State Examination of Nurses

Kai Tiaki : the journal of the nurses of New Zealand, Volume XIV, Issue 1, 1 January 1921, Page 7

State Examination of Nurses

The State Examination was held on Ist and 2nd of December, at Auckland, Waikato, Wellington, Napier, Wanganui, New Plymouth, Christchurch, Timaru, Dunedin, Invercargill, and Greymouth, and results were out before Christmas, so that candidates were relieved of anxiety as to their success. The questions for the medical paper were as follow :— 1. What are the sypm'toms of — (a-) Cerebral meningitis, (b) apoplexy, (c) epilepsy, (d) paraplegia 1 2. What is the general management of a case of pulmonary phthisis? What regulations should be observed to prevent risk of infection from a c-ase of phthisis treated at home? 3. What are (a) the symptoms, (b) complications, and (c) general nursing management, of rheumatic fever? 4. What are the general principles involved in dieting a child three months old suffering from gastro-intestinal catarrh? 5. What are the terms used to distinguish the action of drugs? Give one example of each, and the dose. (5. Give the symptoms of poisoning by (a) carbolic acid, (b) atropine, (c) arsenic, (d) digitalis. 7. Describe the nursing management and dieting of a case of gastric ulcer. 8. What signs indicate heart diseases? What are the points to attend to in the observation of pulse? The following comments from the examiners in these subjects should be studied by candidates who have passed as well as those who have failed; and we also commend them to the attention of teachers in nurse training schools: — "This examination should disclose a good knowledge of nursing management, and a fair general knowledge of the symptoms of the principal diseases and their complications, having in mind that the candidates are nurses and not medical students. To this end the paper was set, and the result, on the whole, was excellent, although the answers in some instances were rather meagre, and on the

other hand some of the candidates became discursive in matters of detail belonging to the province of the physician rather than the nurse. The percentage of marks necessary for passing the examination is not at all high, and it may be advisable to raise the marks necessary for a pass. This is preferable to making the examination more difficult — that is, making it more suitable for medical students. The present course of study is advanced enough, and fully taxes the powers of the average nurse, seeing that her time is very fully occupied in actual nursing, and she has only very limited energy and freshness for the study of books and notes. "The faults of candidates recur with monotonous iteration, and t'he chief are : Failure to think out the general scheme of answering a question before putting pen to paper; answering more than is asked, less than is asked, or answering something foreign to the question; and the unconscionable sin of * padding. ' There is often a lack of perspective, and the salient points are missed. For instance, in the description of apoplexy it is not wise to omit paralysis, or the Prince of Denmark from the play of Hamlet. To refer to the details of the examination under review, some of the candidates confused cerebral meningitis with cerebrospinal meningitis, although the name describes not only the nature of the disease but its exact location. It is surprising that some nurses advise as a precaution against phthisis the avoidance of a patient's breath and omit the real danger of the cough and expectoration. The candidates generally had very full knowledge in regard to the nature and nursing management of phthisis and rheumatic fever; but scant knowledge of the principles underlying the dieting and nursing of igastro-intestinal catarrh in an infant, having in this subject taken the royal and not the rocky road to learning. Among the optional questions, those on the classification of drugs and on poisons were not popular, probably because it is

easier to write a narrative than to tabulate. "The spelling and composition showed a good general standard of education. There was only one 'howler 1 produced, and not of the light-humoured variety. It arose in this wise: having in mind the major and the minor prophets, the candidate divided the complications of rheumatic fever into major and minor, and among minor complications cited sudden death. It is quite true that there is an element of surprise in all humour, and also tragedy is close to comedy. In the language of the playgoer, the nurses in the examination put on a very good show, interesting and not at all tiresome, for which the examiner offers them much thanks." The questions in surgical nursing were as follow : — 1. A child is admitted into hospital with a tubercular hip-joint. What would you prepare for the surgeon who -wishes to apply a splint, and what are the important details in the nursing of these cases? 2. A patient is brought back from the theatre, after a prolonged and serious operation, suffering from shock. What signs would be present, ■and how would you proceed to nurse the case? 3. Describe the 'nursing treatment of a case of tracheotomy for the first few days after the operation. ' What complications may arise in such a case, and how would you deal with them? 4. Describe the preparations you would make for the administration of intravenous saline, including the preparation of the patient. For what conditions is intravenous saline usually given . T 5. Enumerate the instruments and appliances you would get ready for an operation for strangulated hernia, the patient being seriously ill. 6. What are the signs of sepsis in an operation wound, and what are the indications for dressing a clean operation wound? 7. What is meant by the following terms: — (a) Gangrene; (b) callus; (c) pyaemia; (d) Colles fracture; (e) Faradism? 8. How would you proceed to pass a catheter for retention of urine? Describe the sterilisation of (a) a plain rubber catheter; (b) a gum elastic catheter; (c) a cystoscope; (d) ia metal and glass serum syringe.

