, neuropathy, cardiovascular disease). Achieved through diet, exercise, medication, monitoring.
๐ฏ Glycemic Targets: HbA1c <7% for most adults. Individualize based on age, comorbidities, hypoglycemia risk. Remember: "Control, don't just treat!"
5
Which of the following findings does a nurse expect to find on assessment of a patient with rheumatoid arthritis?
(a) Early morning joint pain
Morning stiffness >30 minutes is classic for rheumatoid arthritis, an inflammatory arthritis. Pain and stiffness are worst upon waking and improve with movement throughout the day. Synovitis causes warm, swollen, painful joints. Range of motion DECREASES due to pain, swelling, and eventual joint destruction. Contrast with osteoarthritis where stiffness is brief (<30 min).
RA vs OA: RA = Morning stiffness >30 min, symmetrical small joints, systemic symptoms. OA = Brief stiffness, weight-bearing joints, mechanical pain
6
Which of the following is NOT associated with osteoarthritis?
(d) Urinary stones
Urinary stones are renal calculi with no direct association with osteoarthritis. OA is a degenerative joint disease from cartilage wear. While sedentary lifestyle contributes to obesity (risk factor), back pain relieved by rest is typical for mechanical pain, and fractures can occur in osteoporotic bones adjacent to OA joints, urinary stones are completely unrelated to the musculoskeletal pathology of OA.
๐ฆด OA Risk Factors: Age, obesity, joint injury, repetitive stress, genetics. NOT urinary stones! Look for the "odd one out" in these questions.
7
Which of the following is NOT true about stroke?
(d) Sudden epigastric pain
Epigastric pain is NOT a typical stroke symptom. Stroke is a neurological emergency causing sudden onset focal neurological deficits. The "SUDDEN" symptoms follow the FAST acronym: Face drooping, Arm weakness, Speech difficulty, Time to call. Epigastric pain suggests GI pathology (ulcer, pancreatitis, MI) not neurological.
STROKE SYMPTOMS (FAST): Face drooping, Arm weakness, Speech difficulty, Time to call 999
8
A nurse records a blood clot, fat globule or gas bubble created in part of the body that circulates in the blood stream as
(b) Embolus
An embolus is a mobile clot or foreign material traveling in circulation. It can be a blood clot (thromboembolus), fat globule (fat embolism from fractures), gas bubble (air embolism), or amniotic fluid. "Circulates in the blood stream" is the key phrase. Thrombus is stationary; infarction and necrosis are consequences of tissue death after embolic occlusion.
EMBOLUS TYPES: "FAT BAT" - Fat, Air, Thrombus, Bacteria, Amniotic fluid, Tumor
9
Dwarfism is an inherited deficiency of growth hormone with the absence of
(d) Somatotropin
Somatotropin is Growth Hormone (GH) secreted by anterior pituitary. GH deficiency in childhood causes pituitary dwarfism (proportional short stature). Somatotropin directly stimulates linear bone growth via IGF-1. Absence leads to failure of long bone growth. Aldosterone, cortisol, and renin are adrenal hormones unrelated to growth.
๐ Growth Hormone: Secreted in pulses, especially during deep sleep. Peak secretion at puberty. Must be given before epiphyseal plates close for height effect!
10
Which of the following nursing actions is specific to a patient with meningococcal meningitis?
(a) Place the patient in isolation room
Meningococcal meningitis is a notifiable, highly contagious bacterial infection spread by respiratory droplets. Droplet isolation (private room, mask within 3 feet) is mandatory for first 24 hours of antibiotic therapy. Protects staff and other patients. Contacts need prophylaxis (rifampin, ciprofloxacin). HIV status is not immediate priority; amphotericin B is for fungal meningitis; skin lesions are non-specific.
๐ฆ Meningococcal Urgency: Report immediately to public health! Give antibiotics within 1 hour of suspicion. Prophylaxis for close contacts within 24 hours. Mortality 10-15% even with treatment.
11
Unusual vaginal discharge, pelvic and abdominal pain, pain during intercourse, frequency of micturition may be found in patients suspected of
(c) Urethritis
Urethritis is inflammation of the urethra, commonly caused by sexually transmitted infections (chlamydia, gonorrhea). Presents with dysuria, urethral discharge, and urinary frequency. In women, pain can radiate to pelvis and abdomen, and dyspareunia is common due to inflamed urethra. Vaginal discharge suggests concomitant cervicitis from STI. Pyelonephritis causes flank pain and fever but not typically vaginal discharge.
