A. diagnosis of diseases

B. healing process

C. nursing process

D. disease prevention

E. identification of disease risk factors

22. Assessment of the nursing process allows you to determine:

A. speed of nursing care

B. duration of illness

C. quality of nursing care

D. causes of diseases

E. patient problems

23. The patient’s priority physiological problem is

B. anxiety

C. weakness

D. lack of appetite

E. bad dream

24. When establishing the priority of providing medical care to several patients, the nurse is guided by:

A. age, gender of the patient

B. personal attitude towards patients

C. social status of patients

D. medical indications

E. political and religious beliefs

25. Nursing process is:

A. identifying a specific disease in a person;

B. drawing up a treatment plan;

C. definition of the main clinical syndrome;

D. identifying impaired needs, identifying the patient’s problems in connection with the disease;

E. conducting an instrumental examination.

26. The patient’s real problems are:

E. financial problems.

27. Potential patient problems are:

A. problems identified at the time of the examination;

B. problems that can be foreseen;

C. problems that happened in the past;

D. relationship problems between the patient and the nurse;

E. financial problems

28. The patient’s priority problems are:

A. problems that need to be solved first;

B. problems that can be foreseen;

C. problems that happened in the past;

D. relationship problems between the patient and the nurse;

E. financial problems.

29. Dependent nursing activities are:

B. discussion with the patient of his problems;

C. assisting the patient in fulfilling natural needs;

D. teaching the patient self-care;

E. monitoring the patient's response to illness.

30. Independent nursing activity is:

A. the nurse’s fulfillment of doctor’s orders;

B. taking blood for analysis

C. carrying out infusion therapy;

D. ordering laboratory tests;

E. teaching the patient self-care.

1) Place of storage of drugs of groups “A” and “B”

A. desk at the nurse's station

B. cabinet with other medicines under lock and key

C. in the safe

D. separate shelf in the closet

E. in the refrigerator

2) The dosage form prepared in a pharmacy for external use must have a label with a stripe of the appropriate color

A. red

B. yellow

D. blue

E. green

3) A dosage form prepared in a pharmacy for internal use must have a label with a stripe of the appropriate color

A. white

B. yellow

C. blue

D. red

E. green

4) Sterile solutions in bottles prepared in a pharmacy must have a label with a stripe of the appropriate color

B. yellow

C. blue

D. red

E. greenfoot

5) Responsibility for obtaining medicines from the pharmacy is

A. procedural nurse

B. head of department

C. attending physician

D. head nurse

E. head nurse

6) List “B” includes medicinal substances

A. expensive

B. poisonous

C. potent

D. sleeping pills

E. hypotensive

7) List “A” includes medicinal substances

A. poisonous

B. sleeping pills

C. potent

D. hypotensive

E. expensive

8) Shelf life of mixtures and decoctions in the refrigerator (in days)

9) The head nurse should have a supply of medications for the period (in days)

10) The supply of narcotic substances in the department must be for the period

11) Prescribes medications from the pharmacy

A. manager department

B. procedures. nurse

C. head nurse

D. head nurse

E. ward nurse

12) The requirement to receive medications from a pharmacy consists of copies of:

13) The doctor must justify the administration of a narcotic analgesic in:

A. temperature sheet

B. medical history

C. sister leaf

D. drug log

E. patient movement log

14) A specially laced journal with numbered pages is used to record medications

A. antibiotics

B. hard drugs

C. other drugs

E. hormonal

15) Poisonous medications stored in the treatment room in:

A. refrigerator

B. locked cabinet

D. table, locked

E. cabinet with other medicines

16) The sister distributes medicines in

A. treatment room

C. nursing

D. corridor

E. head nurse's office

17) Tinctures are dosed

A. grams

B. milliliters

C. spoons

D. drops

E. beakers

18) The distribution of medicines in the department is carried out by ……. sister

A. junior

B. guard

C. procedural

D. eldest

E. home

19) Suppositories are stored in

A. refrigerator

C. medical cabinet

D. locked cabinet

E. table locked

20)Who fills out the medical prescription sheet

A. head of department

B. attending physician

C. head nurse

D. head nurse

E. guard nurse

21) Main document drug therapy patients for the nurse

A. statistical chart of the patient

B. medical prescription sheet

C. medical history

D. examination sheet

E. temperature sheet

22) Who carries out daily selection of drugs from the prescription list

A. head nurse

B. home

C. guard

D. younger

E. attending physician

23)Who signs the request to receive medicines from the pharmacy for the department

A. head nurse

B. manager department

C. head nurse

D. guard nurse

E. attending physician

24) drugs for parenteral use are stored in

A. glass cabinets in the treatment room

B. at the nurse's station in the closet

C. at the nurse's station in the nightstand

D. in the refrigerator

25) Stocks of toxic drugs in the department should not exceed ..... days

26) Stocks of potent drugs in the department should not exceed ..... days

27.) Solid dosage forms

A. talkers

C. capsules

E. aerosols

28) Soft dosage forms

A. tinctures

C. powders

E. talkers

29) Medicines are taken by the patient

A. independently

C. in the presence of a nurse

D. in the presence of patients

E. in the presence of the attending physician

An increase in blood pressure is defined by the term:

Tachycardia

Bradycardia

Hypotension

Hypertension

Normotonia

Treatment table, which is used for circulatory failure accompanying various diseases of the cardiovascular system:

A decrease in blood pressure is defined by the term:

Tachycardia

Bradycardia

Hypotension

Hypertension

Normotonia

The normal heart rate for a healthy middle-aged adult is:

50-59 beats per minute

60-80 beats per minute

85-90 beats per minute

95-110 beats per minute

120-140 beats per minute

Brief loss of consciousness is

When examining the patient, you discovered that his heart rate increased to 110 beats per minute. What is the term for this condition?

Tachycardia

Bradycardia

Hypotension

Hypertension

Normotoni

What treatment table is prescribed for gastritis, peptic ulcer stomach and duodenum?

Melena is:

Tarry stool

Watery stool

Light feces

- “sheep” feces

Foamy stool

Treatment table, which is used for kidney diseases, usually in the acute period of the disease, as well as in cases of impaired nitrogen excretory function:

Treatment table, which is used for respiratory failure and respiratory diseases:

In a healthy adult, the respiratory rate fluctuates:

From 12 to 15 in 1 minute

From 16 to 18 in 1 minute

From 20 to 23 in 1 minute

From 24 to 28 in 1 minute

From 30 to 34 in 1 minute

Bradypnea is the frequency of respiratory movements

When performing oxygen therapy, oxygen is humidified in order to:

Preventing dry mucous membranes of the respiratory tract

Defoaming sputum

Preventing waterlogging of the mucous membranes of the respiratory tract

Decreased pressure inside the bronchus

Increased blood circulation in the bronchus

For urinary incontinence in women at night, it is advisable to use

Diapers?

Rubber boat

Metal ship

Removable urinal

Lay down oilcloth

The ratio of the amount of fluid drunk and excreted is called

Daily diuresis

Water balance

Enuresis

Daytime diuresis

Night diuresis

Tachypnea is the frequency of respiratory movements

Urinary retention is called

Polyuria

Oliguria

Strangury

A decrease in daily urine output to less than 350 ml is called

Oliguria

Nocturia

Polyuria

Pollakiuria

The predominance of nocturnal diuresis over daytime is called

Polyuria

Nocturia

Oliguria

Strangury

An increase in daily diuresis over 3000 ml is called

Oliguria

Nocturia

Polyuria

The cessation of urine output is called

Oliguria

Nocturia

Polyuria

Pollakiuria

An increase in the number of urinations is called:

Oliguria

Nocturia

Polyuria

Pollakiuria

Painful urination is called:

Oliguria

Nocturia

Polyuria

Strangury

The patient experiences: vomiting, nausea, heartburn, belching, constipation. What nursing diagnosis will you give him?

Dyskinesia

Dyspepsia

Dysphagia

Dystrophy

A 47-year-old patient diagnosed with esophageal cancer complains of impaired swallowing. What nursing diagnosis will you give him?

Dyskinesia

Dyspepsia

Dysphagia

Dystrophy

When examining the patient, you discovered painful and frequent urination. What nursing diagnosis will you give him?

