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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.
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A woman in active labor demonstrates signs of cephalopelvic disproportion (CPD), with the fetal head failing to descend despite strong contractions. What nursing action should be prioritized to address this abnormal labor presentation?
- A. Perform a pelvic exam to assess for CPD.
- B. Assist the mother into a hands-and-knees position.
- C. Administer intravenous oxytocin to augment contractions.
- D. Prepare for immediate instrumental delivery.
Correct Answer: D
Rationale: When a woman in active labor demonstrates signs of cephalopelvic disproportion (CPD) with the fetal head failing to descend despite strong contractions, the nursing action that should be prioritized is to prepare for immediate instrumental delivery. CPD can lead to a prolonged and difficult labor, increasing the risks for both the mother and the fetus. In cases where the fetal head is not descending adequately and the mother's contractions are strong, instrumental delivery, like forceps or vacuum extraction, may be necessary to facilitate the safe delivery of the baby. It is important to act promptly to avoid potential complications associated with prolonged labor. Other actions, such as performing a pelvic exam, changing maternal positions, or administering oxytocin, may be considered but addressing the issue of CPD efficiently through instrumental delivery should take precedence in this scenario.
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.
Which infection control measure should Nurse Emma observe during her visit to the family.
- A. Wear mask
- B. Use face shield
- C. Use gloves
- D. Wear gown
Correct Answer: A
Rationale: Wearing a mask is an essential infection control measure to prevent the spread of respiratory illnesses, including COVID-19. By wearing a mask, Nurse Emma can reduce the risk of inhaling or exhaling respiratory droplets that may contain infectious particles, thus helping to protect herself and the family members she is visiting. Masks are particularly crucial when interacting with individuals who are sick or when physical distancing may be challenging. While using gloves, face shields, and gowns are also important infection control measures in certain situations, wearing a mask is the most relevant and effective measure during a home visit to prevent respiratory transmission of infections.
The young mother wanted to know about the motor development APPROPRIATE in a preschooler. Which of the following statements NOT true?
- A. "He can tie shoe lace"
- B. "He can alternate feet when climbing"
- C. "He has not developed good postures"
- D. "He can hop two or more times"
Correct Answer: B
Rationale: The statement that the preschooler can alternate feet when climbing is not true. Typically, preschoolers at this age group are still developing their coordination and may not have mastered the skill of alternating feet while climbing. It is more common for them to use one foot after the other while climbing. This skill usually requires more advanced motor development and coordination, which may come later in the preschool years.
When a patient develops a temperature of 39.8 degree centigrade after an abdominal surgery with an ongoing blood transfusion, the PACU nurse should notify the surgeon as this may indicate ______.
- A. abdominal tissue injury
- B. on going potential infection
- C. post-anesthesia drug reaction
- D. allergic reaction from blood transfusion
Correct Answer: B
Rationale: A temperature of 39.8 degrees Celsius (103.6 degrees Fahrenheit) in a patient following abdominal surgery and ongoing blood transfusion may indicate an ongoing potential infection. During surgery, the body is exposed to various microorganisms, and the stress of surgery can weaken the immune system, making the patient more susceptible to infections. Blood transfusions also carry a risk of introducing infections if not properly screened. Therefore, in this situation, an elevated temperature may be a sign that an infection is developing, and prompt notification of the surgeon is important for further evaluation and management.