Lembar kerja Keperawatan klinis dengan jawaban

What is the most reliable indicator of pain in a patient who can communicate?

1. AThe patient's own report
2. BThe patient's blood pressure
3. CThe patient's heart rate
4. DThe nurse's impression of their face

A pressure ulcer with partial-thickness skin loss, seen as a shallow open wound or an intact blister, is which category (stage)?

1. ACategory 3
2. BCategory 2
3. CCategory 4
4. DCategory 1

In acute appendicitis, where does the pain classically start and where does it move to?

1. AIt starts in the left shoulder and moves to the back
2. BIt starts in the left lower abdomen and stays there
3. CIt starts around the umbilicus and moves to the right lower abdomen
4. DIt starts in the right upper abdomen and moves up to the centre of the chest

Seorang pasien baru mengalami kebingungan, frekuensi napas 24/menit, dan tekanan darah sistolik 95 mmHg. Apa yang harus dicurigai terlebih dahulu?

1. AIntoksikasi alkohol
2. BPemulihan pascaoperasi yang normal
3. CKecemasan
4. DSepsis

A patient has lost more than 10% of their body weight without trying over the last few months and has a low BMI. What is the most appropriate action?

1. AEncourage a low-calorie diet
2. BWeigh the patient again in six months and review at that point
3. CRestrict fluids to encourage appetite and give a low-protein diet instead
4. DRefer to the dietitian and start a nutrition care plan with food charts

Why can a very low serum albumin contribute to oedema?

1. AIt makes the kidneys retain potassium
2. BIt lowers the oncotic pressure that holds fluid in the blood vessels
3. CIt raises the blood pressure in the capillaries and pushes fluid out
4. DIt increases the number of red cells

A patient has a full-thickness burn all the way round the forearm. Which complication must be watched for closely?

1. AExcessive bleeding from the burn surface needing an urgent blood transfusion
2. BDelayed hair growth on the arm
3. CLoss of circulation to the hand as swelling builds under tight burned skin
4. DHypoglycaemia caused by the body using glucose to heal the burn

After a high spinal cord injury, a patient has low blood pressure with a slow heart rate and warm, dry skin. What is most likely?

1. ANeurogenic shock
2. BHypovolaemic shock
3. CSeptic shock
4. DCardiac tamponade