Nurses thinking multiple choice?

[mario_ragucci]

I'm a first year NS and quarter one is drawing to a close. Do all RN's love and cherish multiple choice tests for all tests of knowledge. Today, the comletion of my labs culminated with a successful IM shot. My clinicals are complete. But the dad burn multiple choice summary II exam today and the Final next Monday are making me bug out. Ok - I can respect A,B,C,D and one answer is truly the best, but some questions can't be one right answer ifI am supposed to think about the question.

For example, one question on todays test asked whats more important/immediate, and the 2 best answers were: difficulty swallowing or bowel obstruction. So I went with BM because the question didn't mention the person was eating. And if you can give a PT thickened liquids and check for aspiration. But if perastasis is obstructed, then I understand you can die. The right answer was difficulty swallowing, but because the question didn't mention the PT was eating or drinking, I ruled it out.

Did any nurses struggle and have self-doubt r/t multiple choice question mega exams. Did any nurses come close to flunking out of a program if their scores were close to passing? Did it take you awhile to get those dad burn tests? I remember facts and information satisfactorily. I know I can be a great nurse. These exams, with the multiple choice describing PT scenarios can go 2 ways, and are not a reflection of my knowledge or understanding. I am having a nervous breakdown waiting for my results today, and next week will be twice as hard because there are 100 questions that are from the entire quarter. I have been doing my studying, but if you have a bunch of them curve questions, I could get tripped. Did yall get straight A's through your 2 year time? Thank you for letting me ask you.

[kmchugh]

Let me add one more thing to the ABC thinking. Lets completely change the conditions of the situation:

Suppose you have a trauma patient, a motorcycle rider in the ER with a femur fracture. Other than the pain of the broken leg, he is in no distress. He is breathing easily, and sats are 98% on room air, improving to 100% on O2 at 3 liters by nasal cannula.

If we follow the rule of ABC's that others have outlined, we must consider that with a bone fracture, this patient is at risk of embolus, that could become a pulmonary or cardiac embolus. Both breathing and circulation are in danger. Therefore, before addressing the problem of the bone fracture, we must prevent these problems. Therefore, anesthesia is called, the patient is intubated (protecting the airway, continuing breathing mechanically), and the patient is taken emergently to the OR for placement of a Greenfield filter, resolving the potential for an embolus. In the meantime, the patient exsangunates and dies because the fractured femur has, in moving the patient from bed to bed, torn the femoral artery. The moral of the story: Treat the problem that exists first, then worry about problems that may or may not crop up later.

Kevin McHugh

[Sleepyeyes]

Originally posted by kmchugh

Mario

It's Wednesday, and I kind of hope you read this before attending the test review. I agree with your answer, and here is my rationale:

The question, as you presented it, did not indicate that the patient was currently swallowing anything, or having any difficulty breathing. So, in any event, as long as conditions remain as they are in the question, the patient is in no danger from dysphagia. If someone hands that patient a glass of water, the whole equation changes, but for now, the patient is safe. Dysphagia only equates to an airway problem if the patient is being given liquids (or food, in some severe cases).

We are all taught the ABC's of treating patients, and they are a good place to begin. However, in determining PRIORITY of treatment, a real, current, life threatening, problem always takes precedence over a problem that may crop up later. Make no mistake, a bowel obstruction is life threatening.

With no further changes in the conditions of the test question, a bowel obstruction is at least an urgent situation. It can rapidly become an emergent situation, requiring emergency surgery, RIGHT NOW, to correct, with no changes in the conditions of the test question. Sometimes, a bowel obstruction will clear up with tincture of time, and decompression of the bowel (i.e.. NG tube). Sometimes, it will not, and will require surgery to correct. In any event, the first order of business for a patient with a suspected bowel obstruction is to make the patient completely NPO. Put nothing else into the bowel to compound the problem. Hence, the first treatment of a bowel obstruction eliminates the part of the aspiration worries for a dysphagic patient. Read on, though, because it does not eliminate the greatest danger.

Now, to take it one step further (I love this, because it demonstrates how neatly our organ systems are interconnected and interdependent). What is one of the principal symptoms of bowel obstruction? Violent, persistant emesis. What is the absolute worst thing that can happen to a patient's lungs, short of a 12 gauge shotgun at close range? Aspiration of stomach contents. The pH of stomach content is so low, it causes immediate, life threatening damage to the lungs. In most cases, these patients, if they recover, spend a minimum of three weeks on the ventilator in the ICU. The patient is already dysphagic. There is no intervention, nursing or otherwise, you can take to change that, or to prevent aspiration of stomach contents when (not if) the patient vomits. So, treatment of the bowel obstruction is even more urgent in a dysphagic patient. Make sense? I know surgeons who would be much more hair trigger to take the dysphagic patient with a bowel obstruction to the OR to prevent the aspiration problems I mentioned above.

I'd also ask to see the reference the instructor used to determine that dysphagia is the more immediate problem.

Kevin McHugh, CRNA

thanks kevin; my thoughts exactly, which is why I thought that question should be challenged.

I think that here's what also triggered my response:

"Difficulty swallowing" is not a medical diagnosis; it is a subjective symptom that is described by the patient. However, "bowel obstruction" IS a medical dx and usually established by scientific tests, and confirmation of the doc.

Because the question didn''t present the patient as "eating or drinking" I assumed that BOTH patients were NPO based on the information given.

But these hypothetical scenarios=== you can go round and round all day, I guess, and all Mario really needs is to pass the tests, jump through the hoops and get out on the floor...

For me, it's just a little exercise in critical thinking.....I have no stake in it...and I can see the others' points... but it just took this long to figure out exactly what tripped my trigger with this one, and I finally realized what it was, when I read your post. there ya have it.

[semstr]

Mario, first of all, congrats on your test. from what I hear and read here 86% is very good!

We never do multiple choice here, when tests are on paper there are "open" questions", for us educators difficult and hard (and long!!) to read sometimes, but then, on the other hand, when people can describe the learned in their own words (not in mine or from the book) and it is correct, I know they understood what the theme was all about.

Mostly we do verbaltest. And I think these are the best for nursing. Talk, communicate, in your own words, of course with the facts, but not learned without understanding. Especially here, I notice very soon when a student "just learned" without understanding. All it takes is one question: "why do you do this or that?"

It sounds hard, but my responsibility is a great one as an educator. I can't let people pass tests, when I know they don't know what they are talking about.

On the other hand, I have the possibility in my system here, to study together with my students, so they know what kind of questions I might ask them.

And I always let the students explain to me, when they say something I never heard of before, when that is ok, although not taught that way, it is fine with me.

Most important thing: no patient endangering!! (even when it sounds pretty "alternative" sometimes, but I am not on the wards everyday, so I don't know everything what's going on.)

Keep it on Mario, you're doing great!! Renee