UHPAB June 2025 Paed Surgery DNE11

Nursing Exam Revision - Complete Guide - Nurses Revision Uganda

🏥 Nurses Revision Uganda

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Nursing Examination Revision Guide

SECTION A: Objective Questions (20 marks)

Remember to read each question carefully! The NOT questions require you to identify the FALSE statement. Take your time and eliminate wrong answers first.

For differential diagnosis questions, use the "SNAP" method: Symptoms, Nature, Associated features, Pattern

Which of the following statements does NOT describe the presentation "airway obstruction" for patients suffering from tonsillitis?

a) Mouth breathing

b) Sleep apnoea

c) Nocturnal snoring

d) Sleep disordered breathing

(d) Sleep disordered breathing

While sleep disordered breathing (SDB) is a consequence of airway obstruction, it is actually an umbrella diagnosis that INCLUDES mouth breathing, sleep apnoea, and snoring. The question asks for specific presentation features, not the overall diagnosis. Options (a), (b), and (c) are all specific observable manifestations of airway obstruction caused by enlarged tonsils.

(a) Mouth breathing: This IS a direct presentation of airway obstruction from tonsillar hypertrophy - patients must breathe through the mouth when nasal/oropharyngeal airway is compromised.
(b) Sleep apnoea: This IS a classic presentation, specifically obstructive sleep apnoea (OSA), caused by tonsillar obstruction during sleep.
(c) Nocturnal snoring: This IS a hallmark presentation due to turbulent airflow through narrowed airway from inflamed tonsils.

💡 Pro Tip: In "NOT" questions, look for the answer that is either too broad, too narrow, or doesn't fit the specific context. Here, SDB is a diagnosis, not a presentation feature.

Upon assessment the nurse discovers that the child's infection of the hair follicle goes into the deeper layers of the skin and records this as

a) Folliculitis

b) Furuncle

c) Carbuncle

d) Boil

(b) Furuncle

A furuncle is an acute, deep-seated infection of a single hair follicle that extends into the dermis and subcutaneous tissue. The key phrase "goes into the deeper layers of the skin" distinguishes it from folliculitis (superficial). While "boil" is a lay term for furuncle, "furuncle" is the precise medical terminology expected in nursing documentation.

(a) Folliculitis: This is a superficial infection limited to the follicular opening, not involving deeper dermal layers.
(c) Carbuncle: This is a collection of interconnected furuncles involving multiple follicles, not a single follicle infection.
(d) Boile: While technically correct (boil = furuncle), it is colloquial terminology. Professional nursing documentation requires precise medical terms like "furuncle."

DEPTH mnemonic: Folliculitis (Surface), Furuncle (Deep), Carbuncle (Deeper, Multiple)

Which of the following terms refers to inflammation of a gland?

a) Furunculosis

b) Adenitis

c) Lymphadenitis

d) Folliculitis

(b) Adenitis

Adenitis comes from Greek roots: "aden" (gland) + "itis" (inflammation). It specifically means inflammation of a gland. While lymphadenitis (inflammation of lymph nodes) is technically a type of adenitis, adenitis is the most accurate general term for inflammation of any gland.

(a) Furunculosis: This refers to the condition of having multiple furuncles (boils), not gland inflammation.
(c) Lymphadenitis: This is specific to lymph nodes only, which are just one type of gland. The question asks for the general term.
(d) Folliculitis: This refers to inflammation of hair follicles, which are not glands.

🔬 Word Root Wisdom: Learning Greek/Latin roots helps decode medical terms! Adeno = gland, Lympho = lymph, Folliculo = follicle.

Which of the following statements is NOT true about an ear infection?

a) It usually begins as a cold

b) It is more common in children

c) Adenoids do not take part in an ear infection

d) The Eustachian tube is the main part of the ear affected

This statement is completely false. Adenoids play a significant role in ear infections (otitis media). Enlarged or infected adenoids can obstruct the Eustachian tube opening, leading to fluid accumulation and secondary bacterial infection. They can also serve as a reservoir for pathogens.

(a) Usually begins as a cold: This is TRUE. Upper respiratory viral infections cause inflammation and swelling of the nasal mucosa and Eustachian tube, predisposing to otitis media.
(b) More common in children: This is TRUE due to shorter, more horizontal Eustachian tubes and immature immune systems.
(d) Eustachian tube is main part affected: This is TRUE as dysfunction of the Eustachian tube is the primary pathophysiological mechanism.

👶 Remember: Children have Eustachian tubes that are shorter, wider, and more horizontal than adults - perfect formula for bacteria to travel from throat to middle ear!