Dyskinesia

Dyspepsia

Dysphagia

Dystrophy

Rare, deep, noisy, observed in deep coma

Kussmaul's Breath

Biotte's Breath

Cheyne-Stokes breathing

Asphyxia

Periodic breathing, in which there is a correct alternation of periods of shallow breathing movements and pauses of equal duration (from several minutes to a minute)

Kussmaul's Breath

Biotte's Breath

Cheyne-Stokes breathing

Asphyxia

This type of breathing is characterized by a period of increasing frequency and depth of breathing, which reaches a maximum on the 5th-7th breath, followed by a period of decreasing frequency and depth of breathing and another long pause of equal duration (from several seconds to 1 minute). During a pause, patients are poorly oriented environment or lose consciousness, which is restored when breathing movements resume. What type of breathing is this?

Kussmaul's Breath

Biotte's Breath

Cheyne-Stokes breathing

Asphyxia

A 32-year-old patient complains of abdominal pain, coffee-ground-colored vomit, general weakness, and lethargy. On examination: condition of moderate severity, forced position with knees brought to the stomach, pale skin, blood pressure 90/60 mm Hg. What state can you think about first?

Poisoning

Gastrointestinal bleeding

Brain hemorrhage

Intestinal bleeding

Hypertensive crisis

1) The sublingual route of administration of medicinal substances is the introduction

A. into the rectum

B. into the respiratory tract

C. under the tongue

D. on the skin

2) Medicinal aerosols include

A. suspensions of medicinal substances in the air

B. aqueous solutions

C. alcohol solutions

D. oil solution

3) The patient takes sleeping pills before bedtime

4) Medications are taken by the patient

A. independently

B. in the presence of relatives

C. in the presence of a nurse

D. in the presence of patients

E. in the presence of lec. Doctor

5) Most often, dosage forms are administered rectally

B. powder

C. suppositories

D. tablets

6) The method of drug administration should be called enteral

A. intramuscular

B. intravenous

C. intraspinal (into the spinal canal)

D. oral (by mouth)

E. intracardiac

7)Capacity of one tablespoon (in ml)

8)Capacity of one dessert spoon (in ml)

9)Capacity of one teaspoon (in ml)

10) Enzyme preparations that improve digestion should be taken

B. during meals

D. between meals

E. 2 hours after eating

11) Medicines that irritate the gastrointestinal mucosa should be taken

B. during meals

C. after meals, with milk or water

D. between meals

E. 30 minutes after eating

12) Take medications that irritate the gastrointestinal tract

A. mineral water

B. milk

D. jelly

13) External use of medicines

A. through the rectum

B. intradermally

C. on the skin, mucous membranes

D. into the joint cavity

E. into the cavity of the heart

14) Enteral method - use of drugs

A. on the skin

B. through the rectum

C. intradermally

D. into the nasal cavity

E. inhalation

15) Medicinal substances used externally have an effect on the body

A. local

B. restorative

C. anticonvulsant

D. tonic

E. relaxing

16) Pills, capsules are used internally

A. chewed

B. contents pour out under the tongue

C. unchanged

D. dissolve in water, drink

E. crushed

17) Drugs prescribed on an empty stomach are taken by the patient

A. in 30 minutes. before meals

B. in 15-20 minutes. before meals

C. in 10 min. before meals

D. in 5 minutes before meals

E. just before eating

18) The inhalation method includes the administration of drugs

A. into the respiratory tract

B. under the tongue

C. in fabric

D. on mucous membranes

E. into blood vessels

19) The external method includes the administration of drugs

A. eye drops

B. subcutaneously

C. into the anterior abdominal wall

D. through the rectum

E. under the tongue

20) Before instillation into the ear, the solution must be heated to a temperature (in °C)

21) In what cases are medications prescribed orally after meals, if...

A. they irritate the gastric mucosa

B. they are involved in digestion processes

C. they are irritated by gastric acid and digestive enzymes

D. they have a shell

E. these are liquid dosage forms

22) The drug administered has a local effect

A. by mouth

B. under the tongue

C. into the rectum

D. intravenously

E. subcutaneously

23) Method of administering drugs through the mouth

A. sublingual

B. oral

C. rectal

D. vaginal

E. intramuscular

24) External use of medicines

A. intradermal

B. sublingual

C. intranasal

D. rectal

E. intramuscular

25) Enteral route of drug administration

A. through the gastrointestinal tract

B. through the respiratory tract

C. intradermally

D. on the skin

E. on mucous membranes

Complications such as Quincke's edema are related to

Pyrogenic reaction

Air embolism

Allergic reaction

Infectious complications

Technical complications

Which method of drug administration is called parenteral?

Administration of drugs by mouth

Any method of administering drugs that bypasses the gastrointestinal tract

External use of drugs

Administration of drugs through the rectum

Administration of drugs through the respiratory tract

Complications due to violation of the rules of asepsis and antisepsis of intravenous injection include:

Post-injection hematoma

Anaphylactic shock

Air embolism

Fat embolism

Method of parenteral administration of drugs:

Intravenously

Through the mouth

Under the tongue

Through the rectum

Intravaginally

A measure to prevent the occurrence of hematoma during intravenous injections is:

Firm and prolonged pressure on the injection site

Nurse hand hygiene

Double treatment of the injection field

Maintaining the sterility of the medicinal solution

Keeping the syringe sterile

Parenteral routes of drug administration do not include:

Intra-arterial

Intravenously

Subcutaneously

Intradermal

Rectally

What complication is associated with violation of the rules of asepsis and antisepsis when performing intravenous injections?

Air embolism

Fat embolism

Anaphylactic shock

Post-infectious hematoma

Formation of post-injection hematoma

Quincke's edema

Serum hepatitis disease

Anaphylactic shock

Complication associated with violation of intravenous injection technique:

Air embolism of a vessel

Quincke's edema

Serum hepatitis disease

Anaphylactic shock

Parenteral routes of drug administration include all except:

Intravenously

Intradermal

Intraosseous

Intra-arterial

Sublingual

What complication is associated with violation of the rules of asepsis and antisepsis during injections?

Air embolism

Fat embolism

Allergic reactions

Development of post-injection infiltrates and abscesses

Quincke's edema

After completing the intravenous injection, the patient bends his arm at the elbow joint to prevent:

Air embolism

Post-injection hematoma

Tissue necrosis

Phlebitis

Anaphylactic shock

The vein puncture site is treated:

Isotonic sodium chloride solution

96° alcohol solution

70° alcohol solution

Distilled water

40° alcohol solution

After intravenous administration of the drug, the patient developed a feeling of fullness, pain and local swelling at the injection site. What do you think has developed in the patient?

Anaphylactic shock

Quincke's edema

Air embolism

Post-injection hematoma

Complications associated with violation of injection technique are

Hematoma formation

Quincke's edema

Abscess

Complications associated with violation of injection technique are

Air embolism of a vessel

Quincke's edema

The occurrence of serum hepatitis

Abscess

When intradermal injections are performed correctly, a

Lemon peel papule

Infiltrate

Seal

Hematoma

Bubble

Hitting the nerve trunk during injection manifests itself as

Seals

Redness of the skin

Parezov

Abscess

Hematomas

For intravenous injection, a venous tourniquet must be applied to:

Upper 1/3 of the shoulder

Middle 1/3 of the shoulder

Lower 1/3 of the shoulder

Shoulder joint

Elbow joint

The parenteral route of drug administration is the use of drugs:

Through the gastrointestinal tract

Bypassing the gastrointestinal tract, through injection

Through the respiratory tract

Through the nose

Through the rectum

When an antibacterial drug was administered intravenously, the patient developed: severe weakness, a feeling of fear of death, dizziness, and difficulty breathing. What are your next tactics?

Will you continue the injection?

Inject only half of the drawn-up medicine

Stop administering the drug

Inject the drug quickly

Inject the drug slowly

The vein puncture site is treated with a 70° alcohol solution

One time

Twice

Three times

Quadruple

Five times

For intravenous injection, the needle is inserted at an angle:

30 0 or less

Isotonic NaCl solution is

0.1% NaCl solution

0.5% NaCl solution

0.6% NaCl solution

0.9% NaCl solution

1% NaCl solution

The length of the needle for intravenous injection is at least:

Concentration of alcohol for treating the injection site (in degrees)

Angle of inclination of the needle during intradermal injection (in degrees)

Depth of needle insertion during intradermal injection

a) only the needle cut

b) two thirds of the needle

c) one second needle

d) the entire length of the needle

d) one third of the needle

Intradermal injection site

b) anterior abdominal wall

c) outer surface of the shoulder

d) inner surface of the forearm

D) upper outer quadrant of the buttock

Injected intradermally

a) tuberculin

b) vitamins

c) hormones

d) antibiotics

d) stroke

No more than (in ml) of medicinal substance can be administered subcutaneously at one time.