"I have been asked to make some comments on the answers to the questions on surgical nursing set at the State examination held in December last. 'The general standard reached by the nurses was, I am pleased to say, very high— a result 1 had been led to expect from my knowledge of the ability of the New Zealand trained nurses during the course of the war. : 'As is usually the case, there was a considerable difference between the answers of the obviously more intelligent and better-educated candidates and those who did not come up to the high -standard of the majority. It seemed to me that the relatively very few nurses who failed had not had sufficient surgical experience and, maybe, required a further six months' training at one of the larger hospitals. ' ' Many found difficulty in arranging their answers satisfactorily, but they made very little difference to the results, as it seemed easy for the nurse to show her knowledge in spite of her lack of examination method. "With regard to the different questions, I will take them in order. "I: The splintage and nursing of a case of tubercular hip. " This question was not answered very well by the majority of the candidates, and rather badly by a few. The first essential in the splintage of these cases is adequate fixation -of the hip-joint, and the second essential is extension applied to the limb to protect the joint cartilage from pressure and erosion. I was very sorry to see that the majority of the candidates had been taught that the long Liston splint satisfied the first essential, and some even put their faith in a straightback splint. Also, I failed to see the logic of some nurses who strongly urged the claim of the Thomas's knee-splint when the designer of that very splint had gone to the trouble of designing a very efficient hip-splint especially for these cases. Of course the Thomas's knee-splint, and still more the Hodgin's splint are not designed to [give any rest to the hip-joint, and so are not efficient splint's for this

condition. Some nurses even went so far as to stress the claims of the Hodgin's splint, as it allowed so much mobility, thus showing their absolute ignorance of the condition they would be called upon to nurse. Many candidates mentioned plaster which would give sufficient fixation, and some mentioned the double abduction frame and Bryant's frame, both of which could give adequate fixation if fitting well. With regard to the nursing of the case, the first consideration is the provision of adequate rest, and the second the prevention of splint and bed and extension sores. To procure rest the splint has to be constantly watched and adjusted, and the extension kept in order, especially at night time. The nursing of the patient must be done gently, any movements being carried out without disturbing or jarring the hip-point. The child must obviously be treated mainly by means of fresh air, sunshine, nourishing food, and cheerful surroundings. Loss of sleep because of pain must be treated by adjusting the extension and not by sedatives, as stated by several nurses. Abscess formation must especially be watched for, and deformity must not be allowed to arise. Lastly, the condition of the muscles and the unaffected joints must be attended to by exercises and massage. I feel strongly that the answers to this question were not up to the standard of the other answers, which seems to point to some neglect of the training in the nursing of tubercular joint disease. "II : The question on shock. "This was, ion the whole, xevy well answered, the main fault being that some nurses were apt to be too active and so spoil any treatment they proposed to carry out. The first part of the question was well answered, but not sufficient stress was laid on the. cardinal factor, that is the listlessness and relaxation of all the muscles, due to profound cerebral exhaustion. It is the profound exhaustion that prevents the ordinary stimulants being of benefit and compels us to nurse very gently back the faint flame of human life which can be snuffed out quite