Which of the following is NOT a feature of acute mastoiditis?

a) Deafness

b) Clouding of air cells

c) Obliteration of retro auricular sulcus

d) Outward and downward displacement of the pinna

(b) Clouding of air cells

While clouding of mastoid air cells is seen on imaging, it is a radiological finding rather than a clinical feature. The question asks for "features" which typically refers to observable clinical signs and symptoms. All other options are clinical features visible on physical examination.

(a) Deafness: This IS a clinical feature due to conductive hearing loss from middle ear effusion and inflammation.
(c) Obliteration of retro auricular sulcus: This IS a classic clinical sign caused by post-auricular swelling making the crease behind the ear disappear.
(d) Outward/downward displacement of pinna: This IS the hallmark clinical sign (pinna pushed out and down by inflamed mastoid process).

⚠️ Exam Strategy: Distinguish between CLINICAL FEATURES (what you see on exam) and INVESTIGATIVE FINDINGS (what appears on tests). Questions often test this nuance!

Which of the following terms refers to a patient who hears better while in noisy places?

a) Paracusis

b) Hyperacusis

c) Hypoacusis

d) Presbycusis

(a) Paracusis

Paracusis of Willis is the phenomenon where patients with conductive hearing loss (like otosclerosis) paradoxically hear better in noisy environments. Background noise causes people to speak louder and with more clarity, which helps these patients. This is a classic distinguishing feature of conductive vs sensorineural hearing loss.

(b) Hyperacusis: This is decreased tolerance to normal environmental sounds - the opposite of what's described.
(c) Hypoacusis: This simply means partial hearing loss or reduced hearing acuity, with no paradoxical improvement in noise.
(d) Presbycusis: This is age-related sensorineural hearing loss, typically worse in noisy environments due to difficulty with speech discrimination.

HEARING LOSS TYPES: Para = Paradoxical (better in noise), Hyper = Hypersensitive, Hypo = Reduced, Presby = Presbyters/Old age

Which of the following characteristics of discharge is true for viral epidemic kerato-conjunctivitis?

a) Copious-purulent

b) Copious mucopurulent

c) Excessive watery

d) Mucoid ropy white

Viral conjunctivitis, including epidemic kerato-conjunctivitis (EKC), characteristically produces a serous (watery) discharge due to viral irritation of the conjunctiva without significant bacterial infection. The discharge is typically clear and watery, not thick or colored.

(a) Copious-purulent: This describes bacterial conjunctivitis with thick, yellow-green pus.
(b) Copious mucopurulent: This also indicates bacterial infection with mixed mucus and pus.
(d) Mucoid ropy white: This is characteristic of allergic conjunctivitis (stringy, white mucus).

DISCHARGE types: Viral = Watery, Bacterial = Purulent, Allergic = Mucoid

Which of the following is a contra indication to the use of topical steroids in viral corneal ulcers?

a) Secondary glaucoma

b) Cortical cataract

c) Corneal perforation

d) Secondary viral infection

Corneal perforation is an absolute contraindication for topical steroids in viral corneal ulcers. Steroids inhibit collagen synthesis and impair wound healing, which would worsen perforation and prevent sealing of the corneal defect. This is a life-threatening emergency requiring immediate surgical intervention, not steroid therapy.

(a) Secondary glaucoma: While steroids can cause or worsen glaucoma, a history of secondary glaucoma is a relative contraindication, not absolute - steroids can be used with IOP monitoring.
(b) Cortical cataract: This is not a contraindication. Steroids may worsen cataracts with long-term use, but they don't prevent short-term therapeutic use for ulcers.
(d) Secondary viral infection: This is the indication for treatment, not a contraindication. Antiviral therapy is primary, steroids are sometimes used as adjunct.

⚠️ CRITICAL: In viral keratitis (especially HSV), steroids can only be used with ACTIVE antiviral coverage and never with corneal perforation. This is a major exam point!

Which of the following treatments is appropriate for an infant with a watering lacrimal sac?

a) Probing

b) Probing with syringing

c) Dacryocystorhinostomy

d) Massaging with antibiotics

(d) Massaging with antibiotics

Congenital nasolacrimal duct obstruction (watering lacrimal sac in infants) is treated initially with Crigler massage (massage of lacrimal sac) combined with topical antibiotic drops if discharge is present. This is successful in >90% of cases by age 12 months. More invasive procedures are reserved for persistent cases.

(a) Probing: This is reserved for cases that fail conservative management after 6-12 months, not first-line treatment.
(b) Probing with syringing: This is also an interventional procedure used when massage fails, not initial therapy.
(c) Dacryocystorhinostomy: This is a major surgical procedure creating a new drainage pathway, only for refractory cases in older children/adults.

