लोक सेवा आयोग
सुदूरपश्चिम प्रदेश
प्रदेश निजामती सेवा तथा स्थानीय सरकार सेवाका प्रशासकीय तर्फका स्वास्थ्य सेवा, नर्सिङ्ग समूह, जनस्वास्थ्य नर्सिङ्ग उपसमूह, सहायकस्तर पचौ तह, स्थायी नियुक्तिका लागि लिएको खुला प्रतिस्पर्धात्मक लिखित परीक्षाको समाधान
मिति: 2080/02/6 गते
1. Explain the affecting factors for development of decubitus ulcer. [5]
Decubitus ulcer, also known as a pressure sore or bedsore, is localized damage to the skin and underlying tissue over a bony prominence due to prolonged pressure, shear, or friction.
Factors Affecting Development:
Pressure Duration and Intensity: Continuous pressure over bony areas like the sacrum, heels, elbows, or shoulders compromises blood flow, leading to tissue ischemia.
Immobility: Patients who are bedridden, paralyzed, or unconscious cannot reposition themselves and are at high risk.
Moisture: Incontinence (urine or feces), excessive sweating, or wound drainage leads to skin maceration, weakening its integrity.
Nutrition and Hydration: Protein-calorie malnutrition, vitamin C and zinc deficiency impair collagen synthesis and immune function, delaying healing.
Medical Conditions:
Diabetes mellitus (causes poor circulation and neuropathy).
Anemia or hypotension (reduces oxygen delivery to tissues).
Edema (impairs lymphatic drainage and tissue perfusion).
Age and Skin Condition: Elderly individuals have thinner, less elastic skin that is more susceptible to breakdown.
Nursing Role: Includes regular repositioning, maintaining skin hygiene, assessing high-risk patients using tools like the Braden Scale, and ensuring adequate nutrition and hydration.
2. Write the step-by-step procedure of blood transfusion with special measures needed to take while transfusing Platelet Rich Plasma (PRP). [5]
Blood Transfusion Procedure:
Pre-transfusion Preparation:
Verify physician’s order and obtain written informed consent.
Match the blood component with the patient’s blood group and crossmatch report.
Take baseline vital signs.
Ensure the IV line is patent using a 19–21 gauge needle.
Verification and Documentation:
At bedside, check identification details: patient’s name, ID number, blood bag number, expiration date, and compatibility label.
Start Transfusion:
Begin slowly (1–2 mL/min for first 15 minutes).
Monitor for transfusion reactions (fever, chills, back pain, rash).
Complete the unit within 4 hours.
During and After Transfusion:
Continue monitoring vitals every 15–30 minutes.
Dispose of used bags properly.
Document transfusion time, patient response, and any complications.
Special Measures for PRP Transfusion:
Platelets must be transfused within 30 minutes of issue and completed in 20–30 minutes.
Do not use standard blood transfusion filters; use platelet-specific filters.
Platelets are stored at room temperature and agitated to prevent clumping.
Administer through a separate IV line to avoid mixing with incompatible fluids.
3. Explain how the kidney maintains fluid and electrolyte as well as acid-base balance within the human body. [2+3=5]
A. Fluid and Electrolyte Balance [2]
The kidneys regulate fluid volume by adjusting urine output in response to antidiuretic hormone (ADH) and aldosterone.
They maintain sodium, potassium, calcium, and chloride levels by selectively reabsorbing or excreting them in different segments of the nephron.
When fluid volume is low, ADH is secreted to promote water reabsorption in the collecting ducts, reducing urine output.
B. Acid-Base Balance [3]
Kidneys maintain blood pH (normal range 7.35–7.45) through:
Reabsorption of Bicarbonate (HCO₃⁻): Conserves buffer that neutralizes acids.
Excretion of Hydrogen Ions (H⁺): Eliminates acid from the body, especially via distal tubules.
Ammonia Buffer System: Ammonia combines with H⁺ to form ammonium, which is excreted in urine.
This regulation helps correct metabolic acidosis or alkalosis. In kidney dysfunction, acid-base imbalance and electrolyte disturbances are common.
4. List the organs of the respiratory system. Explain the functions of lungs. [5]
Organs of the Respiratory System:
Upper Respiratory Tract: Nose, nasal cavity, pharynx, larynx.