URETHRITIS SYMPTOMS: "DUP" - Dysuria, Urethral discharge, Pelvic pain
12
Which of the following findings is associated with glomerulonephritis?
(a) Haematuria
Haematuria is a hallmark sign of glomerulonephritis. Damaged glomeruli allow RBCs to leak into urine, causing "tea-colored" or "cola-colored" urine. Can be microscopic or gross. BUN is ELEVATED (not low) due to impaired filtration. Specific gravity may be low if fluid overloaded, but this is non-specific. Hypertension (not hypotension) is common from sodium/water retention and renin-angiotensin activation.
GN TRIAD: "HAP" - Hematuria, Azotemia, Proteinuria + Hypertension + Edema
13
Nurses advise the patients undergoing dialysis to have a special diet and drugs because
(c) Their appetite is poor and protein is lost during dialysis
Special diet is needed because dialysis causes protein and nutrient losses. Peritoneal dialysis loses 5-15g protein/day; hemodialysis loses amino acids. Uremia causes anorexia, nausea, taste changes. High protein diet (1.2-1.3 g/kg) required to replace losses. Also need controlled sodium, potassium, phosphate, and fluid. Drugs manage anemia (ESA), bone disease (phosphate binders), and complications. Not all patients need weight gain.
๐ฅ Dialysis Diet Principles: "P-P-P-S" - Protein (high), Phosphate (low), Potassium (control), Sodium/fluid (restrict)
14
Which of the following type of headache presents with one sided, throbbing intense pain?
(b) Migraine headache
Migraine is classically unilateral, pulsating/throbbing, moderate-severe pain, worsened by activity, associated with nausea, vomiting, photophobia, phonophobia. Duration 4-72 hours untreated. Pathophysiology involves trigeminovascular activation and cortical spreading depression. May have aura (visual, sensory). Cluster headache is also unilateral but sharp/stabbing; tension is bilateral band-like pressure.
MIGRAINE POUND: Pulsatile, One-day duration, Unilateral, Nausea, Disabling, throbbing, Exacerbated by activity
15
A nervous disorder characterised by tremors at rest, sluggish initiation of movements and muscle rigidity is
(d) Parkinson's disease
Parkinson's disease is characterized by the classic triad: (1) Resting tremor ("pill-rolling"), (2) Bradykinesia (sluggish initiation of movement), (3) Rigidity (cogwheel or lead-pipe). Due to loss of dopaminergic neurons in substantia nigra. Also causes postural instability (late). Tourette's has tics; Huntington's has chorea; glycogen storage affects metabolism.
PARKINSON'S TRIAD: "TRAP" - Tremor (resting), Rigidity, Akinesia/Bradykinesia, Postural instability (late)
16
A disorder where the nerves of the eyes, brain and spinal cord lose patches of myelin is
(c) Multiple sclerosis
Multiple sclerosis is a chronic demyelinating disease of CNS affecting brain, spinal cord, and optic nerves. Patchy loss of myelin (plaques) causes variable neurological deficits. Autoimmune CD4+ T-cells attack myelin sheath. Presents with relapsing-remitting symptoms: visual changes, motor weakness, sensory loss, bowel/bladder dysfunction. MRI shows periventricular white matter lesions.
๐ง MS Key Features: Young women (20-40), relapsing-remitting course, optic neuritis, internuclear ophthalmoplegia, Lhermitte's sign. Diagnosis: MRI + oligoclonal bands in CSF.
17
The degenerative disease of the neck discs and vertebrae is referred to as cervical
(a) Spondylosis
Cervical spondylosis is age-related degenerative osteoarthritis of cervical spine. Involves disc degeneration, osteophyte formation (bone spurs), facet joint arthropathy. Causes neck pain, stiffness, radiculopathy (nerve root compression), and cervical myelopathy if spinal canal narrows. Compression is a consequence, not the disease name. Atrophy is muscle wasting; neuropathy is nerve disease.
SPONDYLOSIS: "S = Spine" - Degenerative changes of vertebrae and discs
18
Total blockage of nerve impulse transmission up and down the spinal cord is referred to as
(a) Acute transverse myelitis
Acute transverse myelitis is inflammation across spinal cord segment causing conduction block. Presents with acute onset paraplegia/quadriplegia, sensory loss below level, and autonomic dysfunction (bowel/bladder). "Total blockage of transmission up and down" describes complete myelopathy. Causes: infections, autoimmune (MS, NMO), post-vaccination. Spinal hematoma is hemorrhage; neuromuscular affects junctions.