NLDO Treatment Ladder: Massage → Probing → Intubation → DCR (Dacryocystorhinostomy)

Active management of trachoma infection includes

a) Contact discontinuation

b) Social isolation

c) Patient education

d) Symptom monitoring

Patient education is the cornerstone of active trachoma management according to WHO's SAFE strategy (Surgery, Antibiotics, Facial cleanliness, Environmental improvement). Education promotes hygiene practices, treatment adherence, and community prevention. It's active, ongoing, and empowers patients/families to break the transmission cycle.

(a) Contact discontinuation: While reducing contact helps, it's impractical and insufficient alone. Trachoma requires mass drug administration and hygiene measures.
(b) Social isolation: This is unnecessary and stigmatizing. Trachoma is not highly contagious through casual contact.
(d) Symptom monitoring: This is passive observation, not active management. Active management requires intervention.

🌍 WHO's SAFE Strategy: S= Surgery for trichiasis, A= Antibiotics (azithromycin), F= Facial cleanliness, E= Environmental improvement. Education underpins all components!

Stridor that occurs when there is airway obstruction in the distal trachea is

a) Monophasic

b) Biphasic

c) Expiratory

d) Inspiration

Distal tracheal obstruction (subglottic or lower trachea) causes expiratory stridor because the obstruction limits airflow OUT during expiration when the airway naturally narrows. Inspiratory stridor typically indicates supraglottic obstruction, while biphasic stridor suggests fixed obstruction at the glottic level.

(a) Monophasic: This is not a standard stridor classification. Stridor is described by phase of respiration, not as monophasic.
(b) Biphasic: This occurs with fixed glottic or subglottic lesions but is less specific than expiratory for distal tracheal obstruction.
(d) Inspiratory: This indicates supraglottic obstruction above the vocal cords (e.g., epiglottitis, laryngomalacia).

STRIDOR LOCATION: Inspiratory = Supraglottic, Expiratory = Subglottic/Distal, Biphasic = Glottic

Nurses educate parents that intrinsic causes of asthma in children include

a) Dust

b) Infections

c) Pollen

d) Drugs

(b) Infections

Intrinsic causes of asthma are factors originating from within the body itself, not environmental exposures. Respiratory infections (viral or bacterial) are intrinsic triggers that can exacerbate asthma by causing airway inflammation and hyperreactivity. All other options are extrinsic environmental allergens.

(a) Dust: This is an extrinsic allergen (environmental trigger), not intrinsic.
(c) Pollen: This is an extrinsic seasonal allergen from the external environment.
(d) Drugs: While some drugs trigger asthma, they are considered external triggers (extrinsic), not originating from within the body.

🔄 Intrinsic vs Extrinsic: Intrinsic = from within (infections, emotions, exercise), Extrinsic = from outside (dust, pollen, smoke, drugs)

Which of the following auto immune disorders is caused by haemolytic streptococcus?

a) Sickle cell disease

b) Rheumatic heart disease

c) Graves' disease

d) Addison disease

(b) Rheumatic heart disease

Rheumatic heart disease is caused by molecular mimicry following infection with Group A β-hemolytic Streptococcus pyogenes. The immune system produces antibodies against streptococcal M proteins that cross-react with cardiac tissue (myosin, valve tissue), leading to pancarditis. This is the classic post-streptococcal autoimmune sequela.

(a) Sickle cell disease: This is a genetic hemoglobinopathy, not an autoimmune disorder. It's inherited, not caused by streptococcus.
(c) Graves' disease: This is an autoimmune thyroid disorder caused by thyroid-stimulating immunoglobulins, not related to streptococcus.
(d) Addison disease: This is autoimmune adrenalitis, often associated with other autoimmune endocrinopathies, not streptococcal infection.

POST-STREP SEQUELAE: "RHEUMATIC" R = Rheumatic fever, H = Heart disease, E = Erythema marginatum, U = Untreated pharyngitis, M = Migratory polyarthritis, A = Aschoff bodies, T = Temperature (fever), I = Increased ASO titer, C = Carditis

Which of the following is NOT a feature of glomerulonephritis?

a) Tea coloured urine

b) Hypotension

c) Diplopia

d) Anorexia

Diplopia (double vision) is not associated with glomerulonephritis. It is a neuro-ophthalmic symptom related to cranial nerve palsies, ocular muscle dysfunction, or neurologic disorders. Glomerulonephritis primarily affects the kidneys and does not involve ocular motor pathways.

