Nokea
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
- A. Holistic healing
- B. Spiritual advising
- C. Herbal preparations
- D. Witchcraft potions
Correct Answer: A
Rationale: A curandero practices holistic healing, which includes addressing the physical, spiritual, and emotional aspects of illness. Choice A is correct because holistic healing aligns with the curandero's approach. Choices B, C, and D are incorrect because while spiritual advising, herbal preparations, and witchcraft potions may be part of some cultural healing practices, they do not fully capture the comprehensive nature of holistic healing provided by a curandero.
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A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Hyperglycemia
- C. Gingival hyperplasia
- D. Hypokalemia
Correct Answer: C
Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.
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.
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.
An example of secondary prevention strategy would be:
- A. Screening for breast cancer in women who have no symptoms
- B. Using pain control medications for terminal cancer patients
- C. Educating teenagers about using condoms to prevent STDs
- D. None of the above
Correct Answer: A
Rationale: The correct answer is A. Screening for breast cancer is a secondary prevention strategy aimed at early detection, which falls under secondary prevention as it focuses on early identification and intervention before the disease progresses. Choice B is incorrect as it refers to palliative care for symptom management in terminal cancer patients, which is not a secondary prevention strategy. Choice C is incorrect as educating teenagers about condom use is a primary prevention strategy to prevent the initial occurrence of STDs rather than intervening after exposure, making it a primary, not a secondary prevention strategy. Choice D is incorrect as there is a valid example of a secondary prevention strategy provided in choice A.
The appropriate order of steps in active management of the third stage of labor includes:
- A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to ensure the placenta is intact.
- B. Intravenous oxytocin, cord clamping and cutting, and fundal massage.
- C. Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage.
- D. Controlled cord traction, fundal massage, and oxytocin.
Correct Answer: C
Rationale: The correct sequence of steps in active management of the third stage of labor includes intramuscular injection of oxytocin to prevent postpartum hemorrhage, controlled cord traction with counter traction to the uterus to facilitate placental delivery, and uterine massage to aid in uterine contraction and prevent excessive bleeding. Choice A is incorrect because ergometrine administration is not routinely recommended in active management. Choice B is incorrect as intravenous oxytocin is not the preferred route of administration. Choice D is incorrect as the order of steps is not accurate.