Nokea
Nurse Victor assesses patient Mil. Decrease of which the following factors would help detect that the patient is at risk at developing cardiogenic shock?
- A. Heart rate
- B. Cardiac index
- C. Cerebral blood flow
- D. Blood pressure
Correct Answer: B
Rationale: Cardiogenic shock is a life-threatening condition where the heart is unable to pump enough blood to meet the body's demands. Monitoring the patient's cardiac index, which is a measure of cardiac output adjusted for body surface area, can help detect the risk of developing cardiogenic shock. A decrease in cardiac index would indicate a decrease in the heart's ability to effectively pump blood, putting the patient at risk for cardiogenic shock. Monitoring cardiac index is essential in assessing cardiac function and guiding interventions to prevent the progression to cardiogenic shock. The other factors listed may provide important information in assessing the patient's condition, but specifically in detecting the risk of developing cardiogenic shock, monitoring the cardiac index is crucial.
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The nurse specialist cites a situation. If a patient experiences episodes of severe nausea and vomiting with more than 1,000 ml. of vomitus with in a period of four hours, which of the following is the nurses MOST appropriate action?
- A. Withhold fluids for four hours
- B. Observe the patient for another four hours
- C. Notify the physician
- D. Place the patient on a liquid diet
Correct Answer: C
Rationale: Severe nausea and vomiting with a large volume of vomitus can indicate a serious underlying issue such as gastrointestinal obstruction or other medical emergencies. In this situation, it is crucial for the nurse to notify the physician immediately so that further assessment and appropriate management can be initiated promptly. Delay in seeking medical help can lead to complications and worsen the patient's condition. It is important to act quickly and involve the physician in situations where the patient's health may be at risk.
A patient appears confused and disoriented during a consultation. What is the nurse's priority?
- A. Assume the patient is not capable of understanding and proceed with the consultation.
- B. Provide clear and simple explanations and assess for any underlying causes of confusion.
- C. Ignore the patient's confusion and proceed with the consultation.
- D. Dismiss the patient's confusion as insignificant and focus solely on the medical information.
Correct Answer: B
Rationale: The nurse's priority when a patient appears confused and disoriented during a consultation is to provide clear and simple explanations and assess for any underlying causes of confusion. It is essential to ensure that the patient understands the information being provided and to address any potential reasons for the confusion, such as medication side effects, medical conditions, or cognitive impairment. Ignoring the patient's confusion or assuming they cannot understand can lead to misunderstandings, errors in care, and ultimately jeopardize the patient's well-being. It is crucial to approach the situation with empathy, patience, and a focus on ensuring effective communication and understanding between the nurse and the patient.
A pregnant woman presents with vaginal bleeding and passage of tissue at 10 weeks gestation. On examination, the cervix is dilated, and products of conception are visualized in the cervical os. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Threatened abortion
- C. Placenta previa
- D. Complete abortion
Correct Answer: D
Rationale: Complete abortion is the most likely cause of the symptoms described. In a complete abortion, all products of conception are expelled from the uterus. Symptoms include vaginal bleeding, passage of tissue, and dilation of the cervix. In this scenario, the presentation of a dilated cervix with visualized products of conception is classic for a complete abortion at 10 weeks gestation.
Upon seeing warning signs of child abuse, the BEST nursing action that Nurse Alma should make is to report the noted observation to __________.
- A. Dept of Social Welfare Development (DSWD)
- B. Headnurse
- C. Philippine National Police (PNP)
- D. Attending Pediatrician
Correct Answer: A
Rationale: Reporting observed signs of child abuse to the Department of Social Welfare Development (DSWD) is the best nursing action in cases of suspected child abuse. DSWD is the government agency tasked with protecting the welfare of children and families. They have the necessary authority and resources to investigate and intervene in cases of child abuse. Reporting to DSWD ensures that professional social workers and experts will step in to assess the situation, provide necessary interventions, and ensure the safety of the child. It is important to involve the appropriate authorities who are trained to handle cases of child abuse effectively. Reporting to the DSWD helps in safeguarding the well-being of the child and taking the necessary steps to address the situation appropriately.
For this patient who is to undergo surgery (closure of the sac), what would be the PRIORITY nursing diagnosis? It is risk for __________.
- A. Activity intolerance
- B. Infection
- C. Respiration
- D. Altered growth and development
Correct Answer: B
Rationale: The priority nursing diagnosis for a patient undergoing surgery (closure of the sac) would be risk for infection. This is because surgical procedures increase the risk of infection due to the breach in the skin and introduction of microorganisms. Infection can lead to serious complications, delay healing, and prolong recovery time. Therefore, prevention, early detection, and prompt treatment of infections are essential in the perioperative period to ensure the best possible outcomes for the patient.