(a) Tea coloured urine: This IS a feature due to hematuria (blood in urine) from glomerular inflammation.
(b) Hypotension: This IS a feature due to fluid and sodium loss from damaged glomeruli (not hypertension in initial phase).
(d) Anorexia: This IS a common feature due to uremia, nausea, and systemic inflammation associated with renal failure.

👁️ Eye Symptoms Alert: Diplopia is a red herring in renal questions! Always associate it with neurological or muscular disorders, not renal disease.

The nurse suspects congenital toxoplasmosis in a child presenting at the clinic with

a) Hydrocephalus

b) Anencephaly

c) Small head

d) Macrocephaly

Congenital toxoplasmosis classically presents with the "Small head" or microcephaly (head circumference <2 SD below mean). This results from intrauterine brain damage and calcifications. The classic triad is CHORIORETINITIS + HYDROCEPHALUS + INTRACRANIAL CALCIFICATIONS, but microcephaly is the most consistent presentation.

(a) Hydrocephalus: While this CAN occur in toxoplasmosis, it's less common than microcephaly. Hydrocephalus means enlarged head due to fluid accumulation.
(b) Anencephaly: This is a neural tube defect (absence of brain), not related to toxoplasmosis.
(d) Macrocephaly: This means enlarged head, which is opposite of toxoplasmosis presentation (except in rare hydrocephalus cases).

CONGENITAL TOXOPLASMOSIS: "MCH" M = Microcephaly, C = Chorioretinitis, H = Hydrocephalus/Intracranial calcifications

Which of the following statements is TRUE about prevention of HIV transmission from mother to child?

a) The baby is given Nevirapine 6 weeks after delivery

b) Exclusively breastfeed the baby as long as the mother is on ART

c) Mothers should not breastfeed babies because breast milk contains HIV

d) Nothing can prevent HIV transmission to the baby

(b) Exclusively breastfeed the baby as long as the mother is on ART

WHO and national guidelines recommend exclusive breastfeeding for HIV-positive mothers on effective ART. ART suppresses viral load to undetectable levels, making breast milk safe. Mixed feeding (breast milk + formula/other foods) increases transmission risk. Option (a) is partially correct but timing is wrong - nevirapine is given immediately after birth, not at 6 weeks.

(a) Nevirapine 6 weeks after: This is INCORRECT. Infant prophylaxis (Nevirapine) starts within 6-12 hours after birth and continues for 6 weeks.
(c) No breastfeeding: This is OUTDATED advice. With modern ART, breastfeeding is recommended in resource-limited settings.
(d) Nothing can prevent: This is FALSE. With proper PMTCT (Prevention of Mother-to-Child Transmission), transmission risk is <1%.

🍼 PMTCT Key Points: ART during pregnancy + intrapartum + postpartum + infant prophylaxis + exclusive breastfeeding + viral load monitoring = >99% prevention rate!

Which of the following is NOT a preventive measure against congenital anomalies?

a) Genetic counselling

b) Avoiding delayed conception

c) Avoidance of self-medication

d) Immunisation with anti immunoglobulin

(d) Immunisation with anti immunoglobulin

"Anti-immunoglobulin" is not a standard preventive measure. The term is nonsensical in medical practice. While immunoglobulin therapy exists for certain conditions (like Rh isoimmunization), there is no vaccine or immunization called "anti-immunoglobulin" for preventing congenital anomalies. Proper immunizations (like MMR, varicella) ARE preventive, but this option is worded incorrectly.

(a) Genetic counselling: This IS a preventive measure - identifies carrier status, recurrence risks, and reproductive options.
(b) Avoiding delayed conception: This IS preventive. Advanced maternal age (>35y) increases risk of chromosomal anomalies like Down syndrome.
(c) Avoidance of self-medication: This IS critical prevention - many drugs are teratogenic (e.g., thalidomide, isotretinoin, warfarin).

🛡️ Primary Prevention: Folic acid supplementation (0.4mg daily preconception) prevents 70% of neural tube defects - the MOST effective congenital anomaly prevention!

Which of the following is NOT an atrial septal defect?

a) Sinus stenosis

b) Ostium secundum

c) Sinus venosus

d) Ostium primum

(a) Sinus stenosis

"Sinus stenosis" refers to narrowing of the sinus venosus or other venous structures, NOT an atrial septal defect. The three types of ASD are: (1) Ostium secundum (most common - central defect), (2) Ostium primum (low septal defect, part of AV canal defects), and (3) Sinus venosus (high septal defect near SVC/IVC).