easily by further trauma. During the war many different methods of 'treating profound shock were tried, and the sheet anchor was found to be the provision of warmth and absolute quiet and rest, with elevation of the foot of the bed and, when possible, hot, nourishing drinks. Intravenous saline is also of benefit, but rectal is not generally retained and subcutaneous often not absorbed. Above all, the patient must be protected from further trauma, and also must have plenty of fresh air. "Ill: The question on tracheotomy was very well answered by the majority of the nurses. The proper protection of the nurse, however, was generally forgotten, although the important details of the nursing of the patient were almost invariably stated. The complications were not given in full, as a rule, but the nurses generally understood how to deal with the difficulties of the tube and the blocking of the trachea. Broncho-pneumonia was, strangely, frequently forgotten, and local sepsis and its very serious results were generally ignored. "IV: This question was well answered. There was considerable discrepancy as to the temperature of the saline. Several of the candidates recognised the rapidity of cooling of the fluid from the receiver to the intravenous needle, but others thought that 100 to 105 degrees was sufficiently warm. Experiments made some years ago demonstrated the fact of the marked cooling of the fluid in the ordinary apparatus, and thermos flasks were employed with short, thick rubber tubing to prevent the cooling. A temperature of 110-115 would be required in the ordinary apparatus to enable the fluid to get into the vein at 100. The second half of the question, as to the conditions calling for saline, was generally well answered. The main indication is, of course, loss of fluid, either blood or fluid by the mouth or rectum. In shock, also, it is of distinct advantage, also in anaemic and in toxsemic conditions. "V: This question was fairly well answered, though there was a distinct tendency to put in an excessive number of in-

xirnments. Many nurses left out the intestinal clamps and the Paul's tubes and intestinal needles and sutures. No candidate mentioned a long rubber tube for emptying possibly deleted paralysed intestine. I nti-a venous saline was also strongly indicated. "VI: This question was not answered very well. The exact time when the rise of temperature would occur was not stated, and this is the important point. The general malaise was often overlooked — the furred tongue, the headache, the constipation, and the sleeplessness. In discussing* the local signs, none pointed out that sepsis arising in deep sutures may show no local signs for days and little or no rise in temperature. The answers were far too much in the nature of an inventory of possible signs without any explanation or co-ordination. The indications for dressing- a clean wound were very poorly given, several of the nurses giving, instead, a detailed account of the technique of an ordinary dressing, which was not asked for. Practically none mentioned the fact that a hardcaked dressing is very uncomfortable and that gauze does get caught in stitches and often causes great discomfort. A hsematoma may arise in a clean operation wound, and would call for dressing. The dressing may become contaminated by urine, saliva, etc. The bandage may become tight, due to swelling of a limb, and the dressing needs adjusting. "VII: This question again was not well answered, considering the choice of questions offered. Several nurses had little idea of the nature of callus, and many put the cart before the horse by saying that it was produced by the deposition of lime salts between the bony fragments. If they have had the opportunity of looking at X-ray plates they will know that the chief characteristic of callus is the absence of lime salts, thus rendering X-ray appearances of recent fractures very obscure with regard to the presence or absence of bony union. The lime salts are only deposited in the late stages of bone repair. Most candidates understood pysemia perfectly well, but Colles fracture

was, strangely, a stumbling-block. This fracture consists of a fracture of the lower end of the radius, with the lower fragment displaced backwards. The Stylord process of the ulna may be fractured, but that is not essential. Smith's or the chauffeur's fracture is also a fracture of the lower end of the radius, but with the lower fragment displaced forwards. Faradisin was not generally understood, due probably to the nurses not having had the opportunity, in some cases, of seeing the application of electricity. "VIII: The first part of this question was very well answered, showing that the training in asepsis had been excellent. The second part was answered fairly well, but the cystosoope and the metal-and-glass syringe troubled some of the candidates. The cystoscope can be sterilised in 1-20 carbolic, but the eyepiece should not be sterilised, as it is unnecessary, and is apt to damage the lenses. Spirit should not be used. The metal-and-glass syringe most people prefer to sterilise in spirit or 1-20 carbolic. Boiling is dangerous, and if it is done at all the water must be cold to start with. "In conclusion, I must say that my endeavour was to get an idea of the candidates' practical knowledge of surgical nursing, and I was delighted to find that the large majority showed they had that practical knowledge well developed." The suggested tests and questions for the oral and practical examinations were as follow : — Questions for the Doctor Examiners. I — (a) Name instruments (selected by the examiner); (b) put out the instruments 'necessary for operation on a case of ruptured ectopic gestation; (c) set a table for an anaesthetist. II — What do you know about preparation of catgut, silkworm gut; scalpels; drainage-tub-ing; gum-elastic catheters; metal catheters .' Ill — (a) How do you test for albumin; sugar? Practical test, (b) What is the average quantity of urine voided in 24 hours by an adult ? . How is this quantity affected by diabetes; by uraemia? (c) Name some means employed to promote an increased flow of urine. (d) What is cystitis, and what are some of the common causes?