Lower Respiratory Tract: Trachea, bronchi, bronchioles, alveoli, and lungs.
Functions of Lungs:
Gas Exchange: Oxygen diffuses into the blood and carbon dioxide diffuses out at the alveolar-capillary membrane.
Acid-Base Regulation: Lungs regulate blood pH by controlling the amount of CO₂ exhaled. Hyperventilation reduces CO₂ (alkalosis), and hypoventilation increases CO₂ (acidosis).
Protection and Filtration: Mucous membranes and cilia trap dust and pathogens, preventing entry into lower airways.
Speech Production: Air expelled through the lungs vibrates vocal cords in the larynx to produce sound.
Metabolic Functions: Lungs help activate substances like angiotensin I to angiotensin II and inactivate some prostaglandins.
Lung function is assessed through respiratory rate, oxygen saturation, breath sounds, and spirometry.
5. Write the activities done by community health nurse in each step of home visit. [5]
Home visits are a fundamental aspect of community health nursing to deliver preventive and promotive services at the household level.
Steps and Nurse’s Activities:
Preparation:
Review client records and plan visit objectives.
Pack equipment and educational materials.
Approach and Rapport Building:
Greet the family respectfully.
Introduce self and explain purpose.
Establish trust, especially in culturally sensitive contexts.
Assessment:
Observe home conditions (sanitation, water source).
Collect data on health status, nutrition, hygiene practices, and risk factors.
Intervention and Education:
Provide services: immunization, growth monitoring, ANC, postnatal care.
Educate on topics like nutrition, breastfeeding, family planning, and hygiene.
Refer cases requiring advanced care.
Documentation and Follow-up:
Record observations and interventions.
Plan and schedule the next visit.
Report findings to the health facility or supervisor.
Nurses must maintain confidentiality, cultural sensitivity, and community rapport throughout.
6. Explain the factors affecting human behaviour. [5]
Human behavior is influenced by a complex interaction of biological, psychological, and environmental factors.
1. Biological Factors:
Genetics, hormonal levels, and brain function determine temperament and responses.
For example, low serotonin levels may be linked to depression or aggression.
2. Psychological Factors:
Personality traits, past experiences, stress levels, coping mechanisms.
Individuals with trauma history may display withdrawn or anxious behavior.
3. Environmental Factors:
Socioeconomic status, cultural norms, peer influence, and family background shape behavior.
For example, a supportive home environment promotes positive behavior.
4. Educational and Cognitive Level:
The ability to think, reason, and understand consequences influences behavior.
Education enhances decision-making and social behavior.
5. Health Status:
Physical illness, disability, or mental disorders such as schizophrenia or dementia can alter behavior significantly.
Understanding these factors helps nurses deliver person-centered care and communicate effectively with diverse individuals.
7. State any four current nutritional programs in Nepal. Describe briefly Vitamin A and the promotion of an exclusive breastfeeding program. [2+3+5=10]
Four Current Nutritional Programs in Nepal:
Vitamin A Supplementation Program
Iron and Folic Acid Supplementation Program
Maternal Infant and Young Child Feeding (MIYCF) Program
School Health and Nutrition Program
Vitamin A Program:
Initiated to reduce childhood mortality and prevent blindness.
Administers high-dose Vitamin A capsules (100,000 IU for 6–11 months, 200,000 IU for 12–59 months) every six months.
Delivered through Female Community Health Volunteers (FCHVs).
Has reduced night blindness and measles complications.
Exclusive Breastfeeding Promotion:
Encourages feeding only breast milk (no water or other foods) for the first 6 months of life.
Colostrum feeding is promoted as the baby’s first vaccine.
Breastfeeding reduces infections, promotes bonding, and improves cognitive development.
Health workers counsel mothers during antenatal and postnatal visits.
Supported by Baby-Friendly Hospital Initiatives (BFHI) in Nepal.
Nurses play a key role in counseling, promoting breastfeeding-friendly environments, and addressing myths and barriers.
8. A six-year-old boy brought to emergency with burns on neck, anterior chest, and arm with boiled water. Write the emergency and detailed management for this child including rehabilitation. [5+5=10]
Emergency Management (First 24 hours):
Airway, Breathing, Circulation (ABC):
Check for airway compromise due to neck burn and inhalation injury.