(b) Ostium secundum: This IS an ASD - most common type (70%), located in the fossa ovalis region.
(c) Sinus venosus: This IS an ASD - located near the superior vena cava entrance, often with anomalous pulmonary veins.
(d) Ostium primum: This IS an ASD - located in the lower atrial septum, part of AV canal defects.

ASD TYPES: "SOS" - Secundum, Ostium primum, Sinus venosus

Measures to promote activity and rest for a child with osteomyelitis exclude

a) Promoting Bed rest initially

b) Starting the child on exercise light away

c) Providing support for affected injury

d) Gradually encouraging out of bed activity as tolerated

(b) Starting the child on exercise light away

Starting immediate exercise is contraindicated in acute osteomyelitis. Initial management requires immobilization and rest of the affected limb to reduce pain, prevent pathological fractures, and avoid spreading infection. Exercise is introduced gradually only after infection control and clinical improvement.

(a) Promoting bed rest: This IS correct - bed rest is essential during the acute phase to facilitate healing.
(c) Providing support: This IS correct - splinting/positioning supports the affected limb, reduces pain, prevents deformities.
(d) Gradual activity: This IS correct - progressive mobilization is introduced after clinical resolution to prevent joint stiffness.

🔥 Acute Osteomyelitis Priority: IMMOBILIZE FIRST! The bone is infected and structurally weak. Early exercise can cause sequestrum formation, pathological fracture, and chronic osteomyelitis.

The sudden and severe haemolysis in sickle cell anaemia is

a) Hemoptysis

b) Hematuria

c) Hemolytic crisis

d) Ecchymosis

Hemolytic crisis in sickle cell disease is characterized by acute, severe breakdown of red blood cells beyond the baseline chronic hemolysis. It causes sudden drop in hemoglobin, jaundice, fatigue, and may be triggered by infections, medications, or G6PD deficiency. This is distinct from vaso-occlusive crisis (pain crisis).

(a) Hemoptysis: This is coughing up blood from respiratory tract, not intravascular hemolysis. While possible in sickle cell, it's not the term for hemolytic crisis.
(b) Hematuria: This is blood in urine - can occur in sickle cell due to renal papillary necrosis, but it's not the term for acute hemolytic crisis.
(d) Ecchymosis: This is a large bruise from extravasation of blood into skin, not hemolysis.

SICKLE CELL CRISES: "HVP" - Hemolytic, Vaso-occlusive (pain), Prapism, Plus: Acute chest syndrome, Aplastic crisis

SECTION B: Fill in the Blank Spaces (10 marks)

A prolapsed oedematous respiratory mucosa is called ________________

Polyp

A nasal polyp is a prolapsed, edematous (swollen) respiratory mucosa protruding into the nasal cavity. It results from chronic inflammation (allergic rhinitis, chronic sinusitis) and appears as a grape-like, pale, translucent mass.

The chart on which patient's visual acuity is tested is referred to as ________________

Snellen chart

The Snellen chart is the standard eye chart used to measure visual acuity. It consists of rows of letters decreasing in size from top to bottom. The patient reads from a distance of 6 meters (20 feet). Normal vision is recorded as 6/6 or 20/20.

The sensation of sound in the absence of an appropriate auditory stimulus is referred to as ________________

Tinnitus

Tinnitus is the perception of ringing, buzzing, hissing, or other sounds without external acoustic stimulation. It can be subjective (only heard by patient) or objective (can be heard by examiner). Common causes include noise exposure, ototoxic drugs, presbycusis, and ear infections.

A patient presenting with impaired tasting, swallowing and gag reflex is suspected of having injured the ________________

Glossopharyngeal nerve (CN IX)

The glossopharyngeal nerve (cranial nerve IX) provides sensory innervation to the posterior 1/3 of tongue (taste), pharynx (swallowing), and carotid body. It also supplies motor fibers to the stylopharyngeus muscle. Injury causes loss of taste, dysphagia, and absent gag reflex.

Excision of all the inner contents of the eye ball including uveal tissue is referred to as ________________

Evisceration

Evisceration is the surgical removal of intraocular contents (cornea, iris, lens, retina) while leaving the scleral shell intact. It is less invasive than enucleation (removal of entire eyeball). Indications include blind, painful eyes or severe ocular trauma.

A child experiencing breathing problems and ear infections due to enlarged adenoids may benefit from a surgery called ________________

Adenoidectomy

Adenoidectomy is the surgical removal of enlarged/infected adenoids. Indications include chronic mouth breathing, snoring, Obstructive Sleep Apnea (OSA), recurrent otitis media, and chronic adenoiditis. Often performed with tonsillectomy (adenotonsillectomy) in children.

