Nokea
The nurse should consider the following when assessing the child for chest indrawing EXCEPT:
- A. Chest indrawing should be present at all times
- B. The lower chest wall does not go in when the child breathes in
- C. The lower chest goes in when the child breathes in
- D. The child should be calm
Correct Answer: A
Rationale: The correct answer is A. Chest indrawing may not always be present and can vary with the child's activity level, so it should not be expected to be present at all times. Choice B is correct because the lower chest wall should not go in when the child breathes in. Choice C is correct as the lower chest should go in when the child breathes in, indicating chest indrawing. Choice D is correct as a calm child makes it easier to assess chest indrawing, but the absence of chest indrawing does not mean the child is not calm.
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A traditional plant used to lower uric acid is used by Rosario, a 55-year-old client with rheumatism. This herbal plant called "ulasimang bato" is commonly known as:
- A. Lagundi
- B. Pancit pacitan
- C. Bayabas
- D. Sambong
Correct Answer: B
Rationale: The correct answer is B, Pancit pacitan (Peperomia pellucida), which is known for its uric acid-lowering properties. Ulasimang bato is the local name for this traditional plant. Choices A, C, and D are incorrect. Lagundi (Choice A) is commonly used for its antitussive and anti-asthmatic properties. Bayabas (Choice C) refers to guava, which is known for its high vitamin C content and other health benefits. Sambong (Choice D) is used for its diuretic properties and is often utilized for kidney health.
The nurse is caring for an acutely ill 10-year-old client. Which of the following assessments would require the nurse's immediate attention?
- A. Rapid bounding pulse
- B. Temperature of 38.5 degrees Celsius
- C. Profuse diaphoresis
- D. Slow, irregular respirations
Correct Answer: D
Rationale: The correct answer is D, slow, irregular respirations. In an acutely ill child, this assessment can indicate impending respiratory failure or neurological compromise, necessitating immediate intervention. Rapid bounding pulse (choice A) may indicate tachycardia but is not as immediately concerning as compromised respirations. A temperature of 38.5 degrees Celsius (choice B) is elevated but may not be the most urgent concern unless accompanied by other symptoms. Profuse diaphoresis (choice C) can indicate increased sympathetic activity but is not as critical as respiratory compromise.
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
- A. Offer ice chips every 2 hours
- B. Place the child in a semi-Fowler's position
- C. Encourage the child to drink from a cup
- D. Observe swallowing patterns
Correct Answer: D
Rationale: Observing swallowing patterns is crucial post-tonsillectomy and adenoidectomy to detect signs of bleeding. Offering ice chips instead of ice cream helps prevent throat irritation. Placing the child in a semi-Fowler's position promotes airway patency and reduces the risk of aspiration. Encouraging the child to drink from a cup instead of a straw minimizes the risk of dislodging the surgical site.
Tertiary prevention would best be described as:
- A. recovery from physical limitation and psychological regression
- B. health teaching and immunization
- C. rehabilitation of alcoholic and drug dependents
- D. preventing disability and maximum use of remaining capacity
Correct Answer: D
Rationale: Tertiary prevention is the stage of prevention that aims at preventing disability and maximizing the use of remaining capacity. Choice A is more aligned with rehabilitation rather than tertiary prevention. Choice B refers to primary prevention by promoting health and preventing diseases. Choice C focuses on rehabilitation specific to alcohol and drug dependence, which is a form of secondary prevention, not tertiary prevention.
In which of the following settings would a community health nurse be less likely to be involved?
- A. neighborhood clinic, community clinic, or senior center
- B. physician's office with a focus on individual client care
- C. home-based care
- D. neighborhood planning board
Correct Answer: B
Rationale: Community health nurses are less likely to be involved in a physician's office with a focus on individual client care because their role primarily revolves around promoting and maintaining the health of populations and communities rather than providing direct care to individual clients. Options A, C, and D are more aligned with the community health nurse's role as they involve working in community-based settings, providing home-based care, and participating in community planning and advocacy.