Nokea
A postpartum client presents with persistent, severe perineal pain despite analgesic medication. On assessment, the nurse observes ecchymosis and swelling of the perineum. Which nursing action is most appropriate?
- A. Applying ice packs to the perineum for pain relief
- B. Encouraging the client to sit on a donut cushion
- C. Notifying the healthcare provider immediately
- D. Administering additional analgesic medication
Correct Answer: C
Rationale: The presence of persistent, severe perineal pain along with ecchymosis and swelling of the perineum can indicate a complication such as a hematoma. A hematoma is a collection of blood that can occur in the perineal area postpartum, usually as a result of trauma during delivery. It is essential to notify the healthcare provider immediately to assess the situation, provide appropriate treatment, and prevent further complications. Applying ice packs or administering additional analgesic medication may not address the underlying issue of a possible hematoma, so prompt medical evaluation is crucial in this situation.
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The patient verbalizes to the nurse about thought to kill his wife". The nurse is in dilemma whether to tell the wife about this Conversation. Given this situation which of the following is the appropriate action of the nurse?
- A. Alert immediately the proper authorities regarding the threat to safeguard the safety of the wife.
- B. Tell the wife to be very extra careful as her life is danger.
- C. Weigh carefully the situation by viewing it as dilemma between disclosing confidential information or warning appropriate authorities.
- D. Keep the information to herself and be vigilant on action of the patient to protect the wife
Correct Answer: A
Rationale: In this critical situation, the safety of the wife is of utmost importance. Whenever a healthcare provider becomes aware of a direct threat to someone's safety, especially related to potential harm or violence, it is their ethical and legal responsibility to report this information to the appropriate authorities promptly. In this case, the nurse should alert the proper authorities, such as law enforcement or a mental health crisis team, to ensure that immediate steps are taken to protect the wife from harm. Confidentiality should be breached in situations where there is a clear threat to an individual's safety. Keeping the information confidential in this scenario could result in serious harm or even loss of life. The nurse must act quickly to protect the potential victim.
Healthy physical development is dependent upon nutrition, brain development, muscle and bone. Which of the following is NOT APPROPRIATE for physical development of a pre schooler?
- A. Sleeps 6 to 8 hours of sleep each day
- B. Assists in brushing and flossing teeth
- C. Gains 5 pounds per year
- D. Eruption of the primary teeth
Correct Answer: A
Rationale: For a preschooler, it is recommended that they get more than 8 hours of sleep each day. Adequate sleep is crucial for their physical development, overall health, and cognitive function. Preschoolers typically need around 10-13 hours of sleep per day to support their growth and development. Getting less than the recommended amount of sleep can lead to issues such as behavioral problems, difficulty concentrating, and poor physical development. Therefore, ensuring that a preschooler gets enough sleep is vital for their physical well-being.
Which of the following is the preventive measure to osteoporosis development
- A. Iron rich food
- B. Daily jogging
- C. Calcium rich food and supplement
- D. Vigorous exercise
Correct Answer: C
Rationale: Calcium is essential for maintaining strong and healthy bones. Osteoporosis is a condition characterized by weakened bones, making them more prone to fractures. Consuming calcium-rich foods such as dairy products, leafy greens, and fortified foods can help prevent osteoporosis development. Additionally, incorporating calcium supplements under the guidance of a healthcare provider can further support bone health and reduce the risk of osteoporosis. Regular intake of adequate calcium is considered a crucial preventive measure for osteoporosis.
Which of the following strategies would prove effective in preventing more incidence of dengue infection?
- A. Healthy nutritious food
- B. Burning of leaves and garbage
- C. Destruction of breeding place of vectors
- D. Adequate rest and sleep
Correct Answer: C
Rationale: The most effective strategy in preventing more incidence of dengue infection is to target the breeding places of the Aedes mosquitoes, which are the vectors responsible for transmitting the dengue virus. By eliminating stagnant water sources where these mosquitoes breed, such as uncovered containers, flower pots, and discarded tires, the mosquito population can be significantly reduced. This, in turn, helps to lower the risk of dengue transmission to humans. While healthy nutritious food, burning of leaves and garbage, and adequate rest and sleep are important for overall health and immune function, they do not directly address the primary cause of dengue transmission, which is the Aedes mosquito population.
A nurse administer as extra dose of vaccine to a child and the patient developed adverse reaction and died. She can be sued for _____.
- A. Negligence
- B. Tort
- C. Malpractice
- D. Battery
Correct Answer: C
Rationale: In this scenario, the nurse can be sued for malpractice. Malpractice refers to the failure of a professional, in this case, a nurse, to provide the standard of care that a reasonably prudent nurse would have provided in similar circumstances, resulting in harm to the patient. Administering an extra dose of vaccine leading to an adverse reaction and death of the patient is considered a form of medical malpractice as it involves a breach in the standard of care. Generally, malpractice cases involve errors or negligence in the performance of professional duties, which result in harm to the patient.