The needle for subcutaneous injection is inserted at an angle (in degrees)

Depth of needle insertion when performing subcutaneous injection

a) only the needle cut

b) two thirds of the needle

c) depending on the location of the vessel

d) the entire length of the needle

e) one second needle

Antibiotics are most often administered

a) subcutaneously

b) intramuscularly

c) intravenously

d) intradermally

d) inhalation

Position of the patient during intramuscular injection into the buttock

a) lying on your stomach, on your side

d) lying on your back

d) knee-elbow

For intramuscular injection, the needle is inserted at an angle (in degrees)

Possible complication of intramuscular injection

a) infiltration

b) air embolism

c) thrombophlebitis

d) bleeding

e) lipodystrophy

Needle length for intramuscular injection (in mm)

The most appropriate site for intramuscular injection

a) subscapular region

b) forearm

d) upper outer quadrant of the buttock

D) near the umbilical region

Possible complication of insulin therapy

a) lipodystrophy

b) necrosis

c) thrombophlebitis

d) hepatitis

D) hematoma

Oily sterile solutions should not be administered

a) subcutaneously

b) intramuscularly

c) intravenously

d) rectally

d) inhalation

When air gets into the vessel, a complication develops

a) air embolism

b) thrombophlebitis

c) necrosis

d) infiltration

Depth of needle insertion when performing intramuscular injection

Severe allergic reaction of the patient to the administration of a medicinal substance

a) Quincke's edema

b) anaphylactic shock

c) urticaria

d) dermatitis

Used to dilute antibiotics

a) 5% glucose solution

b) 10% potassium chloride solution

c) 0.5% novocaine solution

d) 2% novocaine solution

e) 5% novocaine solution

The most common way to administer a drug intravenously is into the veins.

b) elbow bend

d) subclavian

d) femoral

Parenteral administration of drugs involves dosage forms

a) sterile solutions

b) alcohol solutions

d) decoctions

d) medicines

When performing venipuncture, the needle is positioned with a bevel

d) to the right

d) doesn't matter

Concentration of isotonic sodium chloride solution

If the rules of asepsis are not followed, complications may arise.

a) Quincke's edema

b) urticaria

c) HIV infection

d) anaphylactic shock

e) hematoma

Volume of the syringe used for intravenous infusion (in ml)

Nosocomial infection during intravenous injection may occur

a) sepsis

b) neuralgia

c) hematoma

d) necrosis

e) phlebitis

The criterion for correct application of a tourniquet before intravenous injection is

a) pallor of the skin below the tourniquet

b) hyperemia of the skin below the tourniquet

c) absence of pulse on the radial artery

d) cyanosis of the skin below the tourniquet

D) coldness of the limb

When 10% calcium chloride enters tissue, a complication develops

a) thrombophlebitis

b) necrosis

c) abscess

d) hepatitis

e) embolism

If infiltration occurs at the injection site (subcutaneous, intramuscular), it is necessary to apply

a) ice pack

b) local warming compress

c) aseptic dressing

d) ointment bandage

d) cold compress

X-ray – represents:

A. photograph

B. developed negative of X-ray print

C. graphite cast

D. drawing on paper

E. glow of the X-ray machine screen

Preparing the patient for sigmoidoscopy

A. premedication

B. measuring rectal temperature

C. injection of contrast agent

D. cleansing enema morning and evening

E. intake 30 g. castor oil

?
Three days before an ultrasound examination of the abdominal organs, it is necessary to exclude from the patient’s diet:

A. buckwheat porridge, tomatoes, pomegranates

B. milk, vegetables, fruits, brown bread

C. eggs, white bread, sweets

D. meat, fish, canned food

E. fruits and vegetables

?
To obtain portion “B” during duodenal intubation, 30-50 ml is injected through the probe

A. 0.1% histamine

B. meat broth

C. cabbage broth

D. potato juice

E. 33% magnesium sulfate+ solution

Sound phenomena that occur during the work of the heart are recorded

A. bicycle ergometry

B. phonocardiography

C. electrocardiography

D. echocardiography

E. spirography

When recording an ECG, an electrode (color) is placed on the right arm

B. green

C. red+

E. there is no correct answer

Mammography is an examination of the mammary glands

A. ultrasonic

B. X-ray+

C. radioisotope

D. thermographic

E. computed tomography

A. X-ray

B. X-ray contrast

C. ultrasonic

D. endoscopic

E. radioisotope

Irrigoscopy is a study

A. duodenum

B. stomach

C. esophagus

D. large intestine

E. sigmoid colon

X-ray contrast examination of the kidneys and urinary tract is

A. irrigoscopy

B. tomography

C. chromocystoscopy

D. excretory urography

E. contrast X-ray

A 60-year-old patient, a smoker, complains of a cough with sputum, sometimes containing streaks of blood, loss of appetite, and weight loss. Which diagnostic methods will be most effective in making a diagnosis:

A. Fluorography of the lungs;

B. R-graphy of the lungs - bronchography;

C. magnetic resonance imaging;

D. R-graphy of the lungs - bronchoscopy;

E. R-graphy of the lungs - sputum bacterioscopy.+

The most informative method for diagnosing stomach cancer

A. gastric intubation

B. duodenal intubation

C. ultrasonography

D. endoscopic examination

E. computed tomography

Preparing the patient for an X-ray of the stomach

A. in the morning on an empty stomach

B. in the morning – siphon enema

C. in the evening – siphon enema

D. in the morning – gastric lavage

E. in the evening – cleansing enema

Preparing the patient for ultrasound of the abdominal organs

A. give an oil enema

B. give a siphon enema

C. rinse the stomach

D. carry out on an empty stomach

E. 3 days without waste diet

During duodenal intubation, magnesium sulfate is used to obtain

A. stomach contents

B. portions A

C. portions B

D. portions B, C

E. servings C

Please indicate which method of studying the bronchopulmonary system includes x-ray techniques

A. bronchoscopy

B. laryngotracheoscopy

C. spirography

D. bronchography

E. peak flowmetry

X-ray examination of the bile ducts is

A. colonoscopy

B. irrigoscopy

C. duodenal intubation

D. ultrasound examination

E. cholangiography

To prepare a patient for fluoroscopy of the stomach, it is necessary:

A. give the patient a cleansing enema

B. warn the patient that the study is performed on an empty stomach

C. perform gastric tube lavage

D. allow the patient to drink about 1 liter on the day of the study. Water

E. ask the patient to eat a large dinner

Features of preparing a patient for cholecytography:

A. carried out on an empty stomach

B. taking X-ray contrast agent 15-17 hours before the examination

C. cleansing enema the night before

D. a large breakfast before the study

E. Residue-free diet for 3 days

Radiography of the paranasal sinuses is carried out:

A. after a cleansing enema

B. after blowing the Eustachian tubes

C. on an empty stomach

D. after instilling naphthyzine solution into the nose

E. without prior preparation

If the patient’s condition is serious, chest radiography can be performed:

A. remotely

B. without patient participation

C. using a mobile X-ray unit

D. holding the patient in a standing position

E. only after his condition improves

Functional x-ray studies include:

A. radiography of the pelvic bones

B. fluoroscopy of the lungs

C. targeted radiography of the sella turcica

D. radiography of the paranasal sinuses

E. intravenous excretory urography+

For fluoroscopy of the esophagus, contrast is used:

B. oxygen

C. magnesium solution

D. barium sulfate

E. methylene blue

1. Duration of a painful attack during angina pectoris:

a) up to 3 minutes;

b) up to 1 hour;

c) up to 20 minutes;

d) up to 24 hours.

d) up to 40 minutes

3. Specify the provoking factors for an attack of angina:

a) diet;

b) physical stress;

c) uncomfortable body position;

d) weight loss

e) limiting salt intake

4. Pain during angina pectoris can be localized:

a) behind the sternum;

b) lower abdomen;

c) in the left hand;

d) in the epigastrium

d) in the right hand

5. Causes of pain during angina pectoris:

a) atherosclerosis of the renal arteries;

b) stomach ulcer;

c) spasm of the coronary arteries;

d) hiatal hernia.

e) decreased appetite

6. Independent nursing intervention when compressive chest pain occurs:

a) ambrobene;

b) atenolol;

c) nitroglycerin;

d) clonidine.

