Nokea
Upon clinical assessment, the nurse observes that the OUTSTANDING manifestation of the patient is ______.
- A. weight gain
- B. obesity
- C. emaciation
- D. edema
Correct Answer: D
Rationale: Upon clinical assessment, the nurse observes that the outstanding manifestation of the patient is edema. Edema is characterized by the accumulation of excess fluid in the body's tissues, leading to swelling. Edema can be a sign of various health conditions, such as heart failure, kidney disease, liver disease, or injury. It is crucial to identify and address the underlying cause of edema promptly to prevent complications and provide appropriate treatment for the patient.
You may also like to solve these questions
Despite the short staffing, Nurse Cirila also has the responsibility to maintain safe environment for her pediatric patients. The following are the indicators that Nurse Cirila has achieved this goal, EXCEPT __________.
- A. Proper disposal of waste according to color coding
- B. Adherence to policies, protocols and procedures in the prevention and control of infection prevention.
- C. Assessing the competencies of a staff before delegating a task
- D. Observance of protocols in cases of earthquakes, fire and other emergencies.
Correct Answer: C
Rationale: The indicators listed indicate measures that Nurse Cirila can take to maintain a safe environment for her pediatric patients. However, assessing the competencies of staff before delegating a task is more related to ensuring effective delegation and appropriate task assignment rather than directly ensuring a safe environment for patients. While it is important to delegate tasks to qualified staff, this specific action does not directly contribute to maintaining a safe environment in the same manner as the other indicators listed (proper waste disposal, infection control, emergency protocols).
A nurse is preparing to perform an intramuscular (IM) injection for a patient. What action should the nurse take to ensure proper injection technique?
- A. Selecting a small-gauge needle to minimize patient discomfort
- B. Administering the injection rapidly to reduce patient anxiety
- C. Aspirating the syringe to confirm needle placement before injection
- D. Inserting the needle at a 90-degree angle into the muscle
Correct Answer: D
Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.
The patient verbalizes to the nurse about thought to kill his wife". The nurse is in dilemma whether to tell the wife about this Conversation. Given this situation which of the following is the appropriate action of the nurse?
- A. Alert immediately the proper authorities regarding the threat to safeguard the safety of the wife.
- B. Tell the wife to be very extra careful as her life is danger.
- C. Weigh carefully the situation by viewing it as dilemma between disclosing confidential information or warning appropriate authorities.
- D. Keep the information to herself and be vigilant on action of the patient to protect the wife
Correct Answer: A
Rationale: In this critical situation, the safety of the wife is of utmost importance. Whenever a healthcare provider becomes aware of a direct threat to someone's safety, especially related to potential harm or violence, it is their ethical and legal responsibility to report this information to the appropriate authorities promptly. In this case, the nurse should alert the proper authorities, such as law enforcement or a mental health crisis team, to ensure that immediate steps are taken to protect the wife from harm. Confidentiality should be breached in situations where there is a clear threat to an individual's safety. Keeping the information confidential in this scenario could result in serious harm or even loss of life. The nurse must act quickly to protect the potential victim.
Nurse Lyca is aware that testing of vision in infants and children has been treated separately from the testing of adult. which of the statement is NOT true?
- A. Infants and children often cannot be tested with the same materials and techniques as adults.
- B. Special techniques often must be used, especially to test infants and preschoolers, that cannot be held to the same standards that apply to tests for adults
- C. Some infants who appear visually impaired early in life wil1 not Show normal visual responses several weeks or months later
- D. Course of visual and cognitive development must be taken into account in evaluating infants and children's visual abilities
Correct Answer: E
Rationale: All of the statements (A-D) are true when discussing the testing of vision in infants and children separately from testing in adults. However, statement E is NOT true. The course of visual and cognitive development MUST be taken into account in evaluating infants and children's visual abilities. It is crucial to consider the stage of development a child is in when evaluating their vision, as their visual abilities can change rapidly during early childhood. Ignoring the course of development could lead to incorrect assessments and misunderstandings about the child's visual capabilities.
The PRC-Board of Nursing (PR-BON) ha5 the power to regulate Nursing Practice in the Philippines. The regulatory functions include the following except
- A. enforce and monitor quality standards of nursing practice in the county
- B. issue, suspend revoke or reissue certification of registered nurses
- C. ensure proper conduct.
- D. issue permit for the opening of nursing programs in the country
Correct Answer: D
Rationale: The correct answer is D, issuing a permit for the opening of nursing programs in the country. The PRC-Board of Nursing (PR-BON) in the Philippines primarily focuses on regulating nursing practice and ensuring the quality and standards of nursing care provided in the country. While they have the authority to oversee aspects such as certification of registered nurses, enforcing quality standards, and monitoring proper conduct of nurses, the responsibility of issuing permits for the opening of nursing programs typically falls under the jurisdiction of other relevant educational or accrediting bodies.