The abnormal accumulation of cerebral spinal fluid in the intracranial spaces is referred to as ________________

Hydrocephalus

Hydrocephalus is the pathological accumulation of CSF due to impaired drainage (obstructive) or absorption (communicating). Causes include congenital aqueduct stenosis, meningitis, hemorrhage, tumors. Leads to increased intracranial pressure, head enlargement in infants, and brain damage.

The congenital malformation resulting from failure of fusion of first branchial arch during intrauterine life is known as ________________

Cleft palate / Cleft lip

The first branchial arch forms the maxilla, mandible, and facial structures. Failure of fusion between weeks 6-9 of gestation results in cleft lip (failure of medial nasal process to fuse with maxillary process) and cleft palate (failure of palatal shelves to fuse). Can be unilateral or bilateral.

Inflammation of the endocardium and the inner lining of the heart is referred to as ________________

Endocarditis

Endocarditis is inflammation of the endocardium, typically involving heart valves. Infective endocarditis is caused by bacterial (Streptococcus, Staphylococcus) or fungal infection. Non-infective (marantic) endocarditis occurs in hypercoagulable states. Presents with fever, murmurs, embolic phenomena.

The congenital abnormality characterised by absence of one kidney is called ________________

Renal agenesis (or unilateral renal agenesis)

Renal agenesis is the congenital absence of one (unilateral) or both (bilateral) kidneys due to failure of ureteric bud development. Unilateral agenesis is often asymptomatic (compensatory hypertrophy of remaining kidney). Bilateral agenesis is incompatible with life (Potter sequence).

SECTION B: Short Essay Questions (10 marks)

Outline five (5) causes of Epistaxis. (5 marks)

Epistaxis (nosebleed) causes can be local or systemic:

1. Local trauma: Nose picking, foreign bodies, nasal fractures, vigorous nose blowing, post-surgical bleeding.

2. Inflammatory/infectious causes: Rhinitis, sinusitis, upper respiratory infections causing mucosal irritation and congestion.

3. Dry air/low humidity: Dry climates, heated indoor air, dehydration causing mucosal drying and crusting leading to vessel rupture.

4. Coagulation disorders: Thrombocytopenia, hemophilia, von Willebrand disease, leukemia, liver disease affecting clotting factors.

5. Medications: Anticoagulants (warfarin, heparin), antiplatelets (aspirin, clopidogrel), NSAIDs, intranasal steroids.

EPISTAXIS CAUSES: "TIDES" - Trauma, Infections, Drugs/Dryness, Environmental, Systemic diseases

Outline five (5) clinical features of glaucoma. (5 marks)

Glaucoma features depend on type (open-angle vs angle-closure), but common features include:

1. Increased intraocular pressure (IOP): >21 mmHg (normal 10-21 mmHg) measured by tonometry.

2. Visual field defects: Progressive peripheral vision loss (tunnel vision) starting as arcuate scotomas.

3. Cupping of optic disc: Increased optic disc cup-to-disc ratio (>0.5), notching, hemorrhages.

4. Eye pain and headache: Especially in acute angle-closure glaucoma with halos around lights, nausea, vomiting.

5. Reduced visual acuity: Blurred vision, difficulty focusing, especially in advanced stages or acute attacks.

🔍 Silent Thief of Sight: Open-angle glaucoma is often asymptomatic until advanced! Regular screening (especially after age 40) is crucial.

SECTION C: Long Essay Questions (60 marks)

(a) Outline four (4) different types of cataracts. (4 marks)
(b) Describe with a rationale for each, ten (10) nursing interventions performed for a patient for 48 hours after a cataract surgery. (10 marks)
(c) Outline six (6) educational messages shared with a patient being discharged home following a cataract surgery. (6 marks)

(a) Types of Cataracts:

1. Senile/age-related cataract: Most common type in elderly due to natural aging process, lens protein denaturation.

2. Congenital cataract: Present at birth or early infancy due to genetic factors, maternal infections (rubella), metabolic disorders.

3. Traumatic cataract: Results from blunt or penetrating eye injury causing lens capsule rupture and opacification.

4. Complicated/secondary cataract: Develops secondary to other eye diseases (uveitis, glaucoma, retinitis pigmentosa) or systemic diseases (diabetes).

(b) 48-Hour Post-Cataract Surgery Nursing Interventions:

1. Monitor vital signs 2-4 hourly: To detect early signs of infection, hemorrhage, or adverse reactions to anesthesia.

2. Apply eye patch/shield continuously: Protects operated eye from mechanical injury, reduces light sensitivity, prevents rubbing.

