Nokea
The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
- A. Extreme fatigue
- B. Increased appetite
- C. Intense itching
- D. Constipation
Correct Answer: A
Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.
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What role does a community health nurse play in disaster management?
- A. Providing direct patient care
- B. Conducting research on disaster impacts
- C. Coordinating emergency response efforts
- D. Developing new healthcare policies
Correct Answer: C
Rationale: Community health nurses are primarily responsible for coordinating emergency response efforts during disasters. This involves organizing and implementing strategies to address the health needs of the community in crisis situations. Providing direct patient care (Choice A) is often carried out by other healthcare professionals such as doctors and paramedics during disasters. Conducting research on disaster impacts (Choice B) is important for understanding the effects of disasters but is not the primary role of a community health nurse. Developing new healthcare policies (Choice D) is typically the responsibility of policymakers and public health officials rather than community health nurses.
The appropriate order of steps in active management of the third stage of labor includes:
- A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to ensure the placenta is intact.
- B. Intravenous oxytocin, cord clamping and cutting, and fundal massage.
- C. Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage.
- D. Controlled cord traction, fundal massage, and oxytocin.
Correct Answer: C
Rationale: The correct sequence of steps in active management of the third stage of labor includes intramuscular injection of oxytocin to prevent postpartum hemorrhage, controlled cord traction with counter traction to the uterus to facilitate placental delivery, and uterine massage to aid in uterine contraction and prevent excessive bleeding. Choice A is incorrect because ergometrine administration is not routinely recommended in active management. Choice B is incorrect as intravenous oxytocin is not the preferred route of administration. Choice D is incorrect as the order of steps is not accurate.
A client with rheumatoid arthritis is receiving methotrexate (Rheumatrex). The nurse should monitor the client for which of the following adverse effects?
- A. Leukopenia
- B. Hyperglycemia
- C. Hypertension
- D. Hypokalemia
Correct Answer: A
Rationale: The correct answer is A: Leukopenia. Methotrexate, used in the treatment of rheumatoid arthritis, can lead to bone marrow suppression, resulting in leukopenia. This condition increases the risk of infections due to decreased white blood cell count. Choices B, C, and D are incorrect because methotrexate is not known to cause hyperglycemia, hypertension, or hypokalemia as its primary adverse effects.
What components should a nurse include when conducting a community health assessment?
- A. Personal health history of community members
- B. Number of hospitals in the community
- C. Demographic data, health status indicators, and community resources
- D. Results of laboratory tests
Correct Answer: C
Rationale: When conducting a community health assessment, it is essential to gather demographic data (such as age, gender, ethnicity), health status indicators (like prevalence of diseases, mortality rates), and information on community resources (such as healthcare facilities, social services). These components help in understanding the health needs of the community and planning appropriate interventions. Choices A, B, and D are not typically part of a community health assessment as they focus on individual health data or specific medical information rather than the broader population health perspective required for community assessments.
In this municipality, what should the nursing health care plan focus on?
- A. Rehabilitative services
- B. All of these services
- C. Health promotion and disease prevention
- D. Curative services
Correct Answer: C
Rationale: In this municipality, the nursing health care plan should primarily focus on health promotion and disease prevention. This approach addresses the underlying causes of health problems, promotes overall well-being, and helps prevent illnesses before they occur. While rehabilitative and curative services are important, health promotion and disease prevention are crucial for fostering a healthier community in the long term. Therefore, choices A, B, and D are not the best options as they do not prioritize preventing health issues at the root cause.