Nokea
A 16-year-old female client returns to the clinic because she is pregnant for the third time by a new boyfriend. Which vaccine should the nurse plan to administer?
- A. MMR
- B. Hepatitis B
- C. Human papillomavirus
- D. Pneumococcal
Correct Answer: B
Rationale: The correct answer is B, Hepatitis B. The Hepatitis B vaccine is crucial for pregnant women to prevent transmission of the virus to the baby during childbirth. Option A, MMR (Measles, Mumps, Rubella) vaccine, is not indicated during pregnancy. Option C, Human papillomavirus vaccine, is recommended for prevention of HPV infections but is not specifically indicated during pregnancy. Option D, Pneumococcal vaccine, is important for certain populations but is not the priority vaccine for a pregnant woman in this scenario.
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In providing comprehensive family health care, the nurse utilizes four (4) basic processes. These are listed in the order in which they are carried out as follows:
- A. assessment, planning, intervention, and evaluation
- B. assessment, intervention, planning, and evaluation
- C. planning, assessment, intervention, and evaluation
- D. planning, intervention, evaluation, and assessment
Correct Answer: A
Rationale: The correct order for the basic processes in providing comprehensive family health care is assessment, planning, intervention, and evaluation. Assessment is the first step to gather information, followed by planning to set goals and strategies, then intervention to implement the plan, and finally evaluation to assess the outcomes. Choice A is correct as it follows this logical sequence. Choices B, C, and D are incorrect because they do not follow the correct order of these essential processes in nursing care.
The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
- A. Nutrition
- B. Elimination
- C. Activity
- D. Safety
Correct Answer: D
Rationale: In severe depression, the priority nursing diagnosis is safety. Individuals with severe depression are at risk of self-harm or suicide. Ensuring the client's safety by implementing measures to prevent harm to themselves or others is crucial. While nutrition, elimination, and activity are important aspects of care, ensuring the client's immediate safety takes precedence in this situation.
The healthcare provider would expect which eating disorder to have the greatest fluctuations in potassium?
- A. Binge eating disorder
- B. Anorexia nervosa
- C. Bulimia
- D. Purge syndrome
Correct Answer: C
Rationale: The correct answer is C: Bulimia. Bulimia involves cycles of binge eating and purging, where individuals may induce vomiting or use laxatives and diuretics. These purging behaviors can lead to significant fluctuations in potassium levels due to electrolyte imbalances caused by excessive loss of potassium through vomiting and purging. In contrast, Binge eating disorder (A) does not involve purging behaviors, so it is less likely to cause significant potassium fluctuations. Anorexia nervosa (B) is characterized by severe food restriction rather than purging, leading to a different pattern of electrolyte imbalances. Purge syndrome (D) is not a recognized eating disorder and is not associated with specific patterns of potassium fluctuations seen in bulimia.
The nurse uses the DRG (Diagnosis Related Group) manual to
- A. Classify nursing diagnoses from the client's health history
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct Answer: C
Rationale: The DRG manual is used to determine the reimbursement rate for medical diagnoses and treatments under the prospective payment system used by healthcare facilities. Choice A is incorrect because the DRG manual is not used to classify nursing diagnoses, but rather to group medical diagnoses for billing purposes. Choice B is incorrect as the DRG manual is not used to identify findings related to medical diagnoses, but rather to standardize payments for medical services. Choice D is incorrect as the DRG manual is not used to implement nursing care based on case management protocol, but rather to set reimbursement rates.
Which of the following statements about TB treatment is INCORRECT?
- A. Combination of 3-4 anti-TB drugs is the treatment of choice
- B. Single drug therapy is appropriate
- C. Treatment renders patients non-infectious and cured
- D. Tuberculosis is a curable disease
Correct Answer: B
Rationale: The correct answer is B. Single drug therapy is not appropriate for TB due to the risk of developing resistance. The most effective approach to TB treatment is a combination of 3-4 anti-TB drugs. This combination helps to prevent the development of drug resistance and improve treatment outcomes. Choice C is correct as TB treatment, when completed successfully, renders patients non-infectious and cured. Choice D is also correct as tuberculosis is indeed a curable disease with appropriate treatment. Therefore, the incorrect statement is B.