3. Administer prescribed eye drops: Antibiotic drops prevent infection, steroid drops reduce inflammation, mydriatics maintain pupil dilation.

4. Position patient semi-recumbent (30-45°): Reduces intraocular pressure, minimizes edema, prevents supine position bleeding.

5. Monitor for pain and provide analgesia: Mild pain is expected; severe pain may indicate complications (hemorrhage, infection, IOP spike).

6. Strict aseptic wound care: Prevents postoperative endophthalmitis (serious infection) which can cause blindness.

7. Check visual acuity daily: Assesses surgical success and detects early complications like corneal edema, macular edema.

8. Maintain patent IV line: Provides route for emergency medications and maintains hydration if NPO.

9. Monitor for complications: Watch for hemorrhage (hyphema), raised IOP, uveitis, lens displacement, endophthalmitis.

10. Provide emotional support and reassurance: Reduces anxiety, promotes cooperation, and improves overall recovery experience.

(c) Discharge Education Messages:

1. Eye drop administration technique: Wash hands, avoid touching dropper tip, apply prescribed schedule (e.g., 4 times daily for 2 weeks).

2. Eye protection: Wear eye shield at night for 1 week, avoid rubbing/pushing on eye, wear sunglasses outdoors.

3. Activity restrictions: Avoid heavy lifting (>5kg), bending, straining, strenuous exercise for 2 weeks to prevent IOP rise.

4. Hygiene precautions: Avoid getting water in eye (no swimming), no cosmetics on operated eye for 2 weeks, clean eye gently with sterile cotton.

5. Follow-up appointments: Return for review after 1 day, 1 week, and 1 month for visual acuity check and complication assessment.

6. Warning signs and emergency care: Report immediately: severe pain, sudden vision loss, increasing redness, discharge, flashing lights, new floaters.

POST-CATARACT CARE: "DROP-IN" - Drops, Rest, Observation, Protection, Instructions, No rubbing/straining

(a) Outline five (5) clinical features of a child presenting with sickle cell anaemia. (5 marks)
(b) Describe ten (10) nursing interventions implemented for a child admitted with sickle cell crisis for the first 48 hours. (10 marks)
(c) State five (5) complications of sickle cell anaemia. (5 marks)

(a) Clinical Features of Sickle Cell Anaemia:

1. Severe anemia: Hemoglobin 6-9 g/dl causing pallor, fatigue, tachycardia, congestive cardiac failure in severe cases.

2. Jaundice: Yellowish sclera and skin due to chronic hemolysis and elevated bilirubin from sickled cell breakdown.

3. Dactylitis (hand-foot syndrome): Painful swelling of fingers and toes due to vaso-occlusion in small bones - often first sign in infants.

4. Splenomegaly (in early disease) / autosplenectomy (in late disease): Enlarged spleen initially from sequestration, later becomes fibrotic and shrunken from repeated infarctions.

5. Delayed growth and development: Chronic anemia, nutritional deficiencies, and recurrent illnesses lead to short stature, delayed puberty, and poor weight gain.

(b) 48-Hour Nursing Interventions for Sickle Cell Crisis:

1. Aggressive pain assessment and management: Use pain scale, administer opioids (morphine, pethidine) as prescribed, reassess every 15-30 min. Pain is the primary symptom.

2. Hydration therapy: Maintain IV fluids (Normal Saline/Dextrose) at 1.5x maintenance to reduce blood viscosity and prevent further sickling.

3. Oxygen therapy: Administer O₂ at 2-4 L/min via nasal cannula to maintain SpO₂ >95%, reduces hypoxia-induced sickling.

4. Blood transfusion if Hb <5 g/dl or severe symptoms: Raises oxygen carrying capacity, dilutes sickle cells with normal RBCs.

5. Warm compresses to painful areas: Promotes vasodilation and blood flow, reduces pain from vaso-occlusion.

6. Positioning and comfort measures: Semi-Fowler's position, gentle handling, minimize venipunctures to prevent tissue injury.

7. Monitor for complications: Watch for acute chest syndrome (fever, chest pain, cough), stroke (neuro changes), priapism, splenic sequestration.

8. Infection control and antibiotics: Broad-spectrum antibiotics if fever >38.5°C (risk of sepsis from encapsulated organisms like Pneumococcus).

9. Psychological support: Reassure child and parents, explain procedures, reduce anxiety which can worsen pain.

10. Monitor vital signs and urine output hourly: Detect early shock, dehydration, oliguria from renal involvement. Watch for hypotension and tachycardia.