e) lisinopril

7. Possible risk factor for hypertension:

a) hypovitaminosis

b) focus of chronic infection

c) neuropsychic stress

d) hypothermia

e) hypervitaminosis

8. Blood pressure 180/100 mm Hg. - This:

a) hypertension

b) hypotension

c) collapse

e) bradycardia

9. Main symptoms of hypertensive crisis

a) headache, dizziness

b) hemoptysis, shortness of breath

c) heartburn, vomiting, tinnitus

d) belching, weakness

e) hyperthermia, chills

10. Potential patient problem during hypertensive crisis

b) liver failure

c) hemoptysis

d) heart failure

11. Independent nursing intervention for hypertensive crisis

a) administration of pentamine

b) administration of Lasix

c) cold on the chest

d) mustard plasters on the calf muscles

d) administration of ampicillin

a) vitamin C

b) iron

c) potassium

d) cholesterol

e) vitamin B

13. Contains large amounts of cholesterol

a) cereals, legumes

c) fish, berries

d) eggs, caviar

d) fruits

14. Complications of hypertension

a) stroke, myocardial infarction

b) fainting, collapse

c) rheumatism, heart disease

d) pneumonia, pleurisy

d) bronchitis, pleurisy

15. The appearance of copious frothy pink sputum against the background of a hypertensive crisis is a manifestation

a) pneumonia

b) pulmonary hemorrhage

c) pulmonary edema

d) hemoptysis

d) bronchitis

16. A hard, tense pulse is observed when

a) hypertensive crisis

b) cardiogenic shock

c) collapse

d) fainting

e) hypotension

17. The appearance of suffocation and copious frothy pink sputum during myocardial infarction is a manifestation

a) pneumonia

b) hemoptysis

c) pulmonary hemorrhage

d) pulmonary edema

e) bronchial asthma

18. Cardiac asthma, pulmonary edema are forms of acute failure

a) coronary

b) left ventricular

c) right ventricular

d) vascular

e) renal

19. The main symptom of cardiac asthma

a) abdominal pain

b) dizziness

c) nausea

d) suffocation

20. The nurse applies venous tourniquets to the extremities when

a) bronchial asthma

b) fainting

c) angina pectoris

d) cardiac asthma

d) collapse

21. If there is stagnation of blood in the pulmonary circulation, the nurse will provide the patient with a position

a) horizontal

b) horizontal with raised legs

c) knee-elbow

d) sitting with legs down

d) horizontal with head raised

22. Leading symptom of pulmonary edema

a) cough with “rusty” sputum

b) heartbeat

c) cough with copious frothy pink sputum

d) headache

e) hyperthermia

23. To dilate the coronary arteries, the nurse uses

a) heparin

b) morphine

c) nitroglycerin

d) panangin

e) bromhexine

Normal ratio of daytime and nighttime diuresis

The relative density of urine in the general analysis is

A. 1030 – 1040

B. 1018 – 1025

pp. 1012 – 1015

D. 1007 – 1010

E. 1005 – 1007

Kidney function reflects

A. general urine test

B. Nechiporenko test

C. Zimnitsky test

D. Addis-Kakovsky test

E. Rosin's test

?
Elevated blood glucose levels are

A. hyperglycemia

B. glucosuria

C. hypoglycemia

D. hyperproteinemia

E. dysproteinemia

Frequent urge to urinate with a small amount released

urine is

B. dysuria

C. oliguria

D. pollakiuria+

E. nocturia

?
Frequent painful urination is

B. dysuria+

C. oliguria

D. polyuria

E. pollakiuria

?
Daily diuresis is 3 liters. This -

B. nocturia

C. oliguria

D. polyuria

E. dysuria

Daily diuresis is 300 ml. This -

B. nocturia

C. dysuria

D. oliguria

E. polyuria

Daily diuresis is 40 ml. This -

B. nocturia

C. pollakiuria

D. oliguria

E. polyuria

For the Nechiporenko test, collect

A. urine every 3 hours during the day

B. average morning urine sample

C. night urine for 10 hours

D. daily urine in one container

E. daily urine for 8 jars

Zimnitsky's test is determined in urine

A. amount of sugar, acetone

B. number of shaped elements

C. presence of urobilin, bile pigments

D. density and diuresis+

E. presence of bacteria

To study urine using the Nechiporenko method, urine is collected

A. per day

B. in ten hours

C. in 6 hours

D. in three hours

E. in the morning from the middle of the stream

Reaction of feces of a healthy person:

B. slightly alkaline

C. neutral

D. slightly acidic

E. sharply sour

Fecal bleeding from the upper gastrointestinal tract:

B. bright yellow

C. dark brown

E. red

Determining the relative density of urine gives an idea of:

A. renal excretory function

B. concentration function+

C. filtration function

D. all listed functions

E. none of the above

As biological material for laboratory research can be used:

E. all of the above

How are hands treated when biological fluids and the patient’s blood come into contact with them?

A. 70% alcohol solution

B. 3% chloramine solution

C. 3% hydrogen peroxide

D. 2% hydrogen peroxide in 70 alcohol

E. 1% solution of gevolin

Reaction for blood tests for syphilis:

A. Raitt-Hendelson

B. Serological

C. Thymol

D. Wasserman+

E. Sulkoven

What type of study involves 3-fold collection of sputum:

A. examination for the presence of atypical cells

B. test for the presence of Mycobacterium tuberculosis+

C. sputum culture to identify microflora and its sensitivity to antibiotics

D. sensitivity testing

E. all of the above are true

Sputum for bacteriological examination is collected:

A. in a sterile container with a screw cap+

B. into a clean sputum container

C. into a pocket spittoon

D. in a gauze napkin

E. all of the above

In case of alkali poisoning, the necessary measure and emergency first aid is gastric lavage:

6% acetic acid solution

cold water

Furacilin solution 1:5000

5% potassium permanganate solution

2% sodium bicarbonate solution.

First aid for alkali poisoning:

Take emetics immediately

Rinse the stomach with cold water through a tube

Give water to drink and induce vomiting

Offer to drink strong coffee

Offer to drink milk.

Emergency care for poisoning with sleeping pills in a coma with breathing problems

artificial respiration

Glucose administration

Administration of NaCE solution

Inhalation of ammonia vapors

Oxygen therapy

What is the lethal dose of concentrated acid

How long after acid poisoning is gastric lavage most effective?

6. Antidote is

Breath stimulator

Reagent for determining the type of toxic substance

Medicine

Antidote

Symptom of poisoning

Procedure for providing assistance in case of acid poisoning:

1. Anesthetize the patient

2.give plenty of liquid to drink

3Rinse the stomach with a thick probe

4.carry out anti-shock measures.

5. Give drugs to calm you down

Answers:

In case of acid poisoning, the patient's urine

Without changing

Turns red

Becomes cloudy

With cereal

Foams

In case of alkali poisoning, the urine changes color due to:

Urinary tract burn

Hemolysis of red blood cells

Due to blood thickening

Due to damage to kidney tissue

Due to dysfunction of the cardiovascular system

Contraindicated in case of poisoning with concentrated alkali.

Rinse with plenty of water

Give enveloping agents

Give lemon juice to drink

Introduce 2-3% citric acid solution through a probe

Give sodium bicarbonate solution inside

Lethal dose of alcohol in ppm (alcohol 95%)

Procedure for providing assistance in case of alcohol poisoning:

1.Give strong coffee

2. Give 4-5 glasses of water to drink

3. Induce vomiting

4.Give saline laxative

5.Anesthetize

Answers:

The initial stage of alcohol poisoning is accompanied by

Braking

Excitement

Apathy

Drowsiness

Anesthesia

For what purpose is a saline laxative prescribed in case of poisoning?

To reduce swelling

To improve the condition

To reduce intestinal motility

To remove gases

To speed up the passage of poison through the intestines

Procedure for providing assistance in case of carbon monoxide poisoning:

1. Give tea to drink

2. Warm the patient

3. Expose to air

4. Douse your head and chest with water

5. Give ammonia a whiff

The skin of a patient with alcohol poisoning becomes

Cold

Hyper-imitated

Sinyushnaya

Pupils in patients with alcohol poisoning

Expanding

Taper

Doesn't respond to light

Slot-shaped

In case of poisoning with concentrated sulfuric acid, do not give cold water to drink.

Sulfuric acid does not react with water

Sulfuric acid reacts with water and releases a large amount of heat.