IV — (a) Select splints which would be suitable for a case of fractured femur? (d) Demonstrate the method of applying a splint for a patient who suffers from "wrist-drop?" V — How would you treat a patient suffering from shock, pending the arrival of the medical practitioner? Questions for the Nurse Examiner. I — Prepare the articles necessary and demonstrate how you would give diphtheria anti-toxin (all but prick)? II — (a) Make a bed for a rheumatic patient; or (b) make an operation bed; or (c) place patient in Fowler's position. Ill — (a) Sponge a helpless patient and change undersheet or draw sheet; or (b) bathe an eye. IV — Prepare the necessary articles, patient, and bed for washing out the female bladder. V — Enematse: Name four varieties, giving proportions used, and demonstrate one. That the general standard of the candidates was good was evidenced by the fact that, out of 110, 48 passed with honours — that is, with 75 per cent, and over; while in all 95 passed in all subjects, and 13 in one or two subjects. List of passes : — PASSED FIRST. Auckland Hospital: Dorothy Arnold. 75% OR OVER. Auckland Hospital: Sophia E. Black, Ruth C. Johnson, Kathleen G. Latimer, Henrietta M. Goertz, Annie L. Harvey, Gwendoline Langdalc, Heather Sutherland, Mary K. Dixon. Waikato Hospital: Hilda M. McLeod, Lila M. Smith. Thames Hospital: Dorothy R. M. White. Waihi Hospital : Jane Alexander. Wellington Hospital: Mai da I. Asher, Winifred Gale, Daisy A. Whitelaw, Isabel J. H. Jeans, Janet "B. Dunlop, Margaret Maxwell. Masterton Hospital: Irene Hughes. Picton Hospital: Gertrude Eva Check. Napier Hospital: Eleanor McConachie, Elsie I. Sellar, Gladys Wells, Grace Miles, Nellie Smith. Wairoa- Hospital: Louisa Corkill, Wanganui Hospital: Elsie Jackson. New Plymouth Hospital: Winifred Hoskings. Christchurch Hospital: Eulalie Goldsbury, Fanny F. M. Rudman, Clara May T. Brougham,

Ellen McMillan, Florence Maud Nicholson, Alexandra MeLachlan, Katherine Sybil Williams. Timaru Hospital: Evelyn Watson. Waimate Hospital: Barbara E. Gellweilcr. Dunedin Hospital: Theresa Cullington, Helen R. Newlands, Phoebe B. Cameron. Oamaru Hospital: Mary L. Bows, Mary A. Alexander. Southland Hospital: Gladys J. Fox, Isabella Mclvor, Mary Shepherd, Edith E. Perry. Eiverton Hospital: Elizabeth L. Watson. THE FOLLOWING ALSO PASSED. Auckland Hospital: Eunice Laura Preece. Thames Hospital: Annie O'Shea, Annie Greener. Waikato Hospital : Lily Johnson. Waihi and Wairau Hospital: Cora A. M. Burgess. Wellington Hospital: Stella Hilliker, Nance Park, Elsie Lindsay, Annie G. Owen. Blenheim Hospital: Myrtle Mowat. Masterton Hospital : Grace Mclvor. Greytown Hospital: Erica M. Drake, M. R. Beaumont. Nelson Hospital: Ivy Lessels, Margaret Max, Estelle Tunnieliffe. Picton Hospital: Ellen Wise. Blenheim Hospital: Enid Maud Wolferston, Mabel Meehan, Isabel Clunies Ross. Napier Hospital: Georgina M<ason, Ivy L. J. Cornish. Dannevirke Hospital: Evelyn Rood. Wanganui Hospital: Ethel Beal. New Plymouth Hospital: Olive Mary i';i . ter, Daisy Mitchell, Dorothy Dew. Pa tea Hospital: Lucy Heayns. Palmerston North Hospital: Mary Josephine Classon. Hawera Hospital: Ivy Swadling. Christchurch Hospital: Annie Gladys Nicolle, Minnie Piper, Elsie M. Gibbons, Nance Weld. Westport Hospital: Blanch Edwards. Waikato Hospital: Mabel Evans. Timaru Hospital: Isabel Elder, Mary McKay, Annie Aitken, Irene O 'Neill. Waimate Hospital: Gladys Watt. Dunedin Hospital: Charlotte A. Bartlett, Eliza E. Hollands, Ethel I. Miles. Southland Hospital: Ivy M. Spittle, Irene J. G. Renall. Riverton Hospital: Margaret A. Porteous. The above names are not in order of merit.