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The APPROPRIATE nursing diagnosis to protect the patient from further injury is, which of the following?
- A. Altered mucous membrane related to chemotherapy.
- B. Interrupted family processes related to life threatening i1lness of a family member.
- C. Fatigue related to disease process.
- D. Risk for injury related to thrombocytopenia
Correct Answer: D
Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.
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In response to chronic hypoxia, which physiological adaptation occurs in the body to increase oxygen delivery to tissues?
- A. Decreased erythropoietin production
- B. Decreased red blood cell production
- C. Increased cardiac output
- D. Decreased ventilation rate
Correct Answer: C
Rationale: In response to chronic hypoxia, the body adapts to increase oxygen delivery to tissues by increasing cardiac output. This is achieved by increasing the heart rate and stroke volume, allowing more oxygenated blood to be pumped to the tissues. The increased cardiac output helps compensate for the lower oxygen levels in the blood, ensuring that tissues receive an adequate supply of oxygen despite the hypoxic conditions. This physiological adaptation is essential for maintaining tissue oxygenation and supporting overall cellular function in the presence of chronic hypoxia.
The Right to Information does not include _________.
- A. Any change in the plan of care before the change is made
- B. Extent to which payment maybe expected from Philhealth
- C. Discount for the professional fee of the attending doctor(s)
- D. Result of the evaluation of the nature and extent of his/her disease
Correct Answer: B
Rationale: The Right to Information pertains to the patient's right to be informed about their condition, treatment plan, and to have access to relevant medical information. It does not include specific details about payment or insurance coverage, such as the extent to which payment may be expected from PhilHealth. While financial information is important for patients, it does not fall under the scope of the Right to Information in a healthcare context, which focuses more on medical information and decision-making processes.
Which of the following is a common complication associated with untreated clubfoot in infants?
- A. Scoliosis
- B. Hip dysplasia
- C. Osteomyelitis
- D. Cerebral palsy
Correct Answer: B
Rationale: Hip dysplasia is a common complication associated with untreated clubfoot in infants. If clubfoot is not treated promptly and properly, it can lead to abnormal development of the hip joint, resulting in hip dysplasia. This condition involves the abnormal formation of the hip socket, which can cause instability and potential dislocation of the hip joint. Early identification and treatment of clubfoot are important in preventing complications such as hip dysplasia.
After five days of hospitalization, the physician said Mr. Steeve can be discharged. He ordered medications to be taken at home. The client is still weak and symptomatic, which of the following rights could be violated in this case? Right to _______.
- A. Know hospital rules
- B. Refuse treatment
- C. Privacy
- D. Continuity of care
Correct Answer: B
Rationale: The right to refuse treatment is a fundamental patient right. In this case, the physician ordering medications for the client to take at home without the client's input or agreement could possibly violate the client's right to refuse treatment. It is important for patients to have the autonomy to make decisions regarding their own treatment, especially when they are still weak and symptomatic. Patients should have the opportunity to discuss their treatment plan with their healthcare provider and express any concerns or preferences they may have.
A patient receiving palliative care for end-stage chronic obstructive pulmonary disease (COPD) expresses a desire to discuss advance care planning. What action should the palliative nurse take?
- A. Dismiss the patient's request and focus on symptom management.
- B. Initiate a conversation about advance directives and future care preferences.
- C. Encourage the patient to postpone discussions about advance care planning.
- D. Refer the patient to a social worker for assistance with advance care planning.
Correct Answer: B
Rationale: When a patient receiving palliative care for end-stage COPD expresses a desire to discuss advance care planning, the palliative nurse should initiate a conversation about advance directives and future care preferences. Advance care planning involves discussing and documenting a patient's preferences regarding future medical care, particularly in situations where the patient may no longer be able to make decisions. This discussion helps ensure that the patient's wishes are respected and followed in the event they are unable to communicate their preferences. By engaging in advance care planning discussions, the nurse can help the patient feel empowered, supported, and in control of their medical care decisions. It also allows healthcare providers to align care with the patient's values and goals, ultimately improving quality of life and ensuring dignity at the end of life.