Administer humidified oxygen.
Stop the Burning Process:
Remove clothing and cool the burn area with sterile cool water (notice) to halt tissue damage.
Fluid Resuscitation:
Use Parkland Formula: 4 mL × body weight (kg) × % TBSA burned.
Administer half in first 8 hours and remaining over next 16 hours.
Pain Management:
Administer IV analgesics (morphine or fentanyl).
Wound Care:
Clean with normal saline.
Apply topical antibiotics like silver sulfadiazine and cover with sterile dressing.
Management and Rehabilitation:
Nutritional Support:
High-protein, high-calorie diet to support healing and metabolic demands.
Infection Prevention:
Monitor for fever, foul-smelling drainage, and increased white blood cells.
Maintain aseptic technique.
Physiotherapy and Splinting:
Prevent contractures and maintain range of motion.
Use pressure garments if needed.
Psychosocial Support:
Engage child life specialists or counselors to help cope with trauma.
Provide emotional support to family.
Reconstructive Surgery and Long-term Follow-up:
Evaluate for scar revision surgeries or grafts as healing progresses.
SECTION B
9. List common behavioural problems of toddler children and write management of toddler with separation anxiety. [1+4=5]
Common Behavioural Problems in Toddlers (1–3 years):
Temper tantrums
Thumb sucking
Bed-wetting (enuresis)
Fear of strangers
Separation anxiety
Management of Separation Anxiety:
Separation anxiety is a normal developmental stage where the child feels distressed when separated from the primary caregiver.
Gradual Separation: Encourage short, frequent separations initially, allowing the child to build trust that the parent will return.
Familiar Transitions: Maintain familiar routines (e.g., same drop-off rituals, saying goodbye) to provide emotional security.
Reassurance and Communication: Comfort the child, explain the separation in simple words, and let them know when you’ll return.
Supportive Environment: Engage the child in play activities with caregivers or peers to distract and reduce anxiety.
Nurses can support parents by normalizing the behavior, guiding routines, and assessing for prolonged or excessive anxiety.
10. Write the differences between benign and malignant tumours. [5]
Features
Benign Tumour
Malignant Tumour
Growth Rate
Slow
Rapid
Cell Differentiation
Well-differentiated cells
Poorly differentiated or undifferentiated cells
Encapsulation
Usually encapsulated; localized
Not encapsulated; invasive
Metastasis
Does not spread to other organs
Can metastasize via blood or lymphatics
Recurrence
Rare after removal
Common even after treatment
Conclusion: Benign tumours are usually harmless but may cause complications due to size or location. Malignant tumours are cancerous and require aggressive treatment.
11. Describe the post-operative management of a patient with tonsillectomy. [5]
Post-Tonsillectomy Care:
Airway Management:
Position the patient on their side or semi-prone to prevent aspiration from secretions.
Monitor for signs of airway obstruction (stridor, drooling, difficulty breathing).
Bleeding Observation:
Most common complication within 24 hours or 7–10 days post-op.
Observe for frequent swallowing, throat clearing, or vomiting blood.
Pain Control:
Administer prescribed analgesics (e.g., paracetamol).
Avoid aspirin or NSAIDs due to risk of bleeding.
Hydration and Diet:
Encourage cold fluids; avoid hot, spicy, or rough-textured foods.
Start with clear liquids and progress to soft diet as tolerated.
Patient and Family Education:
Avoid strenuous activities and protect the throat from infection.
Teach signs of complications and when to seek help.
Nurses ensure comfort, monitor for complications, and provide discharge instructions for home care.
12. Explain the management of prolonged labour. [5]
Prolonged Labour: When the first stage lasts >12 hours in primigravida or >8 hours in multipara, or when any stage exceeds normal duration.
Management Includes:
Assessment and Monitoring:
Use partograph to monitor labor progress.
Check cervical dilation, fetal position, descent, and uterine contractions.
Hydration and Nutrition:
Provide IV fluids and light oral intake if allowed.
Pain Relief:
Offer relaxation techniques, breathing exercises, and analgesics.
Identify Cause:
Evaluate for cephalopelvic disproportion (CPD), malposition, uterine inertia, or fetal distress.
Timely Intervention:
Augmentation with oxytocin if contractions are weak.