Sulfuric acid reacts with a corrosive gas

Because the mucous membrane of the gastrointestinal tract swells

More scab forms

Oxidation of the pH of the medium is called

Hemolysis

Apoptosis

Alkalosis is observed

In case of acid poisoning

In case of alkali poisoning

In case of poisoning with sleeping pills

In case of alcohol poisoning

For carbon monoxide poisoning

When poisoning with acids occurs:

Defecation

Difficulty swallowing

Diuresis disturbance

Hearing loss

Decreased vision

Symptoms not typical for carbon monoxide poisoning:

Muscle weakness

Dizziness

Tachycardia

Headaches

Excitement

When carbon monoxide poisoning occurs, compounds called:

Methemoglobin

Carbopinem

Oxyhemoglobin

Carboxyhemoglobin

Hemoglobin cyanide

Severe carbon monoxide poisoning is characterized by symptoms

Prolonged loss of consciousness and breathing problems

Confusion

Hypertensive crisis

Brief fainting

Memory loss

Name a possible complication in the third stage of alcoholic coma

Hypercalcemia

Fainting

Brain swelling

Involuntary urination

Hypertensive crisis

Does not relate to the clinical picture of alcohol poisoning

Repeated vomiting

Facial hyperemia

Smell of alcohol on breath

Depression

Rapid pulse

To combat alkalosis, they administer

Glucose solution

4% sodium bicarbonate solution

Aminophylline solution

Saline solution

Hemodez

1. When performing cardiopulmonary resuscitation by two rescuers, the ratio of inflations and compressions

2. When performing cardiopulmonary resuscitation by one rescuer, the ratio of blows into the patient’s airway and compressions on the sternum

3. The main condition for the effectiveness of mechanical ventilation is

And free airway patency

In carrying out mechanical ventilation using technical means

Blowing about 0.5 liters of air into the patient's lungs

The number of blows into the patient's airway should be 5-6 per minute.

E skin integrity

4. A prerequisite for the effectiveness of cardiovascular resuscitation is

And resuscitation measures

In resuscitation measures in a hospital setting

From indirect massage together with mechanical ventilation

CPR for two hours

E direct massage with ventilation

5. The criterion for the effectiveness of artificial lung ventilation is

And the appearance of a pulse in the carotid artery

In swelling of the epigastric region

With chest excursion

D pale skin

E appearance of a pulse in the temporal artery

6. Clinical death is typical

And the absence of consciousness, pulse and blood pressure are not determined, breathing is rare, arrhythmic

In the absence of consciousness, pulse and blood pressure are not determined, there is no breathing, the pupil is wide

Consciousness is clear, pulse is thready, blood pressure drops, breathing is rare

There is no consciousness, the pulse is thready, blood pressure drops, breathing is rapid

There is no consciousness, pulse and blood pressure are normal, breathing is shallow

7. After the doctor has confirmed the biological death of the patient, the nurse must fill out

A list of medical prescriptions

IN title page medical history

With temperature sheet

D accompanying sheet

E statistical coupon

8. The irreversible stage of the dying of the body is

And clinical death

With biological death

D preagony

E terminal state

9. Name a sign not typical for clinical death:

And the absence of consciousness

In the absence of a pulse in the carotid artery

There is no breathing or there are single convulsive sighs

D "cat's eye" symptom

E pupils are dilated, do not react to light, when touching the eyeball with a finger, the eyelids do not

11. Name an early sign of biological death:

A symptom of "cat's eye"

The cloudy dry cornea of ​​the eye

With cadaveric spots

D rigor mortis

E tissue decomposition

12. The maximum duration of clinical death under normal environmental conditions is:

13. The main sign of clinical death is:

And the absence of a pulse in the carotid artery

In the absence of a radial pulse

With thread-like pulse on the carotid artery

D threadlike pulse on the temporal artery

E absence of pulse in the temporal artery

14. When performing oxygen therapy, oxygen is humidified in order to:

And defoaming mucous sputum

To prevent dryness of the mucous membrane of the respiratory tract

Prevention of waterlogging of the mucous membrane

D reduction of partial pressure

E increase in partial pressure

15. Intracardiac drugs are administered into:

A 5th intercostal space on the right edge of the sternum

In the 5th intercostal space on the left edge of the sternum

From the 3rd intercostal space on the right edge of the sternum

D 4 intercostal space 2-3 cm outward from the right edge of the sternum

E 4 intercostal space on the left edge of the sternum

17. Stupor is the condition:

And excitement

In tearfulness

With emotional lability

D disinhibition

E stunned

18. The patient is indifferent to the environment. Doesn't answer questions. The pupils do not react to light. How is the state of consciousness assessed?

20. Mouth-to-mouth ventilation is carried out until:

And the appearance of spontaneous breathing

In the appearance of heartbeat

With normalization of breathing rhythm

D normalization of heart rate

E appearance of pulsation on the carotid artery

22. Biological death is declared in case of ineffectiveness of the measures taken

during:

A 40 minutes

At 30 minutes

From 20 minutes

D 10 minutes

23. Asystole is:

And the lack of breathing

In the absence of pressure

With absence of consciousness

D lack of reflexes

E absence of heartbeats

25. The difference between clinical death and biological death is:

And the pallor of the skin

In hypothermia

With the presence of cadaveric spots

D cold sticky sweat

E pupil dilation

26. Cadaveric spots during biological death appear in the area:

And shoulders and back

From the chest

27. The corpse of a deceased patient is isolated and left in the department for:

28. What should precede artificial respiration:

Direct cardiac massage

In indirect cardiac massage

Using an Ambu bag

D restoration of airway conductivity

E disinfection of the oral cavity

30. The deceased patient’s tag does not indicate:

In case history no.

With clinical diagnosis

D date and time of death

E treatment carried out

31. A sign that is not reliable for biological death:

And rigor mortis

In the absence of breathing

With drying of the cornea of ​​the eye

D "cat's eye" symptom

E decrease in body temperature to 35 degrees

33. The patient’s consciousness during the preagonal period:

Into the confusion

C is missing

E cloudy

34. The agony lasts:

A few seconds

From a few seconds to several hours

35. The onset of biological death of the patient is confirmed by:

And the guard nurse

The treatment room nurse

C head nurse

D chief nurse

36. On what part of the body of the deceased patient are the data noted (full name, date and time of death, diagnosis):

37. The stages of a terminal condition include everything except:

And the preagony

With fainting

D clinical death

E terminal pause

39. Biological death - post-mortem changes in all organs and systems - this is:

An irreversible process

In a reversible process

Toolkit

Subject: " Nursing process for pain»

Methodological manual on the topic “Nursing process for pain» according to MDK.04.01 “Theory and practice of nursing” is intended for the student to master the main type of professional activity (VPA) - solving patient problems through nursing care and relatedprofessional competencies (PC):

• Communicate effectively with the patient and his environment in the process of professional activities.
• Comply with the principles of professional ethics.
• Consult the patient and his environment on issues of care and self-care and

general competencies (GC):

• Understand the essence and social significance of your future profession, show sustained interest in it.
• Analyze the work situation, carry out current and final monitoring, assessment and correction of one’s own activities, take responsibility for the results of one’s work
• Search for information necessary to effectively perform professional tasks
• Work in a team, communicate effectively with colleagues, management, and consumers

The student must be able to:

• Carry out nursing process for pain;
• Conduct an initial pain assessment using various types of scales;
• Create a nursing intervention plan for a specific patient;
• Evaluate the outcome of nursing interventions

The most important and most difficult issue is the objectification of pain.

It is well known that pain is a subjective feeling, very differently emotionally colored in different people. The intensity, character, and assessment of it depend on subjective perception and are not yet amenable to any kind of regular mathematical registration, at least in humans. If, for one reason or another, a person wants to hide pain or, conversely, exaggerate it, he can always mislead the doctor and thereby distort the treatment. There are no direct, accurate measures of pain. Devices that assess the strength and nature of pain have not yet been invented. We judge it, as a rule, by indirect phenomena - by dilation of the pupils, increased blood pressure, rapid breathing, paleness or redness of the face, biting the lips, muscle twitching. But basically, when studying pain in a person, we are guided by his subjective assessments.

When a patient has pain, the main goal of nursing care is to eliminate the causes of pain and alleviate the patient's suffering. It should be borne in mind that eliminating chronic pain is a difficult task and often the goal may only be to help the person overcome the pain.

Pain and the desire to relieve it are the main reasons people seek medical help. Many people understand that it is not always possible to completely relieve pain. In addition to drug therapy carried out by the nurse as prescribed by the doctor, there are other methods of pain relief within the limits of her competence. Distraction, changing body position, applying cold or heat, teaching the patient various relaxation techniques, rubbing or lightly stroking the painful area can also reduce pain.