๐จ Spinal Emergency: Acute transverse myelitis is neurosurgical emergency! Rule out compressive lesions (hematoma, tumor) first - requires MRI immediately. High-dose steroids if inflammatory.
19
Providing a safe environment, assisting with activity and watching for changes in the neurological status and intensity of the pain are nursing measures for patients with
(b) Spinal cord compression
Spinal cord compression from tumor, fracture, abscess, or hematoma is a neurosurgical emergency. Safe environment prevents falls from weakness/paralysis. Activity assistance maintains mobility while preventing injury. Monitoring neurological status and pain detects worsening compression requiring urgent surgical decompression. Pain intensity increase may indicate expanding lesion.
SPINAL COMPRESSION RED FLAGS: "PAN-PAIN" - Progressive neurological deficit, Acute onset, Nocturnal pain, Pain worsened by Valsalva
20
Bradycardia, decreased cardiac output, cool skin and cold intolerance are symptoms commonly seen in patients suffering from
(b) Hypothyroidism
Hypothyroidism slows all metabolic processes. Bradycardia from reduced sympathetic drive. Decreased cardiac output from reduced contractility and heart rate. Cool skin and cold intolerance from reduced thermogenesis and peripheral vasoconstriction. Also causes fatigue, weight gain, constipation, delayed reflexes, dry skin. Hyperthyroidism causes opposite (tachycardia, heat intolerance).
HYPOTHYROIDISM: "COLD" - Cold intolerance, Obesity, Low HR/BP, Dry skin, Depression
SECTION B: Fill in the Blank Spaces (10 marks)
21
The type of arthritis that causes joint pain especially in the great toe is
Gout
Gout is crystal-induced arthritis from monosodium urate deposition. Classic presentation is podagra - sudden, severe, red, hot, swollen first metatarsophalangeal joint (great toe). Triggered by high purine foods (red meat, seafood, alcohol), dehydration. Diagnosed by needle-shaped negatively birefringent crystals in synovial fluid. Treated with NSAIDs, colchicine, or steroids for acute attack; allopurinol or febuxostat for chronic prevention.
๐บ Gout Triggers: "SAD" - Seafood, Alcohol (beer), Dehydration. Also: organ meats, sugary drinks, fructose
22
A metabolic disorder in which there is low bone mass and deterioration of bone structure is
Osteoporosis
Osteoporosis is decreased bone mass and microarchitectural deterioration, increasing fracture risk. "Silent disease" until fracture occurs. Diagnosed by DEXA scan: T-score <-2.5. Risk factors: postmenopausal women, corticosteroid use, smoking, alcohol, sedentary lifestyle, calcium/vitamin D deficiency. Prevent with weight-bearing exercise, calcium/vitamin D, bisphosphonates, denosumab.
OSTEOPOROSIS RISKS: "SCALES" - Steroids, Calcium deficiency, Alcohol, Low estrogen, Exercise deficiency, Smoking
23
Tingling sensations of the fingers and feet in a diabetic patient is termed as
Diabetic neuropathy / Paresthesia
Diabetic neuropathy is nerve damage from chronic hyperglycemia. Distal symmetric polyneuropathy affects feet first (stocking-glove pattern). Causes paresthesias (tingling, burning, numbness), allodynia, severe pain, then loss of sensation leading to foot ulcers. Pathophysiology: microvascular ischemia, oxidative stress, advanced glycation end-products, sorbitol accumulation.
๐ฃ Diabetic Foot Care: Daily inspection, proper footwear, never walk barefoot, regular podiatry. Neuropathy + poor circulation = high ulcer/amputation risk!
24
The auto immune disorder where the body attacks the thyroid gland and stops it from producing T3 and T4 is
Hashimoto's thyroiditis
Hashimoto's thyroiditis is chronic autoimmune destruction of thyroid. Antibodies (anti-TPO, anti-thyroglobulin) attack follicular cells, causing lymphocytic infiltration, fibrosis, โ hormone production. Most common cause of hypothyroidism in iodine-sufficient areas. Presents with painless goiter, fatigue, cold intolerance, weight gain. Diagnose by โ TSH, โ free T4, positive antibodies. Treatment: lifelong levothyroxine replacement.