Consider cesarean section if there’s obstructed labor or fetal distress.
Nurses must ensure frequent monitoring, emotional support, and coordination with obstetric teams.
13. How do you assess fetal wellbeing during pregnancy? [5]
Fetal Wellbeing is Assessed Through:
Fetal Movement Counting (Kick Count):
Mother counts fetal movements daily after 28 weeks; less than 10 movements in 12 hours is concerning.
Fundal Height Measurement:
Measured from pubic symphysis to fundus; correlates with gestational age in cm.
Fetal Heart Rate (FHR):
Auscultated using fetoscope or Doppler.
Normal FHR: 110–160 bpm.
Ultrasound Examination:
Monitors fetal growth, anatomy, amniotic fluid volume, and placental position.
Non-Stress Test (NST) and Biophysical Profile (BPP):
Assesses fetal oxygenation and neurological function through heart rate and movement patterns.
Nurses play a key role in conducting basic assessments and referring high-risk cases for advanced monitoring.
14. Explain the process of conflict management. [5]
Conflict refers to a disagreement between individuals or groups due to differing opinions, goals, or values.
Steps in Conflict Management:
Identification of Conflict:
Recognize early signs such as tension, communication breakdown, or withdrawal.
Understanding the Root Cause:
Analyze sources: poor communication, workload, personal issues, or resource allocation.
Open Communication:
Encourage a nonjudgmental, respectful dialogue.
Allow each party to express concerns.
Problem Solving and Negotiation:
Brainstorm mutually acceptable solutions.
Focus on interests, not personal attacks.
Implementation and Follow-Up:
Apply agreed solution and monitor outcomes.
Modify strategies if conflict persists.
In healthcare, effective conflict resolution promotes teamwork, reduces stress, and improves patient care.
15. Explain the clinical features, treatment and nursing management of pulmonary tuberculosis. [2+3+5=10]
Pulmonary Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis, primarily affecting the lungs.
Clinical Features:
Chronic cough lasting more than 2 weeks
Hemoptysis (coughing blood)
Night sweats, fever, weight loss, and fatigue
Chest pain and difficulty breathing
Treatment:
DOTS (Directly Observed Treatment Short-course):
6-month regimen: Intensive phase (2 months) with 4 drugs: HRZE (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol).
Continuation phase (4 months) with HR.
Regular follow-up and sputum examination.
Nursing Management:
Medication Adherence:
Educate patient on importance of completing full course.
Watch for side effects (e.g., hepatotoxicity, vision changes).
Isolation and Infection Control:
Maintain respiratory precautions during infectious stage.
Educate on cough etiquette and mask use.
Nutritional Support:
Provide high-protein, high-calorie diet to restore body weight.
Monitoring and Follow-Up:
Monitor for drug side effects and sputum conversion.
Psychosocial Support:
Address stigma and support mental well-being.
Encourage family involvement.
16. Explain the causes and management of primary postpartum hemorrhage. [3+7=10]
Definition:
Primary Postpartum Hemorrhage (PPH) is defined as blood loss >500 mL within 24 hours of vaginal delivery or >1000 mL after cesarean section.
Causes (Four Ts):
Tone – Uterine atony (most common cause)
Tissue – Retained placental fragments
Trauma – Vaginal or perineal tears, uterine rupture
Thrombin – Coagulopathies (e.g., DIC)
Management:
Initial Assessment:
Check vital signs, bleeding amount, uterine tone.
Call for help and activate emergency protocol.
Uterine Massage:
Stimulates contraction if uterus is boggy.
Uterotonics Administration:
Oxytocin IV or IM.
If ineffective, use misoprostol, ergometrine, or carboprost.
Treat Retained Products or Tears:
Manual removal of placenta if needed.
Repair any vaginal or perineal lacerations under aseptic conditions.
Fluid and Blood Replacement:
Establish two large-bore IV lines.
Give crystalloids and prepare for blood transfusion.
Monitor and Document:
Closely monitor pulse, BP, uterine tone, and bleeding.
Document time, medications given, and response.
Emotional Support:
Reassure and support the mother emotionally.
Nurses are the first responders to postpartum hemorrhage and play a lifesaving role in early recognition and intervention.
Bottom of Form
~The End