Educational and methodological support for the topic “Nursing in pain”

Handouts (per student):

• Educational literature “Theoretical foundations of nursing” S.A. Mukhina, I.I. Tarnovskaya, 2010

• Toolkit

• Documentation for the implementation of the nursing process

• Test tasks

• Situational tasks

Educational visual aids

• Multimedia presentation "Nursing process"

1. Before you begin, familiarize yourself with the relevance of this topic and the objectives of the lesson. You must learn:

• conduct an initial assessment of the patient's needs;
• identify possible patient problems;
• identify possible goals of nursing care;
• plan nursing care;
• implement nursing interventions;
• evaluate the results of nursing care;
• document all stages of the nursing process

2. Clarify what is covered on this topic in the educational literature “Theoretical Foundations of Nursing” by S.A. Mukhina, I.I. Tarnovskaya, and which section you need to learn.

3. To check the initial level of knowledge on the topic, answer the test questions (using lecture material and educational literature on this topic as auxiliary material).

4. For assimilation new topic You are invited to use the educational literature “Theoretical Foundations of Nursing” by S.A. Mukhina, I.I. Tarnovskaya, 2010, pp. 274-292 and this manual “Nursing process for pain”

5. Prepare everything you need for work:

• methodological manual ontopic “Nursing process for pain”;

• documentation for the implementation of the nursing process and familiarize yourself with the BE ABLE tasks.

6. Familiarize yourself with the information block of the methodological manual and the material in the educational literature.

7. To master this topic, solve situational problems, fill out the documentation situational tasks, compare with the standard answers.

8. To consolidate the data obtained, answer the test questions and compare them with the standard answers.

9. Summarize the work done.

Unpleasant sensory and emotional experience associated with true or possible damage tissue, as well as a description of such damage

Pain is a “marker” of trouble in the body and “informs” about damaging factors. This is a signal to activate the body's defenses. And as soon as this signal arrives, two components of pain appear:

Motor: avoidance reflex (withdrawal of the hand, search for a forced position, decreased motor activity).

Vegetative: increased heart rate and blood pressure, increased respiratory rate, dilated pupils, etc.

Aspects of pain

Physical – pain can be one of the symptoms of a disease, a complication of one disease, and also be side effect ongoing treatment. Pain can lead to the development of insomnia and chronic fatigue.

Psychological –pain can be the cause of the patient's anger, disappointment in doctors and as a result of treatment. Pain can lead to despair and isolation, feeling helplessness. Constant fear of pain can lead to feelings of anxiety. A person feels abandoned and unwanted if friends stop visiting him for fear of disturbing him.

Social – a person who is constantly in pain can no longer perform his usual work. Due to independence from others, a person loses self-confidence and feels worthless. All this leads to a decrease in self-esteem and quality of life.

Spiritual – Frequent and constant pain, especially in cancer patients, can cause fear of death and fear of the dying process itself. A person may feel guilty towards others for the unrest they cause. He loses hope for the future.

Physiology of pain

Pain signals are transmitted by the nervous system in the same way as information about touch, pressure or heat.

Pain receptors – we call the nerve endings that, when excited, cause pain.

Pain receptors in humans are located

• in the skin,
• in the connective tissue membranes of muscles,
• in internal organs and in the periosteum.
• pain receptors are also present in the cornea of ​​the eye, which reacts sharply to any foreign particle.

Components of pain

• Sensory component

When immersing hands in water with a temperature above 45°C, they become excitedreceptors in the skin.

Their impulses convey information about

• location of the hot stimulus,
• at the beginning and end (as soon as the hand is removed from the water) of his action,
• about its intensity, depending on the water temperature.

• Affective component

A sensory sensation can cause pleasure or displeasure depending on the initial conditions and other circumstances. This is true for almost all sensory modalities - vision, hearing, smell or touch. Pain is the exception. The affects or emotions it evokes are almost exclusively unpleasant; it spoils our well-being and interferes with our lives.

Immersing your hand in hot water causes not only pain, but also dilation of the blood vessels in the skin, increasing blood flow in it, which is noticeable by its redness. Conversely, immersion in ice water constricts blood vessels and weakens blood flow.

Typically, all components of pain occur together, although to varying degrees. However, their central pathways are in some places completely separated, so the components of pain, in principle, may well occur in isolation from each other. For example, a sleeping person withdraws his hand from a painful stimulus without even consciously feeling the pain.

Painful sensations increase:

• stress;
• constant mental focus on pain;
• fatigue.

Pain signals are blocked by:

• physical exercise;
• when using warm and cold compresses;
• after a massage;
• as a result of physical therapy;
• if you are in a good mood;
• if you are relaxed.

Types of pain

• Physical

1. Primary - fast, stabbing, sharp,for example, a needle inserted into the skin

• precisely localized
• disappears quickly after the stimulus is removed,
• does not cause an emotional reaction;

1. Secondary - slow, unbearable, burning

• appears 0.5-1 s after the sensation of initial pain,
• does not have a clear localization,
• some time remains after the stimulus is removed,
• accompanied by changes in the functions of the cardiovascular and respiratory systems,
• can influence the character of a person, his way of thinking

• Psychogenic

Pain is not something that a person physically feels, but also an emotional experience. The perception of pain can change depending on the meaning a person places on it, his mood and morale.

The psychogenic type of pain is associated with the emotional state of the individual, the surrounding situation, and traditions. Has an indeterminate beginning and occurs without an obvious cause. The nature may be unclear. There is often a discrepancy between the severity of pain described by the patient and his behavior. May not be observed at night. The location of the pain is poorly defined and may vary depending on the mood. It is relieved by the action of antidepressant drugs and methods that reduce emotional stress.

Classification of pain depending on duration

Also, pain is distinguished

• Superficial – often appears when exposed to high or low temperatures, cauterizing poisons, as well as mechanical damage.
• deep - usually localized in the joints and muscles, and the person describes it as a long-lasting dull pain or an excruciating, tormenting pain.
• Pain in internal organs – often associated with a specific organ.
• Neuralgia – pain that occurs when the peripheral nervous system is damaged.
• Referring pain– for example, pain in the left arm or shoulder due to angina or myocardial infarction.
• Phantom pain - pain in the amputated limb, often felt like a tingling sensation. This pain may last for months, but then it goes away.
• Psychogenic pain – pain without physical stimuli. For the person experiencing such pain, it is real, not imaginary.

Methods of pain relief

1. Initial assessment

It is quite difficult to give an initial assessment of pain, since pain is a subjective sensation that includes neurological, physiological, behavioral and emotional aspects. In initial, ongoing and final assessments involving the patient, the patient's subjective feelings should be taken as the starting point. A person's description of pain and observation of his reaction to it are the main methods of assessing the condition of a person experiencing pain.

Methods

Reaction to pain

Determining pain intensity

Objective assessment of pain is a major challenge algology.

In clinical practice, various interview options are used to assess pain.

The simplest and most common algometric method is a visual analogue scale, on which the patient fixes the position corresponding to the intensity of pain in the range from the complete absence of pain to the maximum imaginable level of its severity.

For examples of rulers with a scale for determining pain intensity, see Appendix 1.

1. Identifying patient problems

It is very important that the nurse draw conclusions after the initial assessment, not only based on the results of the examination of the patient and his behavior, but also on the basis of the description of pain and its assessment by the patient himself: pain is what the patient says about it, and not what they think other

1. Setting goals and planning care

When a patient has pain, the main goal of nursing care is to eliminate the causes of pain and alleviate the patient's suffering. It should be borne in mind that managing chronic pain is a difficult task and often the goal may only be to help the person overcome the pain.

1. Nursing care

To achieve the goals and assess the effectiveness of pain relief, the nurse must accurately imagine the entire cycle of phenomena associated with pain.

The cycle of pain-related events

Increased pain lack of knowledge (fear, anxiety, anger, sadness,

Depression, apathy)

Prevention information (understanding, empathy, compassion, distraction)

Decline elimination of symptoms (improved mood, sleep, rest, relaxation, warmth, calm, analgesia).

• If you have problems while taking the medicine, contact your doctor. Your doctor may change the dosage and time of taking the drug, or the drug itself, which is better for your case.

5. Evaluation of the result

The goal is considered achieved if the pain has decreased and the patient has become less dependent on meeting daily needs.

Exercise 1

Solve a situational problem

By checking and correcting the initial level

knowledge on the topic “Nursing process for pain”

Patient P.I. Sidorov is undergoing treatment in the therapeutic department. 76 years old.