(c) Complications of Sickle Cell Anaemia:

1. Stroke: Vaso-occlusion of cerebral vessels causing ischemic or hemorrhagic stroke, leading to neurological deficits.

2. Avascular necrosis: Bone infarction, especially of femoral and humeral heads, causing chronic pain and arthritis.

3. Acute chest syndrome: Vaso-occlusion in pulmonary vessels causing chest pain, cough, fever, hypoxia - leading cause of mortality.

4. Chronic renal failure: Renal medullary infarcts lead to nephrogenic diabetes insipidus, proteinuria, progressive renal failure.

5. Leg ulcers: Chronic non-healing ulcers over malleoli due to poor peripheral circulation, venous stasis, and infection risk.

🚨 ACUTE CHEST SYNDROME: MOST COMMON CAUSE OF DEATH! Treat as emergency: O₂, antibiotics, transfusion, incentive spirometry, pain control.

(a) Outline six (6) signs and symptoms of nephrotic syndrome. (6 marks)
(b) Outline four (4) expected outcomes for nursing a child with nephrotic syndrome. (4 marks)
(c) Describe ten (10) specific nursing interventions implemented for a child admitted with nephritic syndrome for the first 2 hours. (10 marks)

(a) Signs and Symptoms of Nephrotic Syndrome:

1. Massive proteinuria: >3.5g/day in adults or >40 mg/m²/hr in children, causing frothy/foamy urine due to loss of proteins.

2. Generalized edema (anasarca): Pitting edema starting periorbital (puffy eyes), then dependent areas (ankles), eventually ascites, pleural effusion, and scrotal/labial edema.

3. Hypoalbuminemia: Serum albumin <2.5 g/dl due to urinary loss, causing fluid shift from intravascular to interstitial space.

4. Hyperlipidemia: Elevated cholesterol and triglycerides due to increased hepatic lipoprotein synthesis in response to low oncotic pressure.

5. Hypertension: Due to sodium and water retention, common in many forms of nephrotic syndrome.

6. Susceptibility to infections: Loss of immunoglobulins and complement factors in urine increases risk of bacterial infections (peritonitis, cellulitis).

(b) Expected Nursing Outcomes for a Child with Nephrotic Syndrome:

1. Edema resolution: Child will demonstrate decreased edema with weight loss of 0.5-1kg/day and reduced abdominal girth.

2. Proteinuria reduction: Urine protein will decrease from ++++ to trace/negative within 2-4 weeks of steroid therapy.

3. Maintain fluid balance: Child will have stable vital signs, balanced intake/output, and no signs of dehydration or fluid overload.

4. Prevent infection: Child will remain afebrile with no signs of infection during immunosuppressive therapy.

5. Promote growth and development: Child will maintain adequate nutrition and show age-appropriate developmental milestones despite chronic illness.

(c) First 2-Hour Nursing Interventions for Nephritic Syndrome:

1. Assess and record vital signs (BP, HR, RR, Temp): Establish baseline and detect hypertension (common), tachycardia from fluid overload, or fever from infection.

2. Accurate measurement and strict monitoring of fluid intake and output: Critical for managing fluid balance, detecting oliguria/anuria, and guiding diuretic therapy.

3. Weigh the child on admission and daily thereafter: Weight is the most sensitive indicator of fluid status changes - gain indicates edema, loss indicates diuresis.

4. Measure and mark abdominal girth: Quantifies ascites severity and monitors response to treatment (should decrease with diuresis).

5. Collect baseline urine and blood specimens: Urine for protein analysis (dipstick, 24-hour collection), blood for albumin, cholesterol, electrolytes, creatinine.

6. Administer prescribed medications promptly: Diuretics (furosemide) for edema, steroids (prednisolone) to induce remission, antihypertensives if needed.

7. Position child semi-Fowler's or upright: Reduces periorbital edema and respiratory effort if pleural effusion present; turn every 2 hours to prevent pressure sores.

8. Meticulous skin care and edema management: Inspect skin folds, keep dry, apply barrier creams, prevent friction and breakdown from severe edema.

9. Provide emotional support to child and parents: Explain procedures, reassure about treatability, reduce anxiety from dramatic edema appearance.

10. Initiate low-salt diet and nutritional assessment: Restrict sodium to <2g/day to reduce fluid retention; ensure adequate protein intake despite proteinuria.

NEPHROTIC SYNDROME CARE: "PODCAST" - Protein management, Observation (vitals), Daily weights, Careful I/O, Activity (rest), Skin care, Treatment compliance

⚡ URGENT PRIORITY: In first 2 hours, focus on ASSESSMENT (vitals, weight, edema) and BASELINE DATA (labs, urine). Quick steroid initiation is key to inducing remission!