Nokea
Nurse Selma conducts her INITIAL assessment on Catherine. patient keeps on crying and constantly pulls her right ear. What is her MOST APPROPRIATE action?
- A. Request parent to carry the child
- B. Take Catherine's vital signs.
- C. Refer to the attending physician.
- D. Assess the description and frequency of pain.
Correct Answer: D
Rationale: When a patient is crying and continuously pulling at a specific body part, such as Catherine pulling her right ear, it indicates discomfort or pain in that area. Nurse Selma's most appropriate action would be to further assess the description and frequency of the pain. This will help her identify the possible cause of the pain, whether it is due to an ear infection, injury, or any other underlying issue. Understanding the nature and intensity of the pain will guide Nurse Selma in providing appropriate care and intervention for Catherine. It is crucial to address the patient's pain promptly to ensure their comfort and well-being. Referring to the attending physician may be necessary after this initial assessment but assessing the pain should be the immediate priority.
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A patient presents with knee pain and swelling following a fall onto a flexed knee. Physical examination reveals a palpable effusion and tenderness along the joint line. McMurray's test elicits pain and clicking with passive knee flexion and internal rotation. Which condition is most likely?
- A. Patellar tendinitis
- B. Medial meniscus tear
- C. Lateral collateral ligament (LCL) sprain
- D. uadriceps tendon rupture
Correct Answer: B
Rationale: The presentation of knee pain and swelling following a fall onto a flexed knee, along with a palpable effusion and tenderness along the joint line, is highly suggestive of a meniscus injury. The McMurray's test specifically evaluates for meniscal tears. In this case, the presence of pain and clicking with passive knee flexion and internal rotation indicates a medial meniscus tear as the most likely diagnosis. Patellar tendinitis usually presents with anterior knee pain that is worsened by activities such as jumping or running. Lateral collateral ligament (LCL) sprain typically presents with lateral knee pain and instability. Quadriceps tendon rupture would present with significant weakness and inability to fully extend the knee, which is not described in this scenario.
Nurse Pat promised to a post- surgical patient, that she would come back to assist in his of ambulation after carrying out the physician's order. This follows the principle
- A. beneficence
- B. autonomy
- C. justice
- D. fidelity
Correct Answer: D
Rationale: Fidelity is a principle in nursing ethics that pertains to being faithful or loyal to commitments and promises made to patients. When Nurse Pat promised to come back to assist in the patient's ambulation after carrying out the physician's order, she is demonstrating fidelity by fulfilling her commitment to the patient's care. This principle helps build trust between the nurse and the patient, ensuring continuity and quality of care.
A patient expresses frustration with the long wait times in the healthcare facility. What is the nurse's best response?
- A. Dismiss the patient's frustration and assure them that wait times are unavoidable.
- B. Listen actively to the patient's concerns, acknowledge the inconvenience, and offer support.
- C. Ignore the patient's frustration and proceed with providing care.
- D. Tell the patient that their frustration is unwarranted and unnecessary.
Correct Answer: B
Rationale: The nurse's best response in this situation is to listen actively to the patient's concerns, acknowledge the inconvenience they are experiencing, and offer support. It is essential to validate the patient's feelings and show empathy towards their frustration. By actively listening and addressing the patient's concerns, the nurse can help alleviate some of their frustration and build a positive rapport with the patient. This approach demonstrates respect for the patient's feelings and promotes effective communication in the healthcare setting. Dismissing or ignoring the patient's frustration can lead to further dissatisfaction and impact the quality of care provided.
Mrs. Carpio has an order of Thiazide diuretics for her edema. The following is the entry that you expect to be written in her progress report EXCEPT ______.
- A. Serum electrolyte monitored everyday
- B. Intake and output done every shift
- C. Weight taken before drug is administered
- D. Drug is administered at 8o'clock in the evening
Correct Answer: D
Rationale: The entry you expect to be written in Mrs. Carpio's progress report should include details related to monitoring her response to the Thiazide diuretics and ensuring her safety. Options A, B, and C all focus on these aspects by monitoring serum electrolytes, intake and output, and weight before drug administration, which are important considerations when a patient is on Thiazide diuretics. However, specifying the time of drug administration (8 o'clock in the evening) is not necessary in the progress report entry. The focus should be on the patient's response to the medication and the associated monitoring parameters. Time of administration is more relevant for nursing care plans or medication schedules.
A patient presents with a yellowish-white spot on the cornea, surrounded by a ring of inflammation. Slit-lamp examination reveals branching, filamentous opacities extending from the corneal lesion. Which of the following conditions is most likely responsible for this presentation?
- A. Herpes simplex keratitis
- B. Bacterial keratitis
- C. Fungal keratitis
- D. Acanthamoeba keratitis
Correct Answer: C
Rationale: The described presentation of a yellowish-white spot on the cornea with branching, filamentous opacities is characteristic of fungal keratitis. Fungal keratitis is typically associated with agricultural injuries, trauma involving plant material, or contact lens wear in agricultural environments. Fungal keratitis can be serious and may require intensive antifungal treatment to prevent vision loss. Prompt diagnosis and initiation of appropriate antifungal therapy are essential in managing fungal keratitis.