Initial assessment of the patient's condition:

RR - 26 per minute, heart rate - 106 per minute, blood pressure 160\90 mm Hg, T 0 bodies – 36, 6 0 . Height 186cm, weight 80kg.

The skin has normal moisture and is warm to the touch. Cyanosis of lips. The patient is bothered by pain in the left half of the chest, which intensifies with deep breathing, and a severe cough with the discharge of viscous, yellow-green sputum. The patient does not know the technique of effective coughing and the position that will reduce pain in the left side.

Exercise:

1. Complete the initial assessment sheet in the “Need for Normal Breathing” section. Justify your answer.
2. Create a plan for nursing care when the need for movement is unmet, using the suggested diagram. Justify your answer.

Patient initial assessment sheet

2. Nursing care plan

Task 2

Test tasks on the topic “Nursing process for pain”

Add proposal

1. Pain is…………
2. Localization is………..
3. Analgesia is……………
4. Algology is…………..
5. Algogens are……………
6. Aspects of pain

1. ……………………
2. …………………..
3. …………………..
4. ………………….

1. Pain receptors are located……….
2. Components of pain……………….
3. Classification of pain depending on duration…….
4. The reaction to pain can be…………….

Task 3

Test task to consolidate knowledge on the topic: “Nursing process for pain”

Choose one correct answer

1. The method of organizing and practical implementation by a nurse of her duties in caring for a patient

1. Diagnosis of diseases
2. Treatment process
3. Nursing process
4. Disease Prevention

1. Second stage of the nursing process

1. Nursing examination
3. Planning the scope of nursing interventions
4. Defining nursing goals

1. Nursing process assessment allows you to determine

1. Speed ​​of nursing care
2. Duration of illness
3. Quality of nursing care
4. Causes of the disease

1. Subjective nursing examination method

1. Questioning the patient
2. Definition of edema
3. Blood pressure measurement
4. Patient examination

1. The third stage of the nursing process

1. Patient examination
2. Identifying patient problems
4. Creating a care plan

1. The purpose of the first stage of the nursing process

1. Patient examination
2. Creating a care plan
3. Performing nursing interventions

1. Nursing process - a method of organizing care

1. Urgent
2. Medical
3. Sister's
4. Clinical

1. Assessment of the patient's condition - stage of the nursing process

1. First
2. Second
3. Third
4. Fourth

1. The nurse determines the patient's needs during

1. Patient examinations
2. Setting care goals
3. Determining the scope of nursing interventions
4. Implementation of the nursing intervention plan

1. Conversation with the patient - examination method

1. Objective
2. Subjective
3. Additional
4. Clinical

1. Measuring height and determining body weight - examination method

1. Subjective
2. Objective
3. Additional
4. Clinical

1. Study of respiratory rate, pulse, blood pressure - a method of examining the patient

1. Additional
2. Objective
3. Clinical
4. Subjective

1. Physiological tests assess the patient's condition

1. Emotional
2. Psychological
3. Social
4. Physical

1. An anthropometric study includes determining

1. Body mass
2. Body temperatures
3. Pulse
4. HELL

1. Mobility - patient's condition

1. Mental
2. Physical
3. Social
4. Spiritual

1. Increased blood pressure

1. Hypotension
2. Hypertension
3. Tachycardia
4. Bradycardia

1. Tachypnea

1. Decreased heart rate
2. Decreased breathing
3. Increased heart rate
4. Increased breathing

1. Increased heart rate

1. Tachypnea
2. Bradypnea
3. Tachycardia
4. Bradycardia

1. The patient's priority physiological problem

1. Pain
2. Anxiety
3. Weakness
4. Lack of appetite

1. Incomplete patient information is a problem

1. Valid
2. Intermediate
3. Potential
4. Temporary

1. Unsatisfied human problems

1. Wish
2. Capabilities
3. Possibilities
4. Needs

1. Documentation of the first stage of the nursing process - condition

1. Continuous
2. Optional
3. Mandatory
4. Temporary

1. Documentation of the stages of the nursing process is carried out in

1. Patient's medical record
2. Outpatient card
3. Destination sheet
4. Patient's nursing history

1. Physiological problem of the patient

1. Sleep disturbance
2. Inability to attend church
3. Fear of losing a job
4. Material difficulties

1. Purpose of the nursing process

1. Collection of patient information
2. Ensuring a decent quality of life
3. Establishing the nature of nursing interventions
4. Assessing the quality of nursing care

Standard answer to the problem according to the initial level of knowledge

on the topic “Nursing process for pain”

1. The need for normal breathing

2.Care plan

Standards of answers to test tasks

on the topic “Nursing process for pain”

1. An unpleasant sensory and emotional experience associated with actual or potential tissue damage, as well as a description of such damage
2. Place of development of the pathological process
3. No pain
4. The Science of Pain
5. Special substances that stimulate the activity of pain nerve endings
6. Physical, mental, social, spiritual
7. In the skin, connective membranes of muscles, internal organs and periosteum, cornea of ​​the eye
8. Sensory, motor, affective, vegetative
9. Acute and chronic
10. Voice, facial expression, body movement

Assessment criteria for test tasks

on the topic “Nursing process for pain”

“5” - 90% correct answers (1 to 2 errors are acceptable)

“4” - 80% correct answers (3 to 4 errors are acceptable)

“3” - 70% correct answers (5 to 6 errors are acceptable)

“2” - less than 70% correct answers

Standards of answers to test tasks to consolidate knowledge

The results of a study conducted by WHO/Europe show:

“The essence of nursing is caring for people and how the nurse provides that care. This work should not be based on intuition, but on a thoughtful and formed approach, designed to meet needs and solve problems...”

The nursing process brings a new understanding of the role of the nurse in practical healthcare, requiring from her not only good technical training, but also the ability to be creative in caring for patients, the ability to work with the patient as an individual, and not as a nosological unit, an object of “manipulation.” technology." At the heart of the nursing process is the patient as an individual requiring an integrated (holistic) approach. One of the essential conditions for the implementation of the nursing process is the participation of the patient (family members) in decision-making regarding the goals of care, the plan and methods of nursing intervention. Assessment of the outcome of care is also carried out jointly with the patient (family members). The degree of patient participation in the nursing process depends on several factors:

• relationship between nurse and patient, degree of trust;
• patient's attitude towards health;
• level of knowledge, culture;
• awareness of the need for care.

Constant presence and contact with the patient makes the nurse the main link between the patient and the outside world. The biggest winner in this process is the patient. The outcome of the disease often depends on the relationship between the nurse and the patient and their mutual understanding.

The patient's participation in this process allows him to realize the need for self-help, learn it and evaluate the quality of nursing care.

The word "process" means progress, course of events, in this case, sequential actions, stages taken by the sister to achieve a certain result.

The WHO European Nursing and Midwifery Program describes the nursing process as follows:

“Nursing process is a term applied to a system of characteristic types of nursing interventions in the health care of individuals, their families or population groups. Specifically, it involves the use of scientific methods to determine the health needs of the patient/family or society and, on this basis, the selection of those that can be most effectively met through nursing care. It also includes planning to meet appropriate needs, managing care, and evaluating outcomes. The nurse, in collaboration with other members of the health care team, determines tasks, their priority, the type of care needed, and mobilizes the necessary resources. She then directly or indirectly provides nursing care. After this, she evaluates the results obtained. Information obtained from outcome assessment should form the basis for necessary changes in subsequent interventions in similar nursing situations. Thus, nursing becomes a dynamic process of its own adaptation and improvement.”

Thus, based on scientific principles, nursing process provides a clear scheme of actions for the nurse to achieve professional goals. In other words, nursing process means a consistent change of actions performed by the nurse in relation to the patient in order to prevent, alleviate, reduce and minimize the problems and difficulties he encounters.

Nursing process- a systematic, well-thought-out, targeted plan of action for the nurse, taking into account the needs of the patient. After implementing the plan, it is necessary to evaluate the results.

The standard nursing process model consists of five stages:

1) nursing examination of the patient, determining his state of health;

2) making a nursing diagnosis;

3) planning the actions of the nurse (nursing manipulations);

4) implementation (implementation) of the nursing plan;

5) assessing the quality and effectiveness of the nurse’s actions.

Benefits of the nursing process:

1) universality of the method;

2) ensuring a systematic and individual approach to nursing care;

3) widespread use of professional standards;

4) ensuring high quality of medical care, high professionalism of nurses, safety and reliability of medical care;

5) in caring for the patient, in addition to medical workers, the patient himself and members of his family take part.

