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Nurses may be privy to very personal information of patients and should make every effort to make it confidential, otherwise she can be charged of ______.
- A. negligence
- B. invasion of privacy
- C. malpractice
- D. defamation
Correct Answer: B
Rationale: Nurses are bound by strict confidentiality and privacy regulations in their profession. If a nurse fails to keep a patient's personal information confidential and discloses it without authorization, they can be charged with invasion of privacy. Invasion of privacy is the wrongful intrusion into a person's private affairs without their consent, and it is a serious violation of ethical and legal standards in healthcare. Nurses must always prioritize patient confidentiality to maintain trust and uphold ethical standards in their practice.
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Which of the following is NOT a step of record keeping?
- A. Structuring
- B. Securing
- C. Storing
- D. Easy Disposa l
Correct Answer: D
Rationale: Record keeping involves several key steps such as structuring, securing, and storing information. However, easy disposal is not a step in record keeping. In fact, it is important to carefully consider the disposal of records in a secure and responsible manner to protect sensitive information and comply with relevant regulations. Proper disposal methods should be followed to ensure that records are not accessible to unauthorized individuals and that any sensitive information is properly destroyed to prevent misuse or breaches of privacy. Therefore, easy disposal is not a recommended practice in effective record keeping.
A patient admitted to the ICU develops acute intracerebral hemorrhage (ICH) with elevated intracranial pressure (ICP). What intervention should the healthcare team prioritize to manage the patient's ICP?
- A. Initiate hypertonic saline therapy for osmotic diuresis.
- B. Perform emergent craniotomy for hematoma evacuation.
- C. Implement head-of-bed elevation to promote cerebral venous drainage.
- D. Recommend sedative medications to reduce agitation and anxiety.
Correct Answer: B
Rationale: In cases of acute intracerebral hemorrhage (ICH) with elevated intracranial pressure (ICP), a significant factor contributing to the elevated ICP is often the mass effect caused by the hematoma within the brain. Performing an emergent craniotomy for hematoma evacuation is a critical intervention to relieve the pressure within the intracranial space, thereby mitigating the risk of herniation and further neurological damage. While other interventions such as hypertonic saline therapy, head-of-bed elevation, and sedative medications may have supporting roles in managing ICP, none address the primary cause of elevated ICP in cases of acute intracerebral hemorrhage as effectively as hematoma evacuation through craniotomy.
A woman in active labor is diagnosed with a prolapsed umbilical cord. What is the priority nursing action?
- A. Elevate the mother's hips to relieve pressure on the cord.
- B. Prepare for immediate cesarean section.
- C. Administer intravenous fluids rapidly.
- D. Perform a vaginal examination to assess cervical dilation.
Correct Answer: B
Rationale: A prolapsed umbilical cord is a medical emergency during labor because it can cause compression of the umbilical cord, leading to decreased oxygen supply to the fetus. The priority nursing action in this situation is to prepare for an immediate cesarean section. This is necessary to quickly deliver the baby and relieve pressure on the cord, preventing potential fetal distress or death. Elevating the mother's hips may help reduce pressure on the cord temporarily, but it is not the definitive treatment for a prolapsed cord. Administering intravenous fluids rapidly may be necessary, but it is not the priority intervention when the fetus is at risk due to a prolapsed cord. Performing a vaginal examination to assess cervical dilation is contraindicated in the presence of a prolapsed umbilical cord as it can further compress the cord and worsen the situation.
She was asked by the nurse supervisor about her concern and what are the considered ideal fetal positions for a healthy delivery?
- A. Right occipitoposterior with no flexion
- B. Right occipitoposterior with full flexion
- C. Left transverse anterior in moderate flexion
- D. Left Sacroanterior with full flexion
Correct Answer: C
Rationale: The considered ideal fetal position for a healthy delivery is left transverse anterior with moderate flexion. This position allows for an easier descent through the birth canal and reduces the chances of complications during delivery. This position is optimal for a smoother and safer delivery process for both the mother and the baby.
Which assessment findings is INDICATIVE of the diagnosis of hypertension?
- A. Family members with high blood pressure
- B. Elevation of blood cholesterol level
- C. Stressful work environment
- D. Consistent evaluation of blood pressure
Correct Answer: D
Rationale: The assessment finding that is indicative of the diagnosis of hypertension is consistent evaluation of blood pressure. Hypertension is diagnosed based on repeated measurements of elevated blood pressure. Consistently high blood pressure readings, usually defined as systolic blood pressure consistently at or above 140 mmHg and diastolic blood pressure consistently at or above 90 mmHg, are a key factor in diagnosing hypertension. Family history of high blood pressure (Choice A), elevation of blood cholesterol level (Choice B), and a stressful work environment (Choice C) may be risk factors for hypertension but are not diagnostic criteria. In order to diagnose hypertension, healthcare providers rely on consistent measurement and evaluation of blood pressure over time.