Nokea
A rape victim tells the emergency nurse, I feel so dirty. Help me take a shower before I get examined. The nurse should:
- A. arrange for the victim to shower.
- B. give the victim a basin of water and towels.
- C. offer the victim a shower after evidence is collected .
- D. explain that bathing facilities are not available in the emergency department.
Correct Answer: C
Rationale: The correct response for the nurse in this situation would be to offer the victim a shower after evidence is collected. It is essential to preserve any physical evidence that may be present from the assault during the forensic examination. Allowing the victim to shower before evidence is collected could potentially compromise the evidence and hinder the investigation. The nurse should provide support to the victim during this difficult time and assure them that they will have the opportunity to shower once the necessary evidence is obtained. It is also crucial for the nurse to offer empathy and understanding while explaining the importance of preserving any evidence related to the assault.
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A patient with a history of chronic kidney disease is prescribed a low-protein diet. Which dietary choice indicates understanding of the prescribed diet?
- A. Grilled salmon
- B. Lentil soup
- C. Beef stew
- D. Chicken Caesar salad
Correct Answer: D
Rationale: A patient with chronic kidney disease prescribed a low-protein diet should avoid high-protein foods like grilled salmon, lentil soup, and beef stew. Chicken Caesar salad, on the other hand, typically contains a smaller amount of protein compared to the other options. This choice indicates an understanding of the need to limit protein intake while still enjoying a balanced meal. However, it is important to note that the quantity and portion sizes of high-protein ingredients in the salad should also be moderate to comply with a low-protein diet.
A nurse is delegating tasks to a nursing assistant. What principle should guide the nurse's delegation decisions?
- A. Delegating tasks according to the assistant's job description
- B. Assigning tasks based on the assistant's level of experience
- C. Delegating tasks that the nurse prefers not to perform
- D. Providing tasks that are routine and do not require nursing judgment
Correct Answer: B
Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.
When the nurse placed the patient in restraints before using other methods of intervention, she/he violated the patient's rights to ______.
- A. receive confidential and respectful care
- B. provide informed consent
- C. receive treatment in the least restrictive environment
- D. refuse treatment
Correct Answer: C
Rationale: Placing a patient in restraints before utilizing other less restrictive interventions violates the patient's right to receive treatment in the least restrictive environment. Restraints should be used as a last resort when all other options have been exhausted, as they can be restrictive to the patient's movement and freedom. Patients have the right to be treated in a manner that minimizes limitations on their personal freedom and autonomy. Restraints should only be utilized when absolutely necessary for the safety of the patient or others.
In order for Nurse Cris to facilitate the recognition of the community the existence of their health problems, which nursing action would yield BETTER results?
- A. Asks the barangay head to make the report
- B. Set the ground rule that presence of problem is valid
- C. Allows people's participation to confirm the health problems.
- D. Acts as an expert to communicate to residents.
Correct Answer: C
Rationale: Allowing people's participation to confirm the health problems would yield better results in facilitating the recognition of the community's health issues. By involving the community members themselves in the process of identifying and acknowledging their health problems, there is a higher likelihood of garnering accurate and relevant information. This participatory approach fosters a sense of ownership and empowerment among the community members, making them more likely to actively engage in addressing the identified health concerns. Additionally, community participation can help build trust between the nurse and the residents, leading to more effective communication and collaboration in improving overall health outcomes.
What is the BEST urine sample to be used for an accurate result of pregnancy test done at home?
- A. First-voided evening urine
- B. First-voided morning urine
- C. Mid-afternoon urine sample
- D. Random urine sample
Correct Answer: B
Rationale: First-voided morning urine is the best urine sample to be used for an accurate result of a pregnancy test done at home because it is more concentrated compared to urine samples collected at other times of the day. Overnight, the hCG hormone (human chorionic gonadotropin) builds up in a woman's body, making the early morning urine more likely to contain higher levels of hCG if a woman is pregnant. The concentrated nature of first-morning urine reduces the chances of false-negative results since it provides a higher concentration of the hormone that the test is designed to detect. Therefore, using first-morning urine increases the sensitivity of the pregnancy test and improves the accuracy of the results.