Nokea
A postpartum client exhibits signs of deep vein thrombosis (DVT), including calf pain, swelling, and warmth. Which nursing action is most appropriate?
- A. Applying warm compresses to the affected calf
- B. Encouraging ambulation to promote circulation
- C. Notifying the healthcare provider immediately
- D. Administering anticoagulant medication as ordered
Correct Answer: C
Rationale: Deep vein thrombosis (DVT) is a serious condition that requires prompt medical intervention. The presence of calf pain, swelling, and warmth in a postpartum client are concerning signs of a potential DVT. By notifying the healthcare provider immediately, appropriate diagnostic tests, such as ultrasound imaging, can be ordered to confirm the diagnosis. Timely treatment with anticoagulant medication can then be initiated to prevent complications such as pulmonary embolism. Applying warm compresses or encouraging ambulation may exacerbate the condition by promoting clot dislodgement, making immediate notification of the healthcare provider the most appropriate nursing action in this situation.
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As a nurse, which of the following are the critical factors for successful integration of loss during the grieving process?
- A. The patient 's predictable and steady movement form one stage of the process to the next
- B. Accurate assessment and intervention by the nurse or helping person
- C. The nurse trustworthiness and healthy attitude about grief
- D. The patient's adequate perception, adequate support, and adequate coping
Correct Answer: B
Rationale: Accurate assessment and intervention by the nurse or helping person are critical factors for successful integration of loss during the grieving process. This involves the nurse's ability to assess the patient's grieving process effectively, identify their needs, provide appropriate support, and intervene when necessary. By utilizing proper assessment techniques and offering timely interventions, the nurse helps facilitate the patient's journey through the grieving process, promoting healthy coping mechanisms and ultimately assisting in achieving successful integration of their loss. Trustworthiness and a healthy attitude about grief are important qualities for a nurse, but without accurate assessment and intervention, the grieving process may not progress smoothly.
Kris is a hospitalized movie star. A nursing assistant takes her picture without permission and sells it to a local newspaper. The nursing assistant could be quilts of:
- A. Invasion of privacy
- B. Defamation
- C. Abuse
- D. Assault and battery
Correct Answer: A
Rationale: This scenario falls under the category of invasion of privacy. Invasion of privacy occurs when a person's private information or images are shared or used without their consent, leading to an intrusion of their private life. In this case, Kris, as a hospitalized movie star, had her picture taken without permission by the nursing assistant, which was later sold to a local newspaper. Kris has a right to privacy, especially during a vulnerable time like being hospitalized, and the nursing assistant violated that right by taking and selling her picture without consent. This action constitutes an invasion of privacy.
You have observed presence of drainage in Claudia's eyes. Which of the following eye solution would you use in cleaning her eyes?
- A. Hydrochloric acid
- B. Mineral water
- C. Normal saline solution
- D. Soapsuds solution
Correct Answer: C
Rationale: Normal saline solution is the best choice for cleaning Claudia's eyes with drainage. It is a sterile solution that closely matches the natural pH of the eyes, making it gentle and safe for ocular use. Normal saline can help flush out any debris or discharge in the eye without causing further irritation or complications. On the other hand, hydrochloric acid is a corrosive substance that can cause significant harm if it comes into contact with the eyes. Mineral water may contain impurities that could further irritate the eyes. Soapsuds solution is not recommended for eye cleaning as it can cause irritation and damage to the delicate eye tissues. Therefore, normal saline solution is the most appropriate and safe option for cleaning Claudia's eyes in this situation.
Following a severe traumatic brain injury, a patient is experiencing alterations in consciousness characterized by periods of wakefulness but with no meaningful interaction with the environment. Which term best describes this state?
- A. Coma
- B. Vegetative state
- C. Minimally conscious state
- D. Locked-in syndrome
Correct Answer: B
Rationale: A vegetative state, now more commonly referred to as unresponsive wakefulness syndrome, describes a condition where the patient is awake but with no awareness of themselves or their surroundings. This state usually follows a severe brain injury, such as traumatic brain injury. Patients in a vegetative state may have sleep-wake cycles, open their eyes, and even exhibit reflex movements, but they do not demonstrate any meaningful interaction with the environment. Differentiating between coma and vegetative state is important, as coma implies a complete lack of consciousness, while patients in a vegetative state have preserved wakefulness without awareness. Minimally conscious state (choice C) refers to a condition where there are some minimal signs of awareness or purposeful interaction, making it a different state than the one described in the scenario. Locked-in syndrome (choice D) is a condition where the patient is conscious and aware but unable to move or communicate due to paralysis, which is not consistent
The PRC-Board of Nursing (PR-BON) has the power to regulate Nursing Practice in the Philippines. The regulatory functions include the following except
- A. enforce and monitor quality standards of nursing practice in the county
- B. issue, suspend revoke or reissue certification of registered nurses
- C. ensure proper conduct. Or nurses 1icensure in the county
- D. issue permit for the opening of nursing programs in the country
Correct Answer: D
Rationale: The Philippine Regulatory Commission - Board of Nursing (PRC-BON) has the power to regulate nursing practice in the Philippines.