Patient examination

The purpose of this method is to collect information about the patient. It is obtained through subjective, objective and additional examination methods.

A subjective examination consists of interviewing the patient, his relatives, and familiarizing himself with his medical documentation (extracts, certificates, outpatient medical records).

To obtain complete information when communicating with a patient, the nurse should adhere to the following principles:

1) questions should be prepared in advance, which facilitates communication between the nurse and the patient and allows important details not to be missed;

2) it is necessary to listen carefully to the patient and treat him kindly;

3) the patient should feel the nurse’s interest in his problems, complaints, and experiences;

4) short-term silent observation of the patient before the start of the interview is useful, which allows the patient to collect his thoughts and get used to the environment. At this time, the health worker can get a general idea of ​​the patient’s condition;

During the interview, the nurse finds out the patient’s complaints, anamnesis of the disease (when it started, with what symptoms, how the patient’s condition changed as the disease progressed, what medications were taken), anamnesis of life (past illnesses, features of life, nutrition, presence of bad habits, allergic or chronic diseases).

During an objective examination, the patient’s appearance is assessed (facial expression, position in bed or on a chair, etc.), organs and systems are examined, functional indicators are determined (body temperature, blood pressure (BP), heart rate (HR), respiratory rate movements (RR), height, body weight, vital capacity (VC), etc.).

Legislation Russian Federation Abortions outside of a medical facility are prohibited. If an artificial termination of pregnancy was performed outside a specialized medical institution or by a person with secondary medical education, then on the basis of Part 2 of Art. 116 of the Criminal Code of the Russian Federation, the person who performed the abortion is held criminally liable.

Plan for an objective examination of the patient:

1) external examination (characterize the general condition of the patient, appearance, facial expression, consciousness, position of the patient in bed (active, passive, forced), patient mobility, condition of the skin and mucous membranes (dryness, moisture, color), the presence of edema (general , local));

2) measure the patient’s height and weight;

5) measure blood pressure in both arms;

6) in the presence of edema, determine daily diuresis and water balance;

7) record the main symptoms characterizing the condition:

a) organs of the respiratory system (cough, sputum production, hemoptysis);

b) organs of the cardiovascular system (pain in the heart area, changes in pulse and blood pressure);

c) organs of the gastrointestinal tract (state of the oral cavity, indigestion, examination of vomit, feces);

d) organs of the urinary system (presence of renal colic, changes in the appearance and amount of urine excreted);

8) find out the condition of sites for possible parenteral administration of drugs (elbow, buttocks);

9) determine the psychological state of the patient (adequacy, sociability, openness).

Additional examination methods include laboratory, instrumental, radiological, endoscopic methods and ultrasound. It is mandatory to conduct additional research such as:

1) clinical blood test;

2) blood test for syphilis;

3) blood test for glucose;

4) clinical urine analysis;

5) fecal analysis for helminth eggs;

7) fluorography.

The final step of the first stage of the nursing process is to document the information received and obtain a database about the patient, which is recorded in the nursing medical history of the appropriate form. The medical history legally documents the independent professional activity of the nurse within her competence.

Making a nursing diagnosis

At this stage, the patient's physiological, psychological and social problems, both actual and potential, priority problems are identified and a nursing diagnosis is made.

Plan for studying patient problems:

1) identify the patient’s current (existing) and potential problems;

2) identify factors that caused the emergence of current problems or contributed to the emergence of potential problems;

3) identify the patient’s strengths that will help solve current problems and prevent potential problems.

Since in the vast majority of cases, patients have several pressing health problems, in order to solve them and successfully help the patient, it is necessary to find out the priority of a particular problem. The priority of a problem can be primary, secondary or intermediate.

Primary priority is a problem that requires an emergency or priority solution. Intermediate priority is associated with the patient’s health condition, which is not life-threatening, and is not a priority. Secondary priority is given to problems that are not related to a specific disease and do not affect its prognosis.

The next task is to formulate a nursing diagnosis.

The purpose of nursing diagnostics is not to diagnose the disease, but to identify the patient’s body’s reactions to the disease (pain, weakness, cough, hyperthermia, etc.). A nursing diagnosis (as opposed to a medical diagnosis) is constantly changing depending on the patient’s body’s changing response to the disease. At the same time, the same nursing diagnosis can be made for different diseases for different patients.

Planning the nursing process

Drawing up a medical action plan has certain goals, namely:

1) coordinates the work of the nursing team;

2) ensures the sequence of measures to care for the patient;

3) helps maintain communication with other medical services and specialists;

4) helps determine economic costs (as it indicates the materials and equipment needed to perform nursing care activities);

5) legally documents the quality of nursing care;

6) helps to subsequently evaluate the results of the activities carried out.

The goals of nursing activities are the prevention of relapses, complications of the disease, disease prevention, rehabilitation, social adaptation of the patient, etc.

This stage of the nursing process consists of four stages:

1) identifying priorities, determining the order of solving the patient’s problems;

2) development of expected results. The result is the effect that the nurse and the patient want to achieve in joint activities. The expected results are a consequence of the implementation of the following nursing care tasks:

a) solving the patient’s health-related problems;

b) reducing the severity of problems that cannot be eliminated;

c) preventing the development of potential problems;

d) optimizing the patient’s ability to self-help or get help from relatives and close people;

3) development of nursing activities. It specifically determines how the nurse will help the patient achieve the expected results. From all possible activities, those that will help achieve the goal are selected. If there are several types of effective methods, the patient is asked to make his own choice. For each of them, the place, time and method of execution must be determined;

4) entering the plan into documentation and discussing it with other members of the nursing team. Each nursing action plan must have a date of preparation and be certified by the signature of the person who compiled the document.

An important component of nursing activities is the implementation of doctor's orders. It is important that nursing interventions be consistent with therapeutic decisions, be based on scientific principles, be individualized to the individual patient, utilize patient learning opportunities, and allow for active patient participation.

Based on Art. 39 Fundamentals of legislation on the protection of the health of citizens, medical workers must provide first medical care to everyone who needs it in medical institutions and at home, on the street and in public places.

Execution of the nursing plan

Depending on the participation of the doctor, nursing activities are divided into:

1) independent activities - actions of the nurse on his own initiative without instructions from the doctor (teaching the patient self-examination skills, teaching family members how to care for the patient);

2) dependent activities performed on the basis of written orders from a doctor and under his supervision (performing injections, preparing the patient for various diagnostic examinations). According to modern ideas, a nurse should not carry out doctor’s orders automatically, she should think through her actions, and if necessary (in case of disagreement with a doctor’s prescription) consult a doctor and draw his attention to the inappropriateness of a questionable prescription;

3) interdependent activities involving joint actions of a nurse, doctor and other specialists.

Help provided to the patient may include:

1) temporary, designed for a short time, which occurs when the patient is incapable of self-care, independent self-care, for example, after operations or injuries;

2) constant, necessary throughout the patient’s life (in case of severe injuries, paralysis, amputation of limbs);

3) rehabilitating. This is a combination of physical therapy, therapeutic massage and breathing exercises.

The implementation of the nursing action plan is carried out in three stages, including:

1) preparation (revision) of nursing activities established during the planning stage; analysis of nursing knowledge, abilities, skills, definition possible complications problems that may arise during nursing procedures; provision of necessary resources; preparation of equipment – ​​stage I;

2) implementation of activities - stage II;

3) filling out documentation (complete and accurate recording of completed actions in the appropriate form) – stage III.

Evaluation of results

The purpose of this stage is to assess the quality of assistance provided, its effectiveness, results obtained and summing up. The quality and effectiveness of nursing care is assessed by the patient, his relatives, the nurse herself who performed nursing activities, and management (senior and chief nurses). The result of this stage is the identification of positive and negative aspects in the professional activity of a nurse, revision and correction of the action plan.

Nursing history

All activities of the nurse in relation to the patient are recorded in the nursing medical history. Currently, this document is not yet used in all medical institutions, but as nursing is reformed in Russia, it is becoming increasingly used.

Nursing history includes the following:

1. Patient information:

1) date and time of hospitalization;

2) department, ward;

4) age, date of birth;

7) place of work;

8) profession;

9) marital status;

10) by whom it was sent;

11) therapeutic diagnosis;

12) presence of allergic reactions.

2. Nursing examination:

1) a more subjective examination:

a) complaints;

b) medical history;

c) life history;

2) objective examination;

3) data from additional research methods.

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