HASHIMOTO'S: "HAT" - Hypothyroidism, Autoimmune, Thyroid antibodies (TPO)
25
A tumour of the adrenal medulla that increases blood pressure is
Pheochromocytoma
Pheochromocytoma is catecholamine-secreting tumor of adrenal medulla. Produces excessive epinephrine and norepinephrine causing paroxysmal hypertension (sudden spikes), headaches, palpitations, diaphoresis. Can cause hypertensive crisis. Diagnose by 24h urine catecholamines/metanephrines or plasma free metanephrines. Treatment: surgical resection after alpha-blockade (phenoxybenzamine). Rule of 10: 10% bilateral, 10% extra-adrenal, 10% malignant, 10% familial.
โ ๏ธ Hypertensive Crisis: Pheochromocytoma can cause BP >200/120 mmHg during paroxysm. Emergency: give IV phentolamine. NEVER biopsy without alpha-blockade - can trigger fatal catecholamine surge!
26
An acute and rare condition in which all manifestations of hyperthyroidism are heightened is
Thyroid storm / Thyrotoxic crisis
Thyroid storm is life-threatening exacerbation of hyperthyroidism. Precipitated by infection, trauma, surgery, DKA, radioactive iodine. Presents with extreme hyperthermia (>40ยฐC), severe tachycardia, arrhythmias, heart failure, agitation, delirium, coma. Mortality 10-30%. Emergency: ICU admission, IV fluids, cooling, beta-blockers (propranolol), PTU/methimazole, steroids, iodine solution (after antithyroid drugs).
THYROID STORM TRIGGERS: "SURGERY" - Surgery, Undertreated hyperthyroidism, Radioactive iodine, Infection, DKA, Trauma
27
A patient becomes comatose during retention of ketones and glucose as a result of
Diabetic ketoacidosis (DKA)
DKA is acute metabolic emergency from absolute insulin deficiency. Leads to hyperglycemia (>250 mg/dL), ketosis, metabolic acidosis (pH <7.3), dehydration, electrolyte loss. Ketones (beta-hydroxybutyrate, acetoacetate) cause acidosis. Progressive hyperosmolarity and dehydration lead to altered consciousness, coma. Triggered by infection, missed insulin, MI, new-onset T1DM. Treatment: IV fluids, insulin infusion, potassium replacement, treat precipitant.
๐ DKA Emergency: Mortality 2-5%. Give insulin only AFTER starting fluids and confirming potassium >3.3 mEq/L. Insulin drives K+ into cells - can cause fatal hypokalemia!
28
A paroxysmal discharge of cerebral neurons accompanied by an apparent clinical phenomenon is called a
Seizure / Epileptic seizure
A seizure is abnormal, excessive, synchronous neuronal discharge causing clinical signs/symptoms. Types: focal (partial) or generalized. May cause motor, sensory, autonomic, or psychic manifestations. Epilepsy is recurrent unprovoked seizures. Requires EEG confirmation. First seizure needs full workup (MRI, labs). Treatment based on type; surgical option for refractory cases. Status epilepticus = >5 min or repeated without recovery.
SEIZURE TYPES: "GF" - Generalized (tonic-clonic, absence, myoclonic), Focal (simple, complex)
29
Apart from maintaining a fluid balance chart, salt and water status of a patient may be monitored carefully by accurate
Daily weight measurement / Electrolyte monitoring / Serum osmolality monitoring
Daily weight is the most sensitive indicator of fluid balance. 1 kg weight gain = 1 liter fluid retained. Weigh at same time daily, same scale, same clothing. More accurate than I/O charts which are often inaccurate. Also monitor serum sodium (hyponatremia = water excess; hypernatremia = water deficit), serum osmolality, and physical signs (edema, JVP). Critical in heart failure, renal failure, and critical care patients.
โ๏ธ Daily Weight Gold Standard: More reliable than I/O charts. Best single indicator of fluid status changes. Always document weekly trends!
30
The nurse should prevent dehydration in a patient with excessive fluid loss to avoid a complication known as
Acute Kidney Injury (AKI) / Renal failure / Hypovolemic shock
Severe dehydration โ hypovolemia โ โ renal perfusion โ prerenal AKI. Kidneys are highly sensitive to blood flow; 20-25% cardiac output. Prolonged hypoperfusion causes acute tubular necrosis (ATN). Signs: oliguria, rising creatinine, BUN:Cr ratio >20:1 (prerenal). Treatment: aggressive fluid resuscitation. Also prevents hypovolemic shock (โBP, tachycardia, confusion, organ failure). Early prevention is key!
