Nokea
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to
- A. Insufficient oxygenation of the cardiac muscle
- B. Potential circulatory overload
- C. Left ventricular overload
- D. Electrolyte imbalance
Correct Answer: A
Rationale: The correct answer is A: Insufficient oxygenation of the cardiac muscle. Myocardial infarction pain is primarily caused by inadequate oxygen reaching the heart muscle, leading to ischemia and tissue damage. Choices B, C, and D are incorrect because circulatory overload, left ventricular overload, and electrolyte imbalance are not the primary causes of chest pain in myocardial infarction. Circulatory overload may lead to other symptoms like edema, left ventricular overload can result in heart failure symptoms, and electrolyte imbalance may present with various manifestations, but none of these directly cause the characteristic chest pain associated with an MI.
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The nurse is assessing a newborn the day after birth. A high-pitched cry, irritability, and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?
- A. Reduce the environmental stimuli
- B. Offer formula every 2 hours
- C. Talk to the newborn while feeding
- D. Rock the baby frequently
Correct Answer: A
Rationale: The correct intervention is to reduce the environmental stimuli. In this scenario, the newborn is displaying signs of overstimulation and distress, which can be exacerbated by environmental factors. Offering formula every 2 hours (Choice B) may not address the underlying issue of overstimulation. Talking to the newborn while feeding (Choice C) and rocking the baby frequently (Choice D) may further stimulate the newborn, which is not appropriate in this case.
In this municipality, what should the nursing health care plan focus on?
- A. Rehabilitative services
- B. All of these services
- C. Health promotion and disease prevention
- D. Curative services
Correct Answer: C
Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.
The nurse is caring for a 5-year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?
- A. Kicking balloons with the right leg
- B. Playing 'Simon Says'
- C. Playing handheld games
- D. Throwing bean bags
Correct Answer: C
Rationale: Playing handheld games is an appropriate diversional activity for a child in skeletal traction because it does not require physical movement of the affected limb. This activity can help keep the child entertained and engaged without risking any harm to the tractioned leg. Choices A, B, and D involve physical movements that could potentially interfere with the skeletal traction or cause discomfort to the child.
A client with rheumatoid arthritis is receiving methotrexate (Rheumatrex). The nurse should monitor the client for which of the following adverse effects?
- A. Leukopenia
- B. Hyperglycemia
- C. Hypertension
- D. Hypokalemia
Correct Answer: A
Rationale: The correct answer is A: Leukopenia. Methotrexate, used in the treatment of rheumatoid arthritis, can lead to bone marrow suppression, resulting in leukopenia. This condition increases the risk of infections due to decreased white blood cell count. Choices B, C, and D are incorrect because methotrexate is not known to cause hyperglycemia, hypertension, or hypokalemia as its primary adverse effects.
Manny Pacquiao, a Filipino and world boxing champion, used to advertise a muscle pain-relieving drug popularly known in the Philippine market. What can be an equally effective medicinal alternative, especially in far-flung communities and provinces, to relieve muscles and joint pains and prove to be non-costly?
- A. Sambong
- B. Lagundi
- C. Akapulko
- D. Yerba Buena
Correct Answer: D
Rationale: Yerba Buena is a suitable alternative for muscle and joint pain relief, particularly in remote areas due to its cost-effectiveness and proven efficacy. Sambong is more commonly used for urinary tract problems, Lagundi is known for respiratory conditions, and Akapulko is primarily used for skin diseases, making them less effective alternatives for muscle and joint pain relief.