AKI STAGES: "R-I-F-L-E" - Risk, Injury, Failure, Loss, End-stage
SECTION B: Short Essay Questions (10 marks)
31
Outline the five (5) signs and symptoms of urethritis.
1. Dysuria: Pain or burning sensation during urination due to inflamed urethral mucosa.
2. Increased urinary frequency and urgency: Constant urge to urinate with passage of small amounts due to irritation.
3. Urethral discharge: Purulent, mucoid, or clear discharge from urethral meatus; often worse in morning.
4. Itching or irritation: Urethral itching, discomfort, or feeling of irritation at the tip of penis/vulva.
5. Pain in pelvic area/lower abdomen or dyspareunia: Discomfort during sexual intercourse due to inflamed urethral tissues; pelvic pain from spread of inflammation.
๐ Urethritis Recognition: Common in sexually active individuals. Always consider STI testing (chlamydia, gonorrhea). Partner notification and treatment essential to prevent reinfection!
32
Outline five (5) complications of Parkinson's disease.
1. Falls: Postural instability, gait freezing, and balance problems increase fall risk, leading to fractures, head injuries, and loss of independence.
2. Dementia or cognitive impairment: Progressive decline in executive function, memory, and visuospatial abilities; up to 80% develop Parkinson's disease dementia after 20 years.
3. Dysphagia (swallowing difficulties): Impaired pharyngeal muscle coordination increases risk of choking, aspiration pneumonia, and malnutrition.
4. Speech and communication problems: Hypophonia (soft voice), dysarthria (slurred speech), monotone voice, and reduced articulation impair social interaction.
5. Autonomic dysfunction: Orthostatic hypotension, constipation, urinary urgency/retention, erectile dysfunction, excessive sweating, and drooling.
PARKINSON'S COMPLICATIONS: "FALLS" - Falls, Autonomic dysfunction, Lewy body dementia, Dysphagia, Speech problems
SECTION C: Long Essay Questions (60 marks)
33
(a) Explain five (5) benefits of physical exercises in the management of diabetes mellitus.
(b) Outline ten (10) specific nursing interventions that should be implemented during management of a patient admitted with Glomerulonephritis in the first 24 hours.
(b) Outline ten (10) specific nursing interventions that should be implemented during management of a patient admitted with Glomerulonephritis in the first 24 hours.
(a) Benefits of Physical Exercise in Diabetes Mellitus:
1. Improves insulin sensitivity: Exercise increases glucose uptake by muscle cells via insulin-independent mechanisms (GLUT-4 translocation), reducing insulin resistance for up to 24-48 hours post-exercise.
2. Lowers blood glucose levels: During exercise, muscles use glucose for energy, directly lowering blood glucose. A single session can reduce glucose by 20-50 mg/dL for several hours.
3. Aids weight management: Burns calories and reduces visceral fat. Weight loss of 5-10% significantly improves glycemic control and may induce remission in Type 2 diabetes.
4. Improves cardiovascular health: Reduces blood pressure, improves lipid profile (โTG, โHDL), strengthens heart muscle, and enhances circulation, reducing macrovascular complications.
5. Reduces stress and improves mood: Releases endorphins, reduces cortisol, improves sleep quality and mental well-being, leading to better diabetes self-management and adherence.
(b) Nursing Interventions for Glomerulonephritis (First 24 Hours):
1. Monitor vital signs frequently: Assess blood pressure (often elevated), heart rate, respiratory rate, temperature to detect hypertension, fluid overload, or infection.
2. Monitor fluid balance closely: Maintain strict intake/output chart; weigh daily; restrict fluids as ordered to prevent pulmonary edema and hypertension.
3. Assess for edema: Inspect and palpate for peripheral edema (face, extremities) and auscultate lungs for crackles indicating pulmonary edema from fluid retention.
4. Monitor urine output and characteristics: Note volume, color (hematuria = "tea-colored"), and proteinuria; report oliguria (<400 mL/day) immediately.
5. Monitor laboratory results: Review BUN, creatinine, electrolytes (especially potassium), urinalysis, and protein-creatinine ratio to assess kidney function and imbalances.
6. Administer prescribed medications: Give antihypertensives (ACE inhibitors), diuretics for edema, corticosteroids/immunosuppressants (if autoimmune cause), and antibiotics (if infection-related) as ordered.
7. Implement dietary restrictions: Collaborate with dietitian for sodium restriction (2g/day), controlled protein (0.8 g/kg), and potassium/phosphorus limits as indicated.
8. Provide bed rest: Encourage rest during acute phase to reduce metabolic demands and kidney workload; prevent complications of immobility with repositioning.
9. Assess neurological status: Monitor for changes in mental status, headache, visual disturbances, or seizures from severe hypertension or uremia.
10. Patient and family education: Begin teaching about disease process, medications, fluid restrictions, and importance of reporting changes in symptoms or urine output.
GN CARE: "MONITOR-Vitals, Fluids, Urine, Labs, Meds, Diet, Rest, Neuro, Teach"
34
(a) With rationale for each, explain ten (10) specific nursing interventions for a patient with hyperthyroidism for the first 48 hours of admission.
(b) List five (5) complications of hyperthyroidism.
(b) List five (5) complications of hyperthyroidism.
(a) Nursing Interventions for Hyperthyroidism (First 48 Hours):
1. Monitor vital signs frequently (q2-4h): RATIONALE: Hyperthyroidism increases metabolic rate, causing tachycardia, hypertension, fever. Frequent monitoring detects worsening symptoms or thyroid storm.
2. Monitor cardiac status continuously: RATIONALE: High risk of atrial fibrillation, arrhythmias, heart failure from increased cardiac workload. Early detection prevents cardiovascular collapse.
3. Provide cool, quiet environment: RATIONALE: Patients are heat intolerant and easily agitated. Cool room reduces metabolic demands and sympathetic stimulation; quiet reduces anxiety and tremors.
4. Ensure adequate hydration and nutrition: RATIONALE: Increased metabolism causes high calorie/fluid needs. Monitor intake/output, offer frequent meals, consider IV fluids to prevent dehydration and catabolism.
5. Administer antithyroid medications (PTU, methimazole) as ordered: RATIONALE: Blocks new thyroid hormone synthesis, gradually reducing metabolic rate over days. Monitor for agranulocytosis (fever, sore throat).
6. Administer beta-blockers (propranolol) as prescribed: RATIONALE: Controls sympathetic symptoms (tachycardia, tremors, anxiety) providing symptomatic relief while antithyroid drugs take effect.
7. Monitor neurological and mental status q4h: RATIONALE: Severe hyperthyroidism causes nervousness, restlessness, confusion, psychosis. Changes may indicate thyroid storm requiring emergency intervention.
8. Provide eye care for exophthalmos: RATIONALE: If present, eyes need protection from dryness (artificial tears), corneal ulcers (eye patches at night), and head elevation reduces periorbital edema.
9. Promote rest and reduce activity: RATIONALE: Tremors and muscle weakness increase fall risk. Activity restriction conserves energy, reduces metabolic demands, and prevents injury.
10. Educate patient and family about disease and medications: RATIONALE: Reduces anxiety, promotes adherence, teaches recognition of thyroid storm symptoms, and explains importance of dose adjustments during stress ("sick day rules").
(b) Complications of Hyperthyroidism:
1. Thyroid storm (thyrotoxic crisis): Life-threatening acute exacerbation with extreme hyperthermia, tachycardia, arrhythmias, heart failure, delirium, coma.
2. Atrial fibrillation and cardiac complications: Persistent tachycardia leads to AF (15-20% of hyperthyroid patients), heart failure, angina, and increased risk of thromboembolism.
3. Osteoporosis: Accelerated bone turnover and resorption leads to decreased bone density, increased fracture risk, especially in postmenopausal women.
4. Graves' ophthalmopathy: In Graves' disease, autoimmune inflammation causes proptosis, diplopia, corneal ulcers, and potential vision loss.
5. Graves' dermopathy (pretibial myxedema): Thickened, waxy skin over shins from accumulation of glycosaminoglycans; rare but pathognomonic for Graves'.
๐จ Thyroid Storm = Emergency! Mortality 10-30%. Requires ICU, IV fluids, cooling, beta-blockers, PTU/methimazole, steroids. Recognize early: fever >40ยฐC, HR >140, agitation, vomiting, diarrhea.
35
(a) State five (5) causes of Addison's disease.
(b) State ten (10) clinical manifestations of Addison's disease.
(c) Outline ten (10) specific nursing interventions for a patient with Addison's disease, till discharge.
(b) State ten (10) clinical manifestations of Addison's disease.
(c) Outline ten (10) specific nursing interventions for a patient with Addison's disease, till discharge.
(a) Causes of Addison's Disease:
1. Autoimmune adrenalitis: Most common cause (70-80%) where antibodies attack adrenal cortex cells, causing progressive destruction and atrophy of glands.
2. Tuberculosis: Historic leading cause; Mycobacterium infects adrenal glands causing granulomatous inflammation and destruction, especially endemic areas.
3. Cancer metastasis: Metastatic spread (especially lung, breast, melanoma) to adrenal glands replacing normal tissue with tumor cells.
4. Adrenal hemorrhage (Waterhouse-Friderichsen syndrome): Massive bilateral adrenal bleeding during severe sepsis (meningococcemia) or anticoagulation therapy.
5. Medications: Long-term corticosteroid therapy causing adrenal suppression; abrupt withdrawal precipitates adrenal insufficiency. Also ketoconazole and etomidate inhibit steroid synthesis.
(b) Clinical Manifestations of Addison's Disease:
1. Chronic fatigue and weakness: Persistent tiredness and muscle weakness due to cortisol deficiency affecting energy metabolism.
2. Weight loss and decreased appetite: Anorexia, nausea, vomiting, and abdominal pain leading to significant unintentional weight loss.
3. Hyperpigmentation: Darkening of skin, especially sun-exposed areas, palmar creases, knuckles, gums, and scars from elevated ACTH stimulating melanocytes.
4. Hypotension and orthostatic dizziness: Low blood pressure (<90/60 mmHg) and dizziness when standing due to mineralocorticoid deficiency causing volume depletion.
5. Salt craving: Intense desire for salty foods due to hyponatremia and volume depletion from aldosterone deficiency.
6. Muscle and joint pain: Aching muscles, back pain, and arthralgias from electrolyte imbalances and cortisol deficiency.
7. Gastrointestinal symptoms: Nausea, vomiting, diarrhea, and abdominal pain from cortisol deficiency affecting GI motility.
8. Irritability and depression: Mood changes, apathy, and cognitive dysfunction from cortisol deficiency affecting brain function.
9. Hypoglycemia: Low blood sugar especially during fasting or stress due to impaired gluconeogenesis and glycogenolysis.
10. Loss of body hair (in women): Decreased adrenal androgen production causes loss of axillary and pubic hair.
(c) Nursing Interventions for Addison's Disease (Till Discharge):
1. Monitor vital signs closely: Check BP (especially orthostatic), HR, temperature q4h to detect hypotension or signs of adrenal crisis.
2. Administer hormone replacement therapy as ordered: Give hydrocortisone (glucocorticoid) and fludrocortisone (mineralocorticoid) at exact times. Emphasize lifelong adherence.
3. Monitor fluid and electrolyte balance: Assess hydration status, daily weight, serum sodium and potassium; encourage adequate salt intake.
4. Assess for signs of adrenal crisis: Watch for severe weakness, vomiting, abdominal pain, hypotension, fever, confusion - requires emergency IV hydrocortisone.
5. Provide education on stress dosing: Teach "sick day rules" - double hydrocortisone dose during illness, injury, or stress to prevent crisis.
6. Educate on emergency injection: Teach patient and family to administer IM hydrocortisone emergency injection and when to use it.
7. Promote adequate nutrition: Encourage small frequent meals, adequate protein and calories, and liberal salt intake (unless contraindicated).
8. Provide emotional support and counseling: Address depression, fatigue, and lifestyle adjustments needed for chronic disease management.
9. Ensure medical alert identification: Provide bracelet/necklace indicating adrenal insufficiency and emergency treatment requirements.
10. Schedule follow-up care: Arrange endocrinology appointments, teach importance of regular monitoring, and provide written action plan for emergencies.
ADDISON'S CARE: "S-A-L-T" - Steroids (give), Assess, Labs, Teach (stress dosing, emergency)
โ ๏ธ ADRENAL CRISIS = EMERGENCY! Give 100 mg hydrocortisone IV bolus STAT, then 50-100 mg q6h. Fluid resuscitate with NS. Mortality 25% if untreated. Patients must carry